Why is medical advice all caution and no info?

A Crowd Waits of Emergency Relief

Wordpress now offers me free images of whatever I'm talking about. This is presumably an illustration of how the world doesn't necessarily become a better place if you tell everyone they urgently need to seek medical help for something you won't tell them anything more about. Image by uncultured via Flickr

I had a couple of bad looking medical test results in a row, so I was sent to a specialist, with advice along the lines of ‘well, we can’t say it’s not cancer… probably get checked out as soon as possible’. When I eventually got to the specialist he immediately told me a bunch of relevant conditional probabilities: of any problem at all given such test results, of it being a bad problem given it’s some kind of problem, the probability per year of cancer given each kind of problem. These were not scary numbers at all. Given that it can take months to extract your data from one doctor and get an appointment with a specialist, it would have been very nice to have been told these numbers by the original doctor, instead of just knowing for a few months that such results are some unknown degree of evidence in favor of cancer. Is this just an oversight by a particular useless doctor?

It seems not. I’ve noticed another two examples of the same problem in medicine recently. If you look up symptoms online, you will often be told to seek emergency medical assistance immediately. It often doesn’t even tell you what the potential problem is, and certainly not what the odds are of it occurring, so it’s pretty hard to evaluate the suggestion. If you actually go to a doctor about one of these symptoms, the doctor often tells you not to worry about it without more than knowledge of your age.  Often the website also knows your age, or at least asked it, and it would be simple for them to mention that said symptom is only a concern if you are over fifty, or even just the basic information about how common such a thing is given that symptom. Similarly my region has a free health phone line where you can ask a nurse whether symptoms are worth bothering to go to a doctor about. That seems like a decent idea, since apparently people overestimate when its worth going to the doctor. However in my small amount of experimentation it seems that anything I say prompts the suggestion that I see a doctor ‘within four hours’. I mean, I have tried telling them my bottom hurts at 2am and they tell me to get to a doctor within four hours.  I would be very surprised if an emergency room  was willing to treat sore bottoms in the middle of the night, so why not just tell the caller that at the start? Sending someone to a doctor can’t possibly help if the doctor is guaranteed to send them home.

In all these cases medical advice errs so much in the direction of caution that the doctor finally responsible for treating you will often hardly have to look at you before sending you home. The advice givers also refuse to offer relevant information such as conditional probabilities, so you can’t judge for yourself how far you want to cycle in freezing night to avoid a one in a million chance of arthritis or whatever. The costs of these behaviors in the short term are needless anxiety for patients, and doctors’ visits that informed patients would not want. In the long term patients will learn to distrust such advice givers and will miss out on useful advice when they really should go to an emergency room, while probably still harboring a slight fear that they have done wrong and will prematurely die for their sins. Is this medical advice format as common as it seems to me? Why is it done? I can understand an uninformed relative who is super-concerned about your wellbeing and believes you to be biased telling you you must seek medical advice for everything and refusing you any information. Or a doctor being in favor of it. But why do these presumably informed third parties and other doctors do it?

Added 1 Sept 10: I’m fine, sorry I wasn’t clear enough about that.

17 responses to “Why is medical advice all caution and no info?

  1. One might guess that people feel more cared for when told to be careful, even when that wastes their time. You might also guess that legal liability rules encourage over care. But the simplest explanation stands out to me: it takes time to learn and update the conditional probabilities, and these folks can’t be bothered to do that. Only the specialist bothers.

  2. If people can’t judge how great the harm is, they don’t know whether to feel cared for despite a small harm or not especially cared for and at great danger. I suspect the joy of a doctor liking you is not worth the chance of the second.

    Why would there be a legal responsibility for others to insist you go to a doctor in situations that a doctor has no legal responsibility to treat you in?

    I originally assumed they just did not have the data on hand, but evidently it has been collected. They do these tests very often – would it be so much extra effort to write what the test actually means on the sheet that comes back with it, even if the doctors don’t have time to remember it themselves? All these advice givers base their own advice on *some* information – at the very least why not just admit what that is?

  3. If the test-processing folks gave you medical advice on the test info form they sent back to you, that would violate laws saying only docs can give med advice.

  4. Wow. If giving you info about your test results is illicit med advice, how are they allowed to process tests at all? Especially reporting the results in English seems dangerous – you might easily interpret that as evidence in your med decisions.

    The test goes to the doc anyway, so they could include a note suggesting to the doc what she say to you.

  5. And if the public learned that docs were just directly quoting the advice test companies suggested to them?

  6. What if the public learned they weren’t making up the test results themselves? Surely they can’t do worse by getting information from elsewhere than they can by just not giving any. In either case they can avoid humiliation by adding their own recommendations.

  7. We just had the opposite experience, where 4 or 5 doctors in three states told my spouse that the lump on his foot was almost certainly a cyst or at most a benign giant cell tumour and that he didn’t need to do anything about it. He didn’t do anything about it, until it kept growing, so he got some tests done, and the doctors still told him, after looking at the MRI, that it was very unlikely to be anything serious and that he didn’t need to do anything about it. We decided to have it removed anyway. Only when he had it removed did he (and they) learn that it was a sarcoma. The last 6 months we have been in and out of the hospital 5 or 6 times for a total of 3 surgeries and about a month of in-patient time. I agree that being told to go to the hospital within 4 hours for a hurting butt is crazy cautious but it beats being told everything is fine and finding out later that it’s not.

  8. Successful cartels restrict professional secrets.

  9. Like many others, I have a story of going to a doctor and getting bad advice. I was having chest pains and the doctor thought I probably had an ulcer and told me I should come back in ten days for a breath test to make sure.

    I ended up with bypass surgery two months later. I was having a cardiac event in front of him and he sent me off to quietly have a heart attack alone in my office.

    So, the advice to see a doctor is generally good. However, the qualifier missing from that piece of advice from the nurse is to see a good doctor. And the no one is allowed to tell you which doctors are good and which doctors are bad. This is the real issue.

  10. I think you’re reading to much into the advice your getting. It has nothing to do with ability or lack of it; it is all about liability. Since the nurse and medical sites aren’t licensed practitioners of medicine they cannot offer any truly helpful advice other than to seek the advice of a licensed practitioner. Anything less than this could result in a lawsuit.

  11. Have you tried actually asking someone in the medical profession?

    Of course the answer is liability. This is not even a close call.

    If, based on someone’s advice, you failed to seek medical attention, and then it turned out your problem was serious, you (or your next of kin) could easily sue and win, depending largely on the skill of the attorneys and the ignorance of the jury. The average moron is not going to understand that your symptoms only had a 10% or 1% or 0.1% chance of being serious; they are just going to see the grieving widower / father / brother and the person whose advice convinced you not to seek help.

    Even licensed medical professionals get into this kind of trouble, which is why they almost always order too many tests and prescribe too many drugs. (And ask any OB/GYN how much they pay for malpractice insurance…)

    Just for kicks, here is one example:

    “In 1984 Edwards was assigned to a medical malpractice lawsuit that had been perceived to be unwinnable; the firm had only accepted it as a favor to an attorney and state senator who did not want to keep it. Nevertheless, Edwards won a $3.7 million verdict on behalf of his client…”

    Just how little merit does a malpractice case need to have, I wonder, for a malpractice law firm to consider it “unwinnable”?

  12. Another aspect of the issue is how people like engineers, doctors and mechanics tend to treat dealings with other folks. Most tend to give people enough information not to damage themselves (first, cause no harm), this cautionary principle becomes even more pronounced if the person isn’t the expert, or the one who is supposed to make the final call.

    Another line of reasoning is that the one doctor was of a more intuitive school, and less concerned with full fledged statistical probabilities then with qualitative measures (which would be a reason to try a different doctor, as your preference is a “more information” approach, as opposed to a “just the basics” thing).

    Finally, there is Murphy’s Law (the original formulation): If something can be done in more than one way, and one of those ways will result in something catastrophic, someone will perform the catastrophic one. In this case, ignoring the data as unlikely to come about.

  13. It is all about the non specificity of early manifestations.
    As some of the above people mentioned, like the guy with symptoms of indigestion which later was found to be a manifestation of heart disease and the mass that turned out to be a sarcoma. Symptoms that most people have do not mean serious illness ,because most people don’t have a serious illness until one day when they do.

    Tests doctors do usually show non-specific results. There are all sorts of “tricks of the trade” that doctors use to make probabilistic guesses,such as age, course of the disease,etc. For example the foot mass. A mass in the soft tissue is almost always benign, (with some exceptions such as breast or lymph node) if less than 2 cm.in diameter. But a horrible sarcoma starts out at less than two cm. The patient doesn’t really care about probabilities . The problem of uncertainty in medicine is intractable. The public mostly hears about the outliers. The demand for more and more diagnostic tests is unstoppable ,especially since most of them are paid for by third parties. Litigation is also a factor.

  14. Why would there be a legal responsibility for others to insist you go to a doctor in situations that a doctor has no legal responsibility to treat you in?

    It’s not that they have a specific legal obligation to urge you to see a doctor.

    It’s that they don’t want to be sued by someone who followed advice that didn’t work out well. In the event of a lawsuit, they want to be able to say that their website (or hotline or whatever) was very clear that it wasn’t giving medical advice and that you had to see a doctor for that.

  15. I’m glad you’re okay. Interestingly I feel the same way except about legal advice (you think once you’re *paying* somebody for it, they should be willing to be nailed down, even if with clearly state contingencies. Amazingly, usually not!) With all respect to Prof. Hanson, I think the best explanations for this problem in medicine don’t have to do with signaling.

    1) Doctors aren’t great communicators. Explaining this in the most charitable sense, docs sometimes don’t realize that patients don’t have the medical experience to assign their own weightings to open-ended medical statements .

    2) Liability issues. How that differs in Oz vs US I don’t know, but that would be a way to test this part of the explanation.

    3) False positives are always better than false negatives. Although you’re temporarily more nervous than you have to be, it’s better to tell a healthy patient they might be sick than a sick patient they might be okay.

  16. Pingback: Don’t warn nonspecifically! | Meteuphoric

  17. Pingback: Overcoming Bias : Which biases matter most? Let’s prioritise the worst!

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