“People who look through keyholes are apt to get the idea that most things are keyhole shaped.”
-Author Unknown
The cost of expertise
Abraham Maslow famously spoke of the Golden Hammer:
“I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”
What if that hammer is one’s health or medical profession and all the associated knowledge that goes along with it?
In a clever paper from a few years back, Hashem, Chi and Friedman (2003) asked this question with specialist physicians from cardiology, hematology, infectious diseases, and internal medicine general practitioners (open access at the link below)
Medical errors as a result of specialization
One important type of medical error occurs at the time of diagnosis…cases such as that of Dr. Franklin K. Yee, whose abdominal pain was diagnosed as viral gastroenteritis by a gastroenterologist, caused him to be admitted to a coronary care unit by a cardiologist, was suspected by a nephrologist to be the result of kidney stones, and eventually was found on abdominal surgery to be the result of a ruptured appendix
It may seem strange to talk about the costs of being an expert, but there is increasing experimental evidence that the benefits of expertise are not without costs…
The main point of this study was to examine whether physicians with a given specialty have a bias in diagnosing cases outside their own domain as being within that domain. The answer appears to be yes, and several pieces of evidence support this view.
It is particularly interesting to note that generalists do better than the baseline, whereas specialists tend to be biased toward their own specialty.
I only treat…
I once heard a well known therapist explain “I only treat [very specific spinal joint] problems these days”. A rather clever person on the periphery of the conversation asked “How do the patients know that they have a [very specific spinal joint] problem before they come to you?” and moved on, leaving the therapist looking a bit like they had been hit with the very Golden Hammer of their own making.
There are all kinds of biases, and by virtue of their nature, they can be hard to spot within, and even harder to remove from, oneself. Perosonal awareness is always suggested as a good place to start, but perhaps professional bodies that emphasise specialisation and titling as career advancement and professional marks of distinction also need to consider the danger of what the French call déformation professionnelle:
“Every specialist, owing to a well-known professional bias, believes that he understands the entire human being, while in reality he only grasps a tiny part of him.”
Alexis Carrell
L’Homme, cet inconnu 1935
Keyhole shaped ideas
The danger of expertise and specialisation then, is beautifully summed up in the quote above. The deforming keyholes that we look through can take on many shapes, from professional titles such as doctor, surgeon, physiotherapist, psychologist, chiropractor, to subprofessional specialties – neurology, orthopaedics, musculoskeletal, cardio-thoracic, pain (of course, we are players all, on this stage), and so on. The temptation is to suggest that we simply stop looking through the keyhole and open the door, but this is clearly no easy task.
Here, some words from the Bard seem appropriate as both warning and admonishment
“Let the doors be shut upon him, that he may play the fool no where but in’s own house.”
Hamlet (Act 3, Scene 1)
-Tim Cocks
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This could all be avoided if we could only learn to treat “beings”. Organisms that are suffering physically and emotionally. Whether a Hindu walking with a brush to avoid crushing an ant with his feet or a cardiologist avoiding to use the only hammer he has to hit, or miss the nail trying to do no harm would go a long way. If we could only set out to prove ourselves wrong rather than right we might be less keyhole minded and more panoramic……
DB London
Still at the window 🙃🙃🙃
I for one would vote to replace the (now clichéd, overused but misunderstood) phrase “Biopsychosocial” with “panoramic”! 😉
Let’s do it 👍