A primary care physician’s job is to exercise judgment about what should be referred to a specialist. Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, recently wrote about his primary care doc “protecting” him from specialists. Mr. Levy was preparing for a kayaking trip and needed a physical exam to ensure he was medically fit for the endeavor.
He asked for a stress test and his primary care doc refused to approve it. Her reasoning: the attending cardiologist, knowing Paul was the CEO of the hospital, would probably be unnecessarily thorough. “[The] cardiologist will note some odd peculiarity about your heartbeat. He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience.”
I’m not knocking specialty doctors - they are, of course, critical to public health. However, primary care docs provide balance and perspective to specialists who must, by virtue of their specialities, focus on a small piece of the puzzle. Charlie Munger gave a famous speech called “The Psychology of Human Misjudgment,” which, in my humble opinion, is one of the most brilliant pieces every conceived about how human biases. In the speech Munger talks about how people tend to like their own ideas, their own areas of study, and seek confirmation that their ideas are valid…while filtering out evidence that challenges their long-held beliefs. He calls it “Hammer-and-Nail Syndrome,” and smart people are not immune from it:
“Why is man-with-a-hammer syndrome always present? Well if you stop to think about it, it’s incentive-caused bias. His professional reputation is all tied up with what he knows. He likes himself and he likes his own ideas, and he’s expressed them to other people — consistency and commitment tendency. I mean you’ve got four or five of these elementary psychological tendencies combining to create this man-with-a-hammer syndrome.”
Munger presents The doctor’s dilemma: “my early experience was a doctor who sent bushel baskets full of normal gall bladders down to the pathology lab in the leading hospital in Lincoln, Nebraska. And with that quality control for which community hospitals are famous, about five years after he should’ve been removed from the staff, he was. And one of the old doctors who participated in the removal was also a family friend, and I asked him: I said, “Tell me, did he think, ‘Here’s a way for me to exercise my talents’” — this guy was very skilled technically– “‘and make a high living by doing a few maimings and murders every year, along with some frauds?’” And he said, “Hell no, Charlie. He thought that the gall bladder was the source of all medical evil, and if you really love your patients, you couldn’t get that organ out rapidly enough…he believes his own idea structures will cure cancer, and he believes that the demons that he’s the guardian against are the biggest demons and the most important ones, and in fact they may be very small demons compared to the demons that you face. So you’re getting your advice in this world from your paid advisor with this huge load of ghastly bias. And woe to you.”
Paul Levy’s primary care doctor was exercising judgment in a way only a generalist can…free from Hammer-and-Nail syndrome. There is something to be said for multiple perspectives: a 10,000 foot view and a 1 inch view. We need both if we want efficient and effective health care. Primary care physicians cannot go extinct.
Hammer and Nail syndrome… Interesting.