First law of motion , or principle of inertia :
Every body persists in its state of being at rest or of moving uniformly straight forward ,
except insofar as it is compelled to change its state by force impressed.
Sir Isaac Newton, Mathematical Principles
of Natural Philosophy (1687)
Insanity : doing the same thing over and over again and expecting different results .
Einstein \
Nonadherence by Patients It might seem that nonadherenc e by patients to a medical or behavioral regime prescribed to them by their doctors can only be characterized as irrational. They want to get better; they know what to do to get better; and yet they don ’ t do it . In some cases, this characterization seems correct. Patients may fail to take their medication because it reminds them of their mortality, just as people sometimes put off writing a will until it’s too late because they don’t want to entertain the thought of their death. Anyone can forget to take their medication, but sometimes the forgetfulness is motivated . They may fail to do their midday injection because they would feel ashamed to do so in front of their peers .
People who are told by their doctor to cut down their wine consumption to two glasses a day, may start using larger glasses;
Like the Nawab's laddu story
the initial enthusiasm to fight an illness typically wanes with time. As these energetic but short-lived emotions wane, so does treatment adherence . In this case, the irrationality consists in the failure to understand that the emotion is unlikely to last – the “hot-to-cold empathy gap”
but are there any more realistic technologies of self-control available? One possibility would be an automated phone-call, “It is time to take your daily medication”. If the doctor has ordained regular physical exercise, the patient can motivate himself by going to a fitness center where he pays a large down payment that is reimbursed in part after each visit.
patients sometimes do not want to exercise their autonomy, preferring to leave the decisions in the hand of the doctor. In a variation on a phrase by T. S. Eliot, one might say that humankind cannot bear very much freedom. Some people, though, are obsessed with their freedom and Foreword xi autonomy of choice, and hate doing what they are told to do.
Let me mention some sources of rational non- compliance . First, there may be rational distrust of the doctor – either of the doctor’s competence or of his honesty . In the case of psychiatric treatment, for instance, the low degree of intersubjective agreement among doctors that belong to different schools of thought would seem to justify skepticism and sometimes nonadherence. Prescription of medication for attention deficit disorder may be an example. In the case of surgeons, their notorious eagerness to operate, sometimes motivated by a financial interest, can justify resistance to their advice. Four years ago, a doctor told me that I needed to have knee surgery immediately, since there was no cartilage left, only “bone on bone”. I discarded the advice, and instead lost weight, resumed biking, and am doing just fine. In such cases, one might want to seek a second opinion – but not tell the second doctor what the first doctor concluded!
The mirror image of rational distrust is that of irrational trust . When deciding whether to follow the doctor’s advice, patients may attach unwarranted importance to his or her bedside manners. Psychologists have labeled this phenomenon the halo effect , and found it in a number of situations. “If we think a baseball pitcher is handsome and athletic, for example, we are likely to rate him better at throwing the ball, too” ( Kahneman 2011, p. 199). Patients, in other words, should learn to distrust their trust , just as doctors should learn to distrust their beliefs in their own competence and be willing to admit ignorance (see below). Second, there may be excusable ignorance on the patient’s part. As Dr. Reach mentions, if the doctor fails to educate the patient, he or she may pay excessive attention to the list of scary secondary effects – most of them very rare – that are usually listed on the instruction sheet that comes with the medication. In a very different set of cases, the patient may be exposed to a biased sample. People on dialysis sometimes refuse an offer to get a transplantation because the only transplantees they meet at the dialysis center are those whose grafts failed to take.
Among the sources of irrational or unjustified nonadherence, Dr. Reach singles out, once again, myopia as a main culprit. In a phrase, myopia causes inertia , that is, under-treatment or non-treatment. Before I proceed, I want to mention the possibility of overtreatment , not, as in the case of my knee-surgery, because of the pecuniary interest of the doctor, but because of an engrained medical “tendency toward action rather than inaction ”. Such an error is more likely to happen with a doctor who is overconfident, whose ego is inflated, but it can also occur when a physician is desperate and gives in to the urge to ‘ do something ’. The error, not infrequently, is sparked by pressure from a patient, and it takes considerable effort for a doctor to resist. ‘Don’t just do something, stand there’, Dr. Linda Lewis, one of my mentors once said when I was unsure of a diagnosis”. (Groopman 2007, p. 169; emphasis added). Even when the recommended procedure is to “wait and see”, the doctor’s inaction - aversion might get the better of him.
rationality and morality do not coincide, any more than do rationality and wisdom.
Almost without exception, a simple mechanical formula based on a few variables will outperform the diagnoses and prognoses of experts, including doctors
Groping after straws, terminal cancer patients often ignore the evidence-based advice of the oncologist and turn instead to a quack. By contrast, we would expect doctors to be calm, detached, and rational in their role as mediators between the medical authorities and the patients, disregarding recommendations when and only when they have adequate reasons for doing so. Unlike the patient, they have nothing at stake. As Dr. Reach shows, however, this idyllicizing picture is inaccurate. The amour-propre of doctors is at stake, and so is their professional reputation. Also, like the rest of us, doctors are subject to the horror vacui : “Many of this world’s abuses are engendered – or to put it more rashly, all of this world’s abuses are engendered – by our being schooled to be afraid to admit our ignorance and because we are required to accept anything which we cannot refute”
from Gérard Reach Clinical Inertia
Every body persists in its state of being at rest or of moving uniformly straight forward ,
except insofar as it is compelled to change its state by force impressed.
Sir Isaac Newton, Mathematical Principles
of Natural Philosophy (1687)
Insanity : doing the same thing over and over again and expecting different results .
Einstein \
Nonadherence by Patients It might seem that nonadherenc e by patients to a medical or behavioral regime prescribed to them by their doctors can only be characterized as irrational. They want to get better; they know what to do to get better; and yet they don ’ t do it . In some cases, this characterization seems correct. Patients may fail to take their medication because it reminds them of their mortality, just as people sometimes put off writing a will until it’s too late because they don’t want to entertain the thought of their death. Anyone can forget to take their medication, but sometimes the forgetfulness is motivated . They may fail to do their midday injection because they would feel ashamed to do so in front of their peers .
People who are told by their doctor to cut down their wine consumption to two glasses a day, may start using larger glasses;
Like the Nawab's laddu story
the initial enthusiasm to fight an illness typically wanes with time. As these energetic but short-lived emotions wane, so does treatment adherence . In this case, the irrationality consists in the failure to understand that the emotion is unlikely to last – the “hot-to-cold empathy gap”
but are there any more realistic technologies of self-control available? One possibility would be an automated phone-call, “It is time to take your daily medication”. If the doctor has ordained regular physical exercise, the patient can motivate himself by going to a fitness center where he pays a large down payment that is reimbursed in part after each visit.
patients sometimes do not want to exercise their autonomy, preferring to leave the decisions in the hand of the doctor. In a variation on a phrase by T. S. Eliot, one might say that humankind cannot bear very much freedom. Some people, though, are obsessed with their freedom and Foreword xi autonomy of choice, and hate doing what they are told to do.
Let me mention some sources of rational non- compliance . First, there may be rational distrust of the doctor – either of the doctor’s competence or of his honesty . In the case of psychiatric treatment, for instance, the low degree of intersubjective agreement among doctors that belong to different schools of thought would seem to justify skepticism and sometimes nonadherence. Prescription of medication for attention deficit disorder may be an example. In the case of surgeons, their notorious eagerness to operate, sometimes motivated by a financial interest, can justify resistance to their advice. Four years ago, a doctor told me that I needed to have knee surgery immediately, since there was no cartilage left, only “bone on bone”. I discarded the advice, and instead lost weight, resumed biking, and am doing just fine. In such cases, one might want to seek a second opinion – but not tell the second doctor what the first doctor concluded!
The mirror image of rational distrust is that of irrational trust . When deciding whether to follow the doctor’s advice, patients may attach unwarranted importance to his or her bedside manners. Psychologists have labeled this phenomenon the halo effect , and found it in a number of situations. “If we think a baseball pitcher is handsome and athletic, for example, we are likely to rate him better at throwing the ball, too” ( Kahneman 2011, p. 199). Patients, in other words, should learn to distrust their trust , just as doctors should learn to distrust their beliefs in their own competence and be willing to admit ignorance (see below). Second, there may be excusable ignorance on the patient’s part. As Dr. Reach mentions, if the doctor fails to educate the patient, he or she may pay excessive attention to the list of scary secondary effects – most of them very rare – that are usually listed on the instruction sheet that comes with the medication. In a very different set of cases, the patient may be exposed to a biased sample. People on dialysis sometimes refuse an offer to get a transplantation because the only transplantees they meet at the dialysis center are those whose grafts failed to take.
Among the sources of irrational or unjustified nonadherence, Dr. Reach singles out, once again, myopia as a main culprit. In a phrase, myopia causes inertia , that is, under-treatment or non-treatment. Before I proceed, I want to mention the possibility of overtreatment , not, as in the case of my knee-surgery, because of the pecuniary interest of the doctor, but because of an engrained medical “tendency toward action rather than inaction ”. Such an error is more likely to happen with a doctor who is overconfident, whose ego is inflated, but it can also occur when a physician is desperate and gives in to the urge to ‘ do something ’. The error, not infrequently, is sparked by pressure from a patient, and it takes considerable effort for a doctor to resist. ‘Don’t just do something, stand there’, Dr. Linda Lewis, one of my mentors once said when I was unsure of a diagnosis”. (Groopman 2007, p. 169; emphasis added). Even when the recommended procedure is to “wait and see”, the doctor’s inaction - aversion might get the better of him.
rationality and morality do not coincide, any more than do rationality and wisdom.
Almost without exception, a simple mechanical formula based on a few variables will outperform the diagnoses and prognoses of experts, including doctors
Groping after straws, terminal cancer patients often ignore the evidence-based advice of the oncologist and turn instead to a quack. By contrast, we would expect doctors to be calm, detached, and rational in their role as mediators between the medical authorities and the patients, disregarding recommendations when and only when they have adequate reasons for doing so. Unlike the patient, they have nothing at stake. As Dr. Reach shows, however, this idyllicizing picture is inaccurate. The amour-propre of doctors is at stake, and so is their professional reputation. Also, like the rest of us, doctors are subject to the horror vacui : “Many of this world’s abuses are engendered – or to put it more rashly, all of this world’s abuses are engendered – by our being schooled to be afraid to admit our ignorance and because we are required to accept anything which we cannot refute”
from Gérard Reach Clinical Inertia
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