Several plumbers have come over to examine my situation. They listen to my story and hear my explanation, an account that to me, a nonplumber, makes perfect sense. Then they look at me like I am crazy — not a little crazy but completely nuts — and tell me to either buy a new dishwasher (tried it already: didn’t work) or else wash my dishes more thoroughly before loading the dishwasher (vide above: done, no luck). Then they tighten something or loosen something, nod sympathetically to my wife, and head for the door — fast — leaving me with flecks on the glasses and mounting disappointment. But, hey, what do they know?
During the latest round, I realized how similar these exchanges are to those I sometimes have with patients. Patient concerns obviously are of a scope and scale completely different from those of my appliances; yet the patients too have a problem, a problem that is clearly defined to them, a problem they have spent hours, days, weeks, perhaps years mulling over. They understand their situation exactly and unflinchingly. Most have tried this and that to assess its impact on their condition: they eat less or differently; they exercise more or change sports; they sleep in the other room for a week or two; they try their child’s medicine given years ago for something possibly similar. They are little Pasteurs pursuing a solution in the lab of their own body, adhering to the scientific method with admirable rigor.
And yet often I dismiss their ideas with the same careless flick of the wrist I have come to expect from the latest in my long line of plumbers and dishwasher subspecialists. Like the plumber, I’ve heard that one before, whatever the complaint; I’ve previously spent time and wasted patient hope chasing the same false lead down a dead-end path. I hope I have learned from my missteps, gained in wisdom, tempered my own eagerness to order test after test. I am the one with more experience at this, right? Isn’t that the point?
Many patients sense my reluctance to consider their theories. One recently asked me to evaluate him because of a sense of deepening fatigue without fever or weight loss; might it be an infection? I explained that I had tried many times through the years to diagnose infection in patients with his specific set of complaints but had never turned up an answer. In my judgment, the “million dollar work-up” was a waste of his time and money. After I finished, we stared at each other in awkward silence. I had broken his heart a little, and I too was demoralized. It is not enjoyable to trample hope.
It seems to me that what we have here is a basic problem with our attitude toward experts. The calculation ought to be simple: we all seek people who know more about a situation than we do exactly because they know more than we do. Of course, we always want experts. And when we find them, we ought to trust them, right? Instead, however, we dismiss them when they aren’t whistling our tune. We suddenly become more expert at the very thing we thought they were expert at. After all, patients come to see me in a major research hospital, the ultimate house of science, a temple to the rational mind built on a foundation of countless sharp-edged logical observations made by experts from Hippocrates right up to the doctors and researchers published in this week’s New England Journal of Medicine. I am the somber keeper of this great tradition, the translator of the randomized double-blinded placebo-controlled studies conducted by thousands of researchers on hundreds of thousands of patients. I have the facts.
Ah, but there’s the rub. When matters of personal health (or home appliances) are at stake, we want a lot more than expertise from our experts. The rational world suddenly loses its appeal; dull, steady scientific observation seems only dull and steady. We want some pixie dust, a little magic, an eccentric genius who can see through the usual mumbo-jumbo to the core of the problem (paging Dr. House).
But until our prince comes, we are left with the most basic, bare-bones determination: do we trust this guy or not? And this decision, rather than following along a perfectly manicured line of reasoning and evidence, relies on that least scientific of all human inclinations — the simple leap of faith.
Dr. Kent A. Sepkowitz is vice chairman of medicine at Memorial Sloan-Kettering Cancer Center.
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