The Gospel of Headaches

In the beginning was Migraine. And G-d saw that it was bad. And for many centuries His people suffered and cried out for succor.

And so G-d commanded Man to maketh of the bark of the white willow tree a broth, and to seethe it for numerous hours until there be rendered a fine white powder. And thus was acetylsalicylic acid begotten, which Man named Aspirin. 

And lo! Man now found himself plagued with gastrointestinal torment and disorders of an internal hemorrhagic ilk, and in the ears was heard a strange ring. And G-d saw that Migraine still bedeviled His people. 

So G-d created Cluster headaches to distract the people from Migraine. And G-d saw that it too was bad. So He proclaimed, "Let there be Doctors!" And so it came to be that a Doctor was required to rule between Migraine and Cluster, lest a man believe he suffers from one but indeed be possessed of the other. 

And the Doctors held cleverly and talked amongst themselves, presuming to be out of earshot of G-d and His people.  And the cleverest amongst them spoke, avowing, "Who sayeth that the Divine taxonomy of headaches should number only two? Are we not Doctors, to whom G-d hath given dominion over the Contagions, and over the Ailments, and over all the Maladies and Disorders, and over the Syndromes, even to the least of the aches and itches and discomforts?" to which there was sizeable acclamation. And the clever one stayed further his discourse, proclaiming, "Let us hence go forward. Let us be indefatigable in our quest. And let us not enjoy repose—apart from the Sabbath, of course, and for the day preceding the Sabbath and, too, the day that follows the Sabbath—until we have categorized oodles of headaches, such that every Man and Woman and their progeny shall each be afflicted uniquely."

And it came to pass that the multitudes did suffer from headaches by the score, and G-d felt their pain. And He commanded, Let there be Drugs! And there were Drugs, which henceforth became known as pharmaceuticals, as it was proclaimed that among syllables five was superior to one.

And the pharmaceuticals increased in numbers exponential. And as the pharmaceuticals multiplied, so proportionately did the agony of G-d's people. And G-d saw that it really sucked. 

And G-d was angry, and He cried out in His anger, "Is there not one who can cure the afflicted without ministrations of a chemical nature?" 

But G-d's remonstration was met with quietude, for all the headaches of all G-d's people had caused them to take to their beds, and to pull their blankets up over their heads, so as to ease their photophobia, and to insert all manner of fabric into their ears, so as to allay their phonophobia. And there was no one to hear the anguished plea of the Lord on that day.

So G-d thought He must create one who suffered not from headaches. A man who was afflicted not by Migraine, nor of Cluster, nor of Cervicogenic, nor of Myofascial. One who suffered neither from the headache known as Tension-type, nor from the other kind called Tension to which the word type was not affixed, yet was otherwise indistinguishable from it. One who did not consume Drugs, and was thus spared the infirmities that cometh of the pharmaceuticals. Strong of body and pure of mind came forth this man. And he was called Palmer. And he was good.

Overconfident Doctors Make More Mistakes

A study on false-positive mammography findings, published in the Journal of the American Medical Association in 2003, noted a huge difference between US and UK radiologists. US radiologists recommended follow-up (imaging, biopsy, or clinical follow-up) twice as often as their UK colleagues. Not coincidentally, US patients had twice the rate of normal biopsies as patients in the UK. However, the actual rate at which cancer was detected was similar in the two countries. Meaning? US radiologists tend to read normal mammograms as potentially abnormal more often. This can result in unnecessary invasive diagnostic procedures (e.g., biopsy) and additional testing which contributes to increasing healthcare costs as well as anxiety and greater risk of adverse events for those misdiagnosed. Interestingly, radiologists in the US are required to read a minimum of 480 mammograms per year to maintain their certification while those in the UK must read 5000 (that’s right - a 5 followed by 3 zeroes!) to meet the standards.

I found this interesting tidbit in an article titled Overconfidence as a Cause of Diagnostic Error in Medicine, published in the American Journal of Medicine in 2008. As is true in general (and there’s research to back this up), confidence tends to be inversely proportional to knowledge. That is, the less knowledge of a particular subject one possesses, the more confident that person is likely to feel or, conversely, “He who knows best knows how little he knows” (attributed to Thomas Jefferson). According to Charles Darwin, “Ignorance more frequently begets confidence than does knowledge.” A large majority of medical mistakes, something like 80%, is due to cognitive errors, i.e., mistakes in thinking. For example, if a doctor has characterized a particular patient as a whiner, a hypochondriac, that doctor may dismiss a seemingly trivial complaint without thinking of other, more serious possibilities. Jerome Groopman, M.D., in How Doctors Think, described exactly this situation. An elderly woman presented with heartburn, and he prescribed an antacid. Had he given it more thought, and thus performed a proper physical examination, he would have discovered the aortic aneurysm that was the cause of the symptom. (I highly recommend this book; it was written for a lay audience and is available in paperback in lots of bookstores. It will help you to help your doctor think better!)

Diagnostic error occurs between 5 and 15% of the time, depending on the medical specialty. (Radiologists and pathologists have the lowest rates.) Clinical guidelines and computerized decision-support systems exist to help doctors make more accurate diagnoses and prescribe better treatments, but it seems that most physicians disdain from using these tools. A study published in 2000 showed that lipid treatment guidelines (i.e., treatment for high cholesterol and hyperlipidemia) were followed only 18% of the time, even though 95% of physicians in the study were aware of the guidelines. Decision-support tools are often disregarded, even when easily available and integrated into electronic medical record systems. Overconfidence, it appears, lies at the root of many medical mistakes. (As a chiropractor, I would not exclude members of my own profession, perhaps myself at times, from this characterization.) Patients want their health care providers to be confident of their diagnostic and treatment decisions, but the doctor who appears less certain and thus digs deeper to find the answers may be more competent. Embrace uncertainty!