Islon Woolf MD
Concierge Medicine and review of specialists
Updated: Jun 14, 2020
In science, peer review is the process of subjecting a scientist's ideas to the scrutiny of unbiased experts in the same field. Peer review is necessary because it's easy for scientists to fall in love with their own ideas, and become biased. As physicist and Nobel laureate Richard Feynman famously said,
“The first principle [of science] is that you must not fool yourself, and you are the easiest person to fool.”
In much the same way, specialists in medicine fall in love with their specialty. They tend to have a specialty bias.
What is specialty bias?
Specialists are financially, philosophically, and personally bound to their specialty. There is no turning back. They naturally view their specialty positively. They tend to see all disease from the perspective of their specialty, and then, treat all disease with the tools of their specialty. As psychiatrist Abraham Maslow famously said in the 1940's,
"I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail".
This was in response to the overuse of the newly discovered antipsychotic drug, Clozapine. Psychiatrists were using it indiscriminately for almost every psychiatric condition.
Specialty bias and back pain
Specialty bias is evident when observing the many approaches to back pain. There are many types of specialties that deal with back pain: Surgeons, Chiropractors, Acupuncturists, Physical therapists, etc. However, each specialty diagnoses and treats back pain completely different: the Spine Surgeon will see mechanical defects on MRI and fix it with surgery, the Chiropractor will find vertebral subluxations on exam and fix it with spinal adjustment, the Acupuncturist will detect blocked Chi and fix it by inserting needles into the appropriate meridians, and the Physical Therapist will observe muscle imbalances and fix it by strengthening weak muscles and stretching over-activated muscle. Which one of the above treatments actually works for back pain?
Specialists defend their specialty with echo-chambers and confirmation bias
Ironically, the worst person to ask if one of the treatments works, is one of the four specialists. Imagine, if you will, that new strong evidence emerged disproving the Chiropractic theory of vertebral subluxation - spinal adjustments do not help back pain. The last person to agree with this new evidence would be the Chiropractor. After all, the Chiropractors livelihood depends on spinal adjustments working. As American author Upton Sinclair once said,
"It is difficult to get a man to understand something when his salary depends upon his not understanding it."
Like all specialists, the Chiropractor is driven to defend his profession. First, he must try to avoid receiving disconfirming evidence about his specialty. This is easily accomplished by creating an echo chamber - surrounding himself with other like-minded individuals - such as: other Chiropractors, Chiropractic specialty journals, and patients that love Chiropractors. Second, he must alter the way he weighs the evidence that comes through. Evidence that confirms his specialty is given more weight, and is seen as more credible, than evidence that disconfirms his specialty. This is known as confirmation bias.
The necessity of reviewing specialists
Because specialists in medicine are prone to bias, their recommendations need to be reviewed. The importance of this cannot be overstated. Specialists are entrusted to make the most critical medical decisions. Such as, whether you should spend hundreds of thousands of dollars on stem cell infusions - and, life and death decisions - such as, whether you should get chemotherapy or not. Specialist review is your best defense against the conflicting interests of others. It is key to empowering you as a patient.
Who should review specialists?
It is essential that reviewers have expertise - a comprehensive training in medicine. Unfortunately, many patients take on the role of reviewer themselves. Either because they are empowered by the information age, or because they are abandoned by their overworked primary care doctors. Nonetheless, without adequate training, the novice is vulnerable to the specialist. Specialists can easily win over the novice with confidence, technobabble, testimonials, and authority status.
Primary care doctor are ideal to review specialists. They have a broad and comprehensive understanding of medicine, they see you as a whole person, and they understand your values and preferences. Unfortunately, there are several obstacles preventing primary care doctors from providing this service: lack of time, lack of incentive, bias, and lack of critical thinking skills:
Lack of time
Review of specialists takes time. It is very labor intensive. This is, by far, the rate limiting step for primary care doctors. They are overwhelmed as it is with patients and paperwork. Physician burnout rates over 50% in primary care. There is simply no time in the day to provide this crucial service.
Lack of incentive
Review of specialists is not a billable item. The current fee-for-service model does not reimburse for solving problems. It only reimburses for office visits, and procedures. In fact, it incentivizes the primary care doctor to punt your problems off to the specialist.
Reviewers of specialists must be objective and willing to change their beliefs based on evidence. Primary care doctors are mostly unbiased. For example, when evaluating treatments of back pain, my livelihood does not depend on Surgery, Spinal Adjustment, Acupuncture, or Physical Therapy. As a result, I have no issue dropping or accepting any or all of the four treatments. I have no skin in the game. My only concern is to get you better. However, some primary care doctors are biased, and some are actually specialists in disguise; such as, doctors that sell supplements, doctors that offer Acupuncture, or doctors that practice Homeopathy, Functional Medicine, or Anti-Aging Medicine. They are promoting a pet idea or treatment, which makes them specialists. They have skin in the game, and it is difficult for them to remain unbiased.
Beware of primary care doctors with bias, or primary care doctors that are specialists in disguise.
Lack of critical thinking skills
The reviewer must have critical thinking skills. Critical thinking acknowledges that our brains, and the ideas generated by our brains, are prone to error - logical fallacies and biases. Critical thinking tries to correct these errors by providing an objective framework to evaluate ideas. These skills are difficult to learn and require decades of experience. Not all primary care doctors have them. Click here to read more about critical thinking and medicine.
Concierge Medicine and review of specialists
The Concierge Medicine model effortlessly solves the problem of the time required to review specialists. With a low patient load, and two for four cases per day, time is not an issue. However, not all Concierge Medicine practices emphasize review of specialists.
I believe the review of specialists is one of the most important roles of the primary care doctor. My practice is designed specifically to optimize the review of specialists. It has taken me over twenty-five years to build the necessary resources. They include:
Unbiased practice - I removed all sources of bias from my practice to remain objective.
Unbiased specialists - Referring patients to specialists without bias avoids the need to review specialists. Over the decades I have cultivated a group of exceptional specialists selected for their lack of bias, critical thinking skills, and integrity.
Critical thinking - I apply critical thinking skills to help evaluate complex medical topics.
Comprehensive knowledge base - I practice lifelong learning to maintain a comprehensive knowledge base. This is essential to be able to understand, and challenge, the recommendations of specialists.
Ultimately, the review of your specialist's recommendations aims to empowers you as a patient. It tries to provide you with the best information possible - information free from bias. Only with the best information can you make the best decisions for your health.