Panglossian Medical Fallacies

From Dr. Benjamin Mazer’s “Medicine’s dangerous optimism – Lessons from Dr. Pangloss,” published in The Journal of the Royal Society of Medicine.

Consider the story of Dr. Pangloss, the fictional “professor of metaphysico-theologico-cosmolo-nigology” in Voltaire’s satirical eighteenth-century novel Candide. Dr. Pangloss is remembered for declaring that we live in the “best of all possible worlds.” Pangloss could find logical explanations for the pain and turmoil he saw around him. No one suffered without a good reason. In the face of healthcare’s overwhelming complexity, doctors can also inadvertently resort to assuming our current situation is the best we can hope for.

I am defining Panglossian optimism as the unproven assumption that an observed outcome is the necessary outcome.

That’s the delightful set-up. He discusses four such fallacies:

  1. Favorable outcomes are attributable to medical care, unfavorable outcomes to a lack of it
  2. Arduous training and examination are what produce good doctors
  3. Physician outcomes predict patient outcomes
  4. A sufficiently popular intervention cannot be tested

I particularly love #2. It is, in part, the fallacy of hazing as a constructive and formative practice.

If evaluating applicants is currently too challenging without a Step 1 score, then a Step 1 score must be necessary to evaluate applicants. This is not a sound assumption. A tool that does not select for the qualities we desire inserts bias and noise into the process, making it less efficient.

We also encounter faulty Panglossian reasoning in debates over whether residency duty hours should be restricted for patient and trainee wellbeing. Many experienced physicians imagine their skills molded in the cauldron of inhumane work hours. It is true that they worked inhumane hours, and that many possess excellent skills. The Panglossian assumption is that the latter derives from the former.

For those dejected by the state of high-stakes exams, the arduousness of the journey to attendinghood, or the feebleness of so much of our tautological medical science, his conclusion:

We rationalize the irrational in times of perceived helplessness. By creating an environment more hospitable to questioning and change, we may be less drawn to false comforts.

So, when you are done, or, when you have a position of authority: be part of the solution.

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