Who are the Dumbest Doctors?

We've all heard jokes involving members of several different occupations. They start out something like "An engineer, a mathematician, and a lawyer are riding on a plane..." And the joke ends with one of them being the butt of the joke. These jokes are based on stereotypes of different professions. Well, doctors have this type of joke too, based on different medical subspecialties. Here is an example:

(This example is for illustrative purposes only. It is NOT meant to be disparaging to surgeons. Well, maybe a little ;-)

A surgeon gets on an elevator. An internist sees the open elevator door and comes running down the hall shouting, "Hold the elevator!" The surgeon doesn't want to wait, so he starts mashing on the CLOSE DOOR button. The internist gets there just as the door is almost closed, and sticks his hand in to stop the door.

As he gets in, the surgeon gives him a dirty looks and says, "If you were a surgeon, you would never have stuck your hand into a closing door like that!" To which the internist replies, "You're right. I would have stuck in my head!"

Anyway, the point of all this is to examine the question of which medical subspecialty is the dumbest. Dumb is, of course, relative. Pretty much all doctors have to get through four years of college with a pretty high grade point average, do well on the Medical College Admission Test, and survive medical school. But like any form of education, 50% of the students are in the bottom half of the class, and there is one poor schmoe who graduates at the very bottom. Where do these guys end up?

Well, we doctors have our own stereotypical opinions. Being a Radiologist, I obviously believe that Radiology gets the upper crust. This opinion is not simply an effect of my being a Radiologist. I chose this field because I had a high opinion of it.

So which specialties are looked down upon by other doctors? Let us look at some more doctor jokes:

The Surgeon: Knows nothing, does everything.
The Internist: Knows everything, does nothing.
The Psychiatrist: Knows nothing, does nothing.
The Pathologist: Knows everything, does everything, but a day too late.

Q: How do they pick the Gynecologists and Orthopedic Surgeons?
A: Take the bottom 10% of the medical school class and pith them (i.e., stick an ice pick into their brains and scramble them). The ones that can still walk become the Orthopedic Surgeons, and the rest become Gynecologists.

Orthopedic Surgeons: Strong as an ox, and almost as smart.

Gynecologists only know how to do three operations:
1. Hysterectomy.
2. Ligation of the left ureter.
3. Ligation of the right ureter.
(Putting a metal clip across a ureter, i.e. ligating it, is an occasional mistake made during hysterectomy.)

Q: How do you hide something from a Surgeon?
A: Put it in a book.

Q: How do you hide money from a Cardiologist?
A: You can't.

Alright, enough. I'm starting to digress. Orthopedic Surgeons take a lot of flack because their work requires more physical strength than that of other doctors, and physical strength is perceived to be associated with less intelligence (i.e. football players are dumb jocks). Also, procedures like joint replacement and fixing fractures with screws and metal plates are sort of like what a car mechanic or handyman might do. True, if they do a lot of the same procedure it gets to be pretty routine and mindless, but the same is true of urologists who do a lot of "Roto-Rooter" work on prostates, or Radiologists who read a lot of mammograms.

I have my own opinion of who the dumbest doctors are. Oncologists (doctors who treat cancer). Yes, their work is extremely important. My mother's life was saved 35 years ago by oncologists, and she is still alive and kicking today. And if you are a cancer survivor, and love your oncologist dearly, please do not take offense. But what they do just doesn't take a lot of brains.

A lot of cancer research involves testing of treatment protocols. These involve criteria for when to operate, when to radiate, and schedules for treating with chemotherapy. The result of this research is a series of well defined and accepted protocols for treating various types and stages of tumors. In other words, it's all cookbook. The oncologist uses information about each patient to decide which protocol to use. They gather very little of this information themselves. The surgeon examines the tumor while it is in the patient, and reports where it is invading, and other things which can be determined by direct observation. The pathologist provides a specific diagnosis as to the type of tumor, biochemical information, information on microscopic invasion, and anything else which can be determined by microscopic examination. The radiologist provides pre-operative and follow up information on the location of the tumor, the presence of spread into lymph nodes, and evidence for recurrence. The oncologist merely collects all this information (plus a little more information from talking to the patient and performing a physical exam), and plugs it into an algorithm to determine treatment.

Occasionally a patient will not fall clearly into a treatment protocol. For example, he may have been partially or inappropriately treated elsewhere. Or he may have two different tumors. In these situations, the patient is discussed at a "tumor board", in which a large group of oncologists, surgeons, radiation therapists, and radiologists meet to discuss the situation and come up with a treatment. Generally, if a patient does not clearly fit into a protocol, there is a long unproductive discussion, and they end up just winging it.

There. Now I finally have produced a significant contribution to the field of medicine. A case for oncologists being the dumbest medical specialty. Remember, you heard it here first. Stay healthy.

A Case of Winging It

I would like to describe an example of a doctor's thought process. I have encountered this actual scenario during my training. Hopefully I have never practiced in this manner.

The scene is an emergency room in the middle of the night. The patient is a toddler, say about 1.5 to 2 years old. He has a fever, cough, runny nose, and is irritable. He cannot sleep, and is keeping his parents up as well. Everyone is exhausted and feeling miserable. This is a very common situation. Just about any parent has been here.

Here is the parents' perspective: The child is much easier to deal with during the day because the parents are wide awake and rested. At 2am, when the parents are exhausted, the situation is intolerable, and that is what prompts the ER visit.

Here is the doctor's perspective: The child most likely has a cold or the flu. These are viral infections, for which there is no specific treatment. The only treatment is supportive, i.e. relief of symptoms using Tylenol for fever and aches, decongestants to reduce the runny nose, cough suppressants to help the child rest, and perhaps a vaporizer to keep the secretions from drying out and becoming more difficult to clear. On the other hand, the child could have a bacterial infection, in which case antibiotics should be used.

The main focus of the doctor will be to try to determine if there is a bacterial infection. First he may consider a bacterial infection of the lungs, i.e. pneumonia. By listening to the child's lungs with a stethoscope, he will try to detect fluid deep in the lungs. Fluid in the deep airspaces (alveoli) imply pneumonia, and this will give a characteristic fine crackling sound, as opposed to a coarser upper respiratory sound one hears with infections such as uncomplicated flu, which only infect the large airways. In between is bronchitis, which is an infection of the smaller airways, but not involving the alveoli. This will cause a mild wheezing sound. Bronchitis is generally a bacterial infection, and would also require antibiotics.

This works in theory, but at 2am, a two year old in an ER will often be crying and inconsolable. This may make it impossible to be confident about what you are hearing through the stethoscope. So the doctor may consider obtaining a chest x-ray. This, too, is not perfect. A chest x-ray is most useful when it is obtained with the patient taking in a deep breath. Good luck getting a two year old to do that. Most likely it will be obtained with the patient exhaling. This makes is difficult or impossible to detect bronchitis or a small area of pneumonia. Also, even a good quality chest x-ray may appear normal in the early stages of pneumonia. In ordering the chest x-ray the doctor must consider how suspicious he is of a bacterial infection, how useful the x-ray is likely to be, and the small but real risk of radiation exposure to the child. Some children are particularly prone to bad respiratory infections, and could end up with a large radiation dose over time. And, of course, the x-ray will increase the cost of the visit.

Another possible site for a bacterial infection is the throat, i.e. a strep throat. This can be checked for quickly with a throat swab. Not too easy to do in a two year old. And again, it adds to the cost.

Other serious things to consider are sepsis (a bacterial infection in the bloodstream), and meningitis, an infection of the covering of the brain, both of which are life threatening. In a two year old, these can usually be ruled out by examining the child.

So we may have a situation in which we cannot reliably tell by examination whether this is a viral infection or a bacterial infection. Perhaps we have spent some extra money on x-rays and lab tests, and still do not have a clear answer. The doctor should not give antibiotics if this is only a viral infection. Firstly, even though antibiotics are fairly safe, there is a risk of adverse reaction, possibly serious. And secondly, overuse of antibiotics leads to resistant strains of bacteria. This is the reason we now are forced to treat some infections with so called third generation, fourth generation, fifth generation etc. antibiotics, and with combinations of multiple drugs, each of which are extremely expensive.

So the doctor wants to do the right thing, but he is presented with limited information with which to make his decision. Another thing to consider is that if he decides not to give antibiotics, the parents may become angry. They brought the child to the ER in the middle of the night in order to receive some sort of treatment, not to be told to continue using over-the-counter medications, give him plenty of fluids, etc. So if the doctor can justify the use of antibiotics, everyone is happy, and he can move on to the next patient.

The solution to this problem is the ears. Middle ear infections are quite common in two year olds, are often associated with respiratory infections, and are an indication for antibiotics. Ear infections are diagnosed by looking into the child's ears with an otoscope and identifying a red, inflamed ear drum. Therefore, if the ear drum is red, the problem is solved.

One would think that this is a pretty objective determination, but not necessarily. If a child is doing a lot of screaming (which most two year olds will do at 2am), his ear drums may get red, just as his face gets red. This presents an out for the doctor. Pin the child down, put the otoscope into his ear, he fights and screams, his ear drum is red, and you declare him to have a middle ear infection. No one else sees the ear drum, so your word is law. If the child sees his regular doctor the next day, and the ears are normal, then the antibiotics worked!

I am certain that this sort of thing does not happen very often. However, most doctors encounter clinical situations with which they have little experience, and have no back up, so they are forced to wing it. For example, a doctor with little pediatric experience may be working alone in an ER, and fall into this method.

That's all for now. Until next time, stay healthy.

The Problem with Medicine

Let us begin by examining the nature of the medical profession. Medicine is, most basically, the practice of the prevention and treatment of disease. Disease is an impairment of a vital function of the body. In this sense, doctors are similar to other "repair" professionals, such as auto mechanics or computer technicians. Of course, there are much greater emotional issues with the practice of medicine, which makes the doctor's job unique in its need for compassion. But when you get down to the basic nuts and bolts, a doctor's job is to fix a malfunctioning machine.

But even at this basic level, there is a big difference between a doctor's job and that of other repair technicians. Any machine made by man is potentially understandable at its most fundamental level. No matter how complex a manufactured device is, one can query the creator, obtain manuals, etc. Not so with the human body. Everything we know about the human body has been discovered by reverse engineering. This process is hampered by several factors:

1. The complexity of the human body is much greater than any man made device. There are immensely intricate processes happening at a molecular level that we can only crudely study.

2. Biological systems such as the human body behave very inconsistently. Under similar circumstances, two different individuals (or the same individual at two different times) will react very differently to the same stimulus.

3. Our methods of studying the human body are limited by ethics. Techniques exist to overcome the above described problems, but often would involve actions which are not considered moral when applied to human subjects, such as withholding treatment from an ill person.

I will examine these issues in more detail in later postings, but for now, the point is that the practice of medicine is far more limited than most people realize. In medical school I was taught that medicine is both a science and an art. At the time I thought this meant that medicine went beyond mere science and approached the sublime. I was just a naive snot-nosed kid at the time. Over the years, I have come to realize what this really means. The science of medicine is limited, and doctors often face situations in which there is no clear objective course. At these times, you must "wing it". And doctor do, indeed, wing it.

Next installment we will further examine what we know and what we do not know. In the meantime, stay healthy.