Tuesday, April 12, 2005

Trouble with Diagnosis: Car Talk vs. Doctors

I was listening to Car Talk over the weekend (totally hooked on the show) and realized some familiarities between doctors making a diagnosis and Tom and Ray making a diagnosis over the phone. This comparison is likely to be nothing new, I’m sure many others have thought of it…I have as well, but for an irrelevant reason decided to post on it (basically, it’s a slow week for the intellect of the Dude, he’s just beat and is, frankly, more concerned about getting outdoors…plus, most thoughts focus on the law, not as much on bioethics.)

There is one part of the show where Tom and Ray call back listeners whom they provided advice to and ask whether the advice was right. For example, when you told us about the creaking and wheezing noises your 1984 Honda Civic (which was one of the ugliest cars Honda made...) was making every time you stopped, and we told you that it was a) a mule trapped in the undercarriage, b) likely to be the break rotor or the pads, was our advice right? and then the listener informs that c) they were right (there really was a mule in the undercarriage) or b) that no, actually it was the front shock absorbers that had been leaking shock fluid all over the driveway for the last two years and have now completely crapped out. Tom and Ray respond: So why the heck didn’t you also tell us that the front of your car bounced like a low-rider gone mad with hydraulics??!! I’d like the readers to know that this is not an actual scenario and that Tom and Ray are right most of the time.

Is this a common occurrence with patients or what? I don’t mean to reduce physicians to automobile mechanics, but the paradigm of obtaining information about symptoms and making an educated assessment of the likely causes (i.e., making a diagnosis) are very similar. The Patients/the Informant has a critical role in the dialogue that can do so much to abate or advance the alleviation of suffering. In both cases the following exist:

  • The patient or car owner provides subjective information, that is used as the primary basis for beginning the inquiry. I stress that it is used as the primary basis, as various diagnostic measures utilizing instruments are available to provide an objective measure of symptoms and underlying mechanisms. Of course, for common ailments (be they colds or infections, or squeaks and rattles) objective measures may not be used at all, may be used de minimus, or may not be used until later on.
  • Yeah, it’s true that it is not the car but the owner who is providing the info, whereas in most medical cases the patient can provide information about themselves, and yes, maybe in the future, cars will be able to provide that autoresponse, and yes, to a certain extent they do now. However, at present all that the sensors and fancy computers tell the mechanic is that there’s something relating to the brake system that is reporting error feedback in the front-left wheel. The mechanic then has to put together feedback info from the owner (e.g., rattling when braking under pressure) to narrow the scope of the inquiry into something relating to the Antilock Braking System –the mechanic, not the software/hardware of the automobile per se, did the narrowin’ of the scope. So in this regard, the analogy from car and owner reporting of symptoms to patient is still accurate. Not to mention cases in which the patient may be incapacitated in some dimension of cognitive/physical capacity and has to have a care-giver provide that info to the doctor…

All this, of course, is the typical black box phenomenon. The cause must be assessed from external or somewhat external symptoms. So in listening to the show and having been a patient during the course of my life and knowing others who have, I can say that the docs have been right most of the time, as have x and y. I do, however, wonder how right both parties have been, and just how right do they need to be? That is, if the ailment (mechanical or biological, or both if there is a varmint chewing up your fuse lines) disappears and the patient lives or the machine works well again, at times it’s not necessarily due to the assumed cause. It’s a complexity issue, as well as a causal or correlative one…but that’s just the amateur philosopher of science in me. Of course, some pragmatist patients and doctors/mechanics may not care either, and then again, those with an academic curiosity would.

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