Does personality drive specialty choice in medicine?

One doctor has a dominant personality, is process-driven, brusque with patients and likes to watch rugby when not working. The other is more kindly and empathetic, and takes a real interest in patients’ lives. Can you guess which is the surgeon and which is the GP?

Such doctor stereotypes pervade not just medicine but the general culture itself. Surgeons are bullish and poor communicators; paediatricians are maternal and all smiles; GPs are people persons; pathologists have a morbid fascination with death; radiologists hide out in a dark room. Of course they’re exaggerations – but is it true that certain personalities are associated with certain specialties? Unsurprisingly, there has been some research done on this.

Two Scandinavian studies published this year look at personality traits and speciality choice. One from Sweden involved 400 doctors training for medical specialties, who were assessed for extraversion, agreeableness, conscientiousness, neuroticism and openness to experience.

Doctors training in surgery and general practice did indeed play to type, with lower scores for agreeableness in the former compared with the latter. On the other hand, psychiatrists and hospital service physicians scored lower for conscientiousness compared with surgeons. The study authors speculate that this may be because surgery is dominated by task-based procedural work and organisational skills that require conscientiousness. Psychiatrists, on the other hand, scored highest for openness to experience, which is perhaps linked to intellectual curiosity.

A Finnish study of almost 3000 physicians had some similar findings using the same assessment test of five personality traits. It, too, found that psychiatrists had a greater openness to experience than other specialists, and it also found openness to experience correlated more with working in private practice. Again, agreeableness levels were higher for general practitioners, while surgeons were more conscientious, although they were also more neurotic. Higher levels of extraversion were found in paediatricians and were also associated with a change of specialty.

The authors of both these studies suggest that personality assessment could play a role in medical career counselling and might enhance the person-job fit among doctors.

Another study, this one from the UK, looked at three pathological personality traits – narcissism, Machiavellianism and psychopathy – in 248 healthcare professionals and compared them with a control group of 159 members of the general public. Thankfully for the medical profession, doctors scored lower for these personality traits compared with the controls. But among doctors, surgeons came off the worst, with higher levels of narcissism and primary psychopathy. And in surgery, vascular surgeons were the most narcissistic. The least narcissistic doctors, on the other hand, were geriatricians, cardiologists, GPs and and paediatricians. They were also the ones least likely to show signs of psychopathy – unlike neurologists and vascular surgeons, who were the most likely.

The authors suggest high levels of narcissism in surgery might actually be a good thing, particularly in vascular surgery, where a strong sense of self-assurance and confidence in one’s abilities might be needed to deal with catastrophic emergencies, such as a ruptured abdominal aneurysm.

And finally a couple of studies suggest that doctors in general have a personality profile that doesn’t match that of the general population. A UK study submitted 464 doctors to the Myers-Briggs personality assessment, finding that they differed from the UK adult population on a number of norms. They were more likely to score as introverted rather than extroverted, were more likely to be judgemental in their approach to life management, and in decision-making were more likely to favour objective evidence over personal values.

And a French study of over 1500 GPs found doctors had very different attitudes to health compared with that of their patients. Doctors were more willing to take risks with their health than their patients were. But they were also more cautious with their patients’ health than they were of their own.

You can access the full studies referenced in this article here, here, here, here and here

Impostor syndrome: the doctors who feel like frauds

Have you ever had the sensation in your professional life that you don’t know what you’re doing, that you’re a fraud, and that one day someone is going to catch you out? If so, you’re far from alone: what’s known as ‘impostor syndrome’ seems to be surprisingly common in medicine.

A recent study of nearly 150 American medical students found that around half the women and just under a quarter of the men suffered from impostor syndrome, which is characterised by chronic feelings of self-doubt and fear of being discovered as an intellectual fraud. And that far from improving as the students progressed from year to year, their symptoms actually got worse. What’s more, the study found a strong correlation between impostor syndrome and some of the components of burnout, such as emotional and physical exhaustion, cynicism and depersonalisation – a disturbing association that the study authors say “cannot be ignored”.

But it’s not just med students who are affected by impostor syndrome. And among doctors, it’s not just the younger, less experienced ones, either: impostor syndrome cuts across all ages and career levels, another recent study has found. Based on interviews with 28 specialists, the Canadian study found that even doctors at advanced stages of their careers often questioned their abilities and the validity of their achievements. One of the interviewees reported that after many years of practising, “I still think someone is going to send me a letter saying ‘actually it was all a mistake. You weren’t supposed to get into medical school, therefore we’re taking it all away.’”

The authors from the University of Ottawa note that the medical profession “neither sufficiently prepares physicians to grapple with mistakes nor adequately supports them to share their insecurities”.

Once they enter clinical and academic medicine, doctors can get shaken by a seemingly endless series of setbacks such as bad clinical outcomes, patient complaints, poor evaluations and rejected grants or manuscripts, all of which can be fodder for insecurity.

With limited support, the authors say, doctors wrestling with errors and self-doubt can become immobilised by fear. This can come at a considerable cost not only to their mental health and well-being, but also to their career.

Female doctors seem to be at particular risk of impostor syndrome, which may be to do with a traditional lack of female role models in the higher echelons of medicine, despite the rising numbers of women graduating from medical school. A position paper published this month on achieving gender equality in medicine singles out impostor syndrome among women as one of the barriers. Impostor syndrome “may bar women’s success if it causes them to pass up career development opportunities”, the paper says.

In a culture where revealing self-doubt is seen as a weakness, doctors suffering from impostor syndrome may be difficult to identify and help. The challenge, the authors of the Canadian study say, is to develop an awareness and understanding that feelings of insecurity in medicine are both common and recurrent, and that features of the medical culture may actually foster those feelings of self-doubt.

“It is critical to develop opportunities for practitioners to safely acknowledge and share their feelings. Rather than ignoring or ‘punishing’ mistakes, medicine needs to cultivate safe spaces to share struggle, and to develop opportunities that transform failure into a teaching tool,” the authors conclude.

Access the full papers referred to in this article here, here and here.

Why male and female doctors burn out differently

Female doctors show more empathy than male doctors. They ask their patients more questions, including questions about emotions and feelings, and they spend more time talking to patients than their male colleagues do. Some have suggested that this might make women better doctors. It may also take a terrible toll on their mental health.

Studies indicate that female doctors are at greater risk of burnout than male doctors, and that this might be linked to differences to do with empathy. Burnout is bad for doctors and their patients. People with burnout feel exhausted, emotionally depleted, cynical and detached. They are also less satisfied with their work.

Doctors who develop burnout make more errors, are less likely to answer patients’ questions or fully discuss their treatment options. Interestingly, as people develop burnout, they show reduced empathy for others (so-called compassion fatigue). Compassion fatigue has been called the cost of caring because it is more commonly seen in health professionals such as nurses, psychotherapists and doctors.

One theory about why compassion fatigue sets in is that high empathy causes greater levels of emotional arousal and distress, so the reduction of empathy is simply a survival mechanism to cope with experiencing long periods or extreme emotional stress. This theory has been used to explain why medical students and doctors report lower levels of empathy as they progress through medical school and their post-graduate medical training. It might also explain why doctors’ brains show a reduced response to witnessing people experience pain, compared with people who aren’t doctors.

Men and women burn out differently

As well as the differences in risk of burnout, the way female doctors burn out appears to be different to the ways male doctors burn out. Identifying and understanding these differences might be important for recognising when doctors are developing burnout and getting help and support for them in time.

A four-year study of Dutch GPs found that, for female doctors, burnout begins with emotional exhaustion (feeling emotionally depleted), and then progresses to feeling increased depersonalisation (feeling detached or cynical about people and work). Finally, they tend to feel less work-related personal accomplishment and have reduced self-belief in their competence at work. This last component of burnout, reduced personal accomplishment, involves evaluating one’s work negatively and is likely to compound the problem as it increases stress and emotional exhaustion.

Conversely, male GPs report depersonalisation first rather than emotional exhaustion. Also, males did not report a reduced sense of personal accomplishment at work, even though this is one of the three traditional components of burnout. This means that, as they burn out, male doctors feel growing depersonalisation and emotional exhaustion but they often still feel effective, capable and competent at work – which is typically not the case for female doctors.

High suicide rates

In 2005, Eva Schernhammer of Harvard Medical School argued that there are stark differences in the psychological demands on female doctors, compared with males. Her review of 25 studies found that the female doctor suicide rate was about 130% higher than women in the general population.

In contrast, the suicide rate among male doctors is 40% higher than the suicide rate of males in the general population. Schernhammer concluded that the stress and burnout experienced by female doctors combines with other risk factors to contribute to high rates of psychiatric illness and suicide, compared with male doctors.

The additional risks include greater demands and expectations related to their family life, trying to succeed in a historically male-dominated profession, and experiencing sexual harassment at work. The influence of gender expectations on women’s suicide has a long history of being overlooked or ignored.

Gender expectations

When female doctors deliver more empathetic care, it may reflect our social expectations of gender roles rather than something innate. These include the idea that women are better at empathising than men, and that women are nurturing or caring. Studies also show that patients have different expectations of female doctors than they do of male doctors. For example, patients assume female doctors are more compassionate.

The idea that men are less likely to be caring and empathetic has possible benefits for male doctors. When male doctors show empathy, it can be an unexpected bonus for the patient, and so the doctor might seem better than anticipated. For example, male medical students with a good bedside manner are rated as more competent than female medical students who have a similarly good bedside manner. It seems that the females are simply expected to be more patient-centered and empathetic.

The disadvantages of these expectations for female doctors is that they are expected to do more “emotion work” than males. A study of more than 7,000 doctors found that female doctors were more likely to feel emotionally exhausted by work. They also felt that their work negatively affected their personal life, and they felt less valued by patients, colleagues and superiors, compared with male doctors.

Different expectations of doctors’ empathy based on their gender makes the job and workplace conditions unequal for doctors. And this appears to be a global phenomenon. Female doctors in Finland, South Africa and China all report higher levels of emotional exhaustion than male doctors. These results support the idea that female doctors’ jobs can be emotionally depleting for them and contributes to their increased risk of burnout.

We need to recognise that doctors face different expectations about empathetic care, depending on their gender. The emotional demands on female doctors puts them at increased risk of poor mental health. Regardless of gender, medical students and doctors should be provided with training that helps them navigate and sensitively address unequal experiences and expectations of delivering empathetic care.

Rajvinder Samra, Lecturer in Health, The Open University

This article was originally published on The Conversation. Read the original article.

How reliable are randomised trials?

When regulatory authorities are deciding whether to authorise the use of a drug or its reimbursement, they almost always demand evidence from at least one major randomised controlled trial (RCT). But should we rely so heavily on them to provide the rigorous evidence we need for policy and therapeutic decisions? Probably not, says a researcher from the London School of Economics, in a new paper published in the Annals of Medicine.

In his article, Dr Alexander Krauss looks at the ten most cited RCTs worldwide, covering areas such as stroke, insulin therapy, breast cancer and chemotherapy, bowel cancer, cholesterol and coronary heart disease. He identifies a range of biases across these highly-influential and often paradigm-changing RCTs.

The emphasis on RCTs, the author says, shifts the focus of medical research towards a small set of questions where RCTs may be able to provide an answer, such as whether single simple treatments with few confounders are effective at an individual level. But RCTs are poorly suited to more complex areas, such as genetics, immunology, mental states, rare diseases, one-off interventions such as health reforms, or interventions with lagged effects such as long-term diseases, he notes.

Below are some of the key biases that Dr Krauss has found even in the most influential of RCTs:

Initial sample selection bias

Most of the studies examined don’t say how the initial sample was selected before randomisation. Others merely say that “patient records” were used or that patients were “recruited from 29 centres”, without saying anything about the quality, diversity or location of these centres. The trial on cholesterol was conducted in just one district of the UK, and the one on insulin therapy was based on patients from one single ICU in Belgium. And yet all these studies assume their treatment outcomes can be scaled up to the general population

Poor distribution in the randomisation

One-off randomisation in a small sample can lead to a poor distribution of background traits. For example, in the stroke trial, those in the treatment arm were 3% more likely to have heart congestion, 8% less likely to be smokers, 14% more likely to have been on aspirin therapy, and 3% more likely to have survived a previous stroke. Factors such as these could be driving the trial’s main outcomes.

Lack of blinding bias

Some of the 10 trials did not double-blind, while others were initially double-blinded but later partly unblinded, or were only partially blinded for one arm of the trial. In some cases, this was due to poor trial design, but in other cases may be inevitable. For example, in the insulin trial, modifying insulin levels required monitoring glucose levels, which in turn required some unblinding.

Small sample bias

Trials of just a few hundred people may be too small to produce robust results. But among the top 10 trials, several had small samples, with one only having 188 participants. Small samples are more likely to have imbalances in background influencers, and their outcomes are more likely to be influenced by mere chance.

Unique time period bias

Outcomes can vary considerably depending on when exactly the investigators collect baseline and endpoint data. The data collection points can also vary considerably within trials. In half of the trials examined, the total length of follow-up varied between patients, and could be up to three times longer for some participants compared to others.

Average effects bias

Although RCTs emphasise the average effect of an intervention, this can sometimes be positive even when the majority of participants are not affected or are negatively affected, because outcomes can be driven by a minority having large effects.

Best results and funder biases

Funders and journals tend to be less interested in negligible or negative results. A funder bias towards positive results has been shown in systematic reviews, and yet seven of the top ten cited trials were funded by drug companies.

Placebo-only bias

Major trials usually randomise a therapy against placebo or conventional treatment only, and therefore do not identify whether the therapy is actually any better than other available treatments.

Dr Krauss says given these and a number of other biases he identifies, no single study should ever be used to inform policy. We need to support RCTs with other tools such as subsequent observational trials and single case studies. Dr Krauss notes that many of the advances in medicine were made without any evidence from an RCT. These include most surgical procedures, antibiotics and aspirin, smallpox immunisation, immobilising broken bones and confirmation that smoking is associated with lung cancer.

You can access the full study here.

When doctors marry doctors

Given the extreme time pressures on most people in medicine, you might think doctors might think twice about getting hitched to someone with exactly the same constraints. Not so: a research report published last month in the Annals of Internal Medicine found that around 17% of male doctors have a spouse who is also a doctor, and whopping 31% of female doctors are married to a doctor. A report published last year put the figures even higher, with around 26% of doctors married to another doctor, and 41% of female doctors with a medical spouse.

How do these inter-medical partnerships fare? Perhaps less well for the female half of the equation. A recent study in JAMA Internal Medicine flagged some striking differences in the working hours of the dual-doctor couple: before the arrival of children, the male spouse worked an average of 57 hours per week, compared with 52.4 hours for the female spouse. But after children, the number of hours women worked dropped to 41.5 hours, and this did not rise again with time. In contrast, men’s hours dropped only slightly and remained steady through the child-rearing years.

“Even within dual-physician couples, societal expectations for women to reduce hours worked to care for children still hold,” the authors note.

Female doctors married to a doctor were more likely than both male doctors and those of either gender in non-dual-doctor households to report having to arrange their work schedules to care for children. They were also less likely to report achieving career goals. And they were more likely to report limitations to their careers for family than their doctor husbands or their colleagues not married to a doctor.

On the economic front, the Annals study found that female doctors earned less than their doctor husbands and less than their colleagues who were not married to a doctor.

But it may not be so great for the men either. A 2010 study of surgeons married to doctors paints a fairly grim picture of the doctor-doctor relationship. This study of 8,000 surgeons – largely men – found that those married to a doctor were more likely to delay having children, more likely to believe child-rearing affects their career and less likely to believe they had enough time with their family, compared with colleagues who were not married to a fellow doctor.

Surgeons whose spouse was a doctor were also more likely to have depressive symptoms and more likely to have experienced career or work-home conflicts compared with surgeons who were married to non-doctors.

“Surgeons whose domestic partner is another physician appear to experience greater challenges balancing personal and professional life than surgeons whose domestic partner is a working non-physician or who stays at home,” the authors concluded.

You have been warned!

The Nazi doctors still casting a shadow over medicine

The one psychiatric diagnosis that probably everyone has heard of is the mild autism spectrum disorder known as Asperger’s syndrome. But there’s a good chance it won’t be called that for much longer. New research published this month casts its originator, Dr Hans Asperger, as a Nazi “fellow traveller” who actively cooperated with a euthanasia program.

The exhaustively researched study, published in the journal Molecular Autism, found that Asperger, a paediatrician who practised in Vienna during the Nazi period, sent children to the notorious Am Spiegelgrund clinic, where hundreds of disabled children were murdered as a part of a “race hygiene” program. The study’s author, medical researcher Herwig Czech, says that although Asperger was not himself a member of the Nazi Party, he joined several organisations affiliated with the Party which supported race hygiene policies such as forced sterilisations, and worked closely with the top figures in Vienna’s euthanasia program.

The new research has led to calls to stop using the term Asperger syndrome. Writing in the New York Times, researcher Edith Sheffer comments that “naming a disorder after someone is meant to credit and commend, and Asperger merited neither”. Stopping using the term Asperger’s would be one way “to honour the children killed in his name as well as those still labelled with it”, she writes.

But medicine remains littered with diseases named after doctors who were either Nazis or closely associated with Nazism. Take the case of Dr Hans Reiter, who while on the Western Front in 1916 reported the case of a severely ill lieutenant who had developed urethritis, arthritis and conjunctivitis. He recognised that all these symptoms were part of a single rheumatological condition which later became known as Reiter’s syndrome.

Reiter became an avowed Nazi, signing an oath of allegiance to Hitler in 1933. He was later convicted of war crimes at the Nuremburg trials for his knowledge of gruesome medical experiments at the Buchenwald concentration camp, and for personally overseeing an experiment with a typhus vaccine that killed over 250 inmates.

Nonetheless, Reiter went on to an illustrious postwar career as a professor of hygiene, and his misdeeds were only rediscovered in the late 1970s. The disease has since been renamed reactive arthritis, but a quick glance at Pubmed reveals that “Reiter’s syndrome” is still in use, as recently as in a paper published this year.

Oddly enough, Reiter’s syndrome is not the only condition named after a Nazi rheumatologist. There is also the case of Friedrich Wegener, who in 1934 performed an autopsy of a man who had died of kidney failure. He discovered a type of necrotising inflammation with granulomas, and theorised that the patient had suffered from a hitherto undescribed form of vasculitis. This became known as Wegener’s granulomatosis.

Wegener had joined the Nazi Party the year before his discovery, and he spent the war working as a pathologist three blocks away from the Lodz ghetto in Poland, whose inhabitants were almost all murdered in extermination camps. Wegener’s granulomatosis has since been renamed granulomatosis with polyangiitis, although, as with Reiter’s syndrome, the old name still lingers in the contemporary literature.

Those two rheumatological conditions are far from the only medical phenomena named after Nazi doctors. There is the “Clara cell”, a type of cell which lines airways in our respiratory system, and which is named after Dr Max Clara. An outspoken Nazi, Dr Clara discovered the cells named after him using tissues from Nazi victims.

Then there is Hallervorden–Spatz disease, a type of neurodegeneration partly named after Julius Hallervorden, who admitted after the war that his research had used brains of children killed in Nazi euthanasia programs. Or there is a type of dystrophy known as Seitelberger disease, named after a Viennese neurologist who was also a member of the SS. And there are several other neurological conditions named after doctors who obtained brains from euthanasia programs, and who in some cases were actively involved in them.

Although all of these conditions have since been renamed, new names don’t always stick. But, as one physician says in an opinion piece in the Scientific American, there is a moral duty not to allow doctors who committed terrible crimes to live on forever in the medical literature.

“Here is my humble request to doctors,” writes Dr Ilana Yurkiewicz. “Please introduce these terms without their Nazi affiliations. If a tainted term has had another one substituted, please, just use the newer term.”

Are doctors swayed by big pharma largesse?

Oncologists are much more likely to prescribe a company’s drug if that company has provided them with gifts, speaker fees, free meals, travel expenses or research money, a US study has found.

The study, published as a research letter in JAMA Internal Medicine, focused on two cancers: metastatic renal cell cancer (mRCC) and chronic myleoid leukaemia (CML), for which there are multiple drug options.

For mRCC, oncologists who had received money from a pharma company were almost twice as likely to prescribe that company’s drug, compared with doctors who had not received any money from the company. It was a similar story in CML, although the effect was not as great, with a 30% difference in prescribing rates between oncologists who did and did not receive money from the drug company in question.

The drug choices were sorafenib, sunitinib malate or pazopanib hydrochloride for mRCC, and dasatinib, imatinib mesylate or nilotinib for CML. For three of these drugs – sunitinib, nilotinib and dasatinib – prescribing rates were higher for oncologists who received payments from the respective drug companies.

Interestingly, prescribing rates for imatinib went down for physicians who received payments from the manufacturer Novartis. But that same company markets the newer drug nilotinib, and the study authors said their findings reflected the fact that Novartis was trying to get physicians to transition from imatinib, which is soon to go off patent, to nilotinib, which has many more years of patent to run.

The study involved around 3,600 oncologists with a history of prescribing for either of the two conditions.

In the US, big pharma spends around $7 billion wooing clinicians with consultancy fees, expenses and research grants. The figures are much smaller in Australia, but are still considerable. In 2016, Fairfax Media reported that big pharma had splurged around $43 million on health professionals over a period of six months.

That expenditure included a $70,000 trip to Sweden for six oncologists and a $176,000 “educational” trip to Vancouver for nine dermatologists.

Novartis flew 19 health professionals to an Amsterdam conference at its own expense, according to figures from Medicines Australia, and the company also sent five oncologists to a four-day conference in Austria, which included two weeks’ accommodation, at a cost of $32,569.

In 2015, Novartis fell foul of Medicines Australia’s Code of Conduct and was fined $90,000 over a breach of ethical guidelines. It concerned a seven-hour event for only three specialists, with no clear link to educational outcomes. Medicines Australia noted concern that the event was “a form of reward to these individuals who prescribed Novartis’s ophthalmological product”.

How safe are older doctors?

Older doctors are considerably more likely to be the subject of an AHPRA notification than their younger peers, according to new research.

The University of Melbourne study, which looked at all 12,878 notifications lodged with Australian medical regulators over a four-year period, found doctors over the age of 65 had 37% more notifications than their younger peers, aged 36 to 60.

The type of notification varied substantially between the two age groups. Health-related notifications, covering both physical illness and cognitive decline, were twice as high among older doctors. They were 40% higher for conduct-related notifications and 10% higher for performance-related notifications, compared with younger doctors.

The researchers from the Melbourne School of Population and Global Health said they had identified several “hot spots” of risk for older doctors. One of these was the prescribing, use and supply of medicines.

“Some older doctors are known to maintain registration in order to prescribe for themselves of for families and friends. Whilst this practice is in breach of ‘Good medical practice: a code of conduct for doctors in Australia’, some older doctors have been slow to adapt to evolving professional standards,” the researchers noted.

They also pointed to some older doctors’ failure to keep abreast of new drugs or changes in drug regimens, their reversion to older, more familiar patterns of practice, and their reluctance or inability to follow new protocols.

“Well documented age-related declines in cognition and physical abilities in the general population are likely to be reflected in the health practitioner community with possible implications for safe clinical decision-making,” the authors write.

“Previous research suggests that some health practitioners lack the ability or insight to self-assess competence and may not be aware of a decline in their cognitive ability or skills.”

But the authors note there are no internationally recognised thresholds of cognitive impairment at which a doctor is considered to be a risk to the public.

The study follows reforms proposed by the Medical Board of Australia late last year that would require doctors aged 70 and over to prove they are competent to continue practising. The reforms would require peer review and health checks for these doctors to be incorporated into their CPD requirements. The health checks would include issues such as cognitive function, eyesight and hearing. But there have been no moves towards introducing a mandatory retirement age for doctors.

There are over 6,600 doctors over 70 registered in Australia, with more than 85% of them still practising.

You can access the study on older doctors and notifications here.

How common is misdiagnosis?

In the news this week has been the horrific case of Magdalena Malec, 31, who, despite showing all the classic signs of sepsis, went undiagnosed as she lay in a UK hospital recovering from an operation. Admitted following an ectopic pregnancy, Ms Malec had a raised temperature and a number of other red flags for sepsis, following her surgery. She later developed extensive limb ischaemia and eventually had to have both of her legs, her right arm and the fingers of her left hand amputated, and she also needed a kidney transplant.

“The catastrophic chain of events which led to Magdalena’s near death and horrendous injuries were completely avoidable if the hospital had followed its own sepsis protocol,” her lawyer said. The hospital has since apologised.

Cases like that of Magdalena Malec put a human face on the very real problem of diagnostic error. More publicity tends to surround cases of wrong-site surgery or drug errors, but the research shows that misdiagnosis is a far more common – and more intractable – issue.

One recent attempt at putting a figure to the problem found that patients were misdiagnosed around 10-15% of the time. And an Australian systematic review of diagnostic error in older patients found rates of over 10% for COPD, dementia, Parkinson’s, heart failure, stroke and MI.

But it’s not easy to nail down figures, as many hospitals and practices don’t keep count and there can be strong motivations for doctors not to report a wrong diagnosis. On top of that, misdiagnosed patients may also follow up with another doctor who makes the correct diagnosis, with the first doctor never realising their mistake.

There are various methods researchers use to try and quantify diagnostic error. The gold standard is said to be autopsy studies, which consistently identify diagnostic discrepancies in 10-20% of cases. Of course, not all deaths are subject to autopsy, and those that are may already be cases where the diagnosis is unclear.

Another, if subjective, method is patient surveys, which show that around a third of patients have been the subject of a misdiagnosis or have had a family member of close friend who has been misdiagnosed. ‘Secret shopper’ studies have also been carried out, where real or simulated patients with classic symptoms of a condition present to a doctor or hospital. In these studies, doctors misdiagnose the patient in around 13% of cases.

Second reviews offer yet another opportunity to quantify diagnostic error. These have shown that 10-30% of breast cancers are missed on mammography, and 1-2% of cancers overall are misread on biopsy samples.

Misdiagnosis and delayed diagnosis are also far and away the greatest cause of malpractice suits, which point to how common they are. Of course, not every misdiagnosis is actionable: under Australian law, diagnostic error is only considered negligent if it falls short of Australian medical standards and is the result of the doctor failing to take “reasonable care” in diagnosing the condition.

Misdiagnosis is “the hidden part of the iceberg of medical errors that dwarfs other kinds of mistakes,” says Dr David Newman-Toker of the Johns Hopkins School of Medicine, who has extensively studied the problem.

In a survey, the top reasons doctors gave for cancer misdiagnosis were “fragmented or missing information across medical information systems”, along with “inadequate diagnostic resources”. But Dr Newman-Toker says they more typically result from flawed ways of thinking, sometimes coupled with negligence.

He says drug errors and wrong-site surgery are not only less common but more amenable to solutions such as color-coded labelling or preoperative checklists. But there is no such easy or obvious fix for diagnostic error, he says.

The strange case of the ice cream scooper’s arm

One of the ice cream scoopers at my favourite gelateria consulted me about her chronically painful right arm. She had the triad of tennis elbow, carpal tunnel syndrome and trigger thumb. Her misfortune became an extension of my interest in the medical problems of tennis players and musicians.

A quick search of PubMed produced one case report of a scooper who had fractured her second metacarpal, along with one study of ice cream scoopers by two American ergonomists. Sadly, there were no studies from New Zealand or Australia, despite their respective ranking of first and third in the world ice cream consumer league table (second is the USA). Clearly, ice cream scoopers’ arm is an under-researched Repetitive Strain Disorder worthy of further exploration!

In 2016-7, I conducted an opportunistic series of between two and three separate purchases at 14 ice cream and 16 gelato shops in four Australian states. I explained my interest in ice cream or gelato and observed and discussed the ergonomic set up of the counters, the type of scoops and the ways they were used. I was also able to obtain an occupational medical history from 52 (32 females, 20 males) of the scoopers who served me.

Only two of my informants, who worked for an international ice cream chain, had received a considered training on scooping ice cream. They were advised to put their right foot forward, keep their wrist locked and use the muscles in their upper arm and forearm to scrape from the centre of the circular ice cream container to its side. The only instruction given to the other scoopers was that the ice cream ball should be round and of a regular size and that the pan containing the ice cream should always look neat and attractive to the customers.

All but two of my informants had developed a sore arm, wrist and /or shoulder in their first two weeks on the job. With time, most of the scoopers got stronger and became pain free. Those who scooped ice cream as their permanent job usually looked like a professional tennis player with their scooping arm having a larger diameter than their non-scooping arm.

Ten of my informants had continued to suffer from a sore arm, especially after a busy weekend when they might serve more than 400 customers in a 10 to 12 hour working day. All of these ice cream scoopers were women and were physically less robust than their male counterparts. Their symptoms were exacerbated by carrying heavy ice cream canisters, reaching into poorly set up ice cream and gelato containers and by serving nut flavoured ice cream varieties eg pistachio, that have a high freezing point and can be rock hard.

Scoops

The most commonly used scoops were hemispherical in shape, made of aluminium with a heat conducting fluid in their handle. This aims to facilitate the release of the ice cream by conducting heat from the ice cream server’s hand to the ball of the scoop. Their main advantage is that they are cheap and produce a neat rounded ball of ice cream or gelato. These scoops are not dishwasher safe and have been reported to explode if dipped in hot water.

I identified over 100 different makes of ice-cream scoops that can be purchased online. Most are a variation of the one already described. There are also a small number of scoops that have various spring mechanisms to facilitate the release of the ice cream ball. They require the use of the thumb to work the release mechanism. Scoopers with small hands and weak grips find them difficult and tiring to use. Their moving parts are also prone to sticking and jamming. They are adequate for the home but not for repetitive commercial use.

There are several new ingenious scoops developed by American ice cream aficionados with a parallel interest in ergonomics. They are designed to maximise the use of the larger, stronger muscles of the scooper’s arm. None of my informants were aware of them.

The size and composition of the scoop handle is also important. It should be large enough for power and comfort and made of a non-slip material. The commonly used aluminium scoop fails all these criteria.

Ice cream scooper’s arm is one of the large family of repetitive industrial musculoskeletal disorders. It consists of many related but separate underlying pathologies. It could be prevented or mitigated by attention to training, optimum freezing temperatures of different types of ice cream, the ergonomic set up of ice cream counters and the type of scoop that is used. Tennis players customize their racquets and chefs have their personal and much prized cutting knife. Ice cream scoopers use whatever their shop makes available. Ice cream scoopers come in all shapes, sizes and strengths and one type of scoop does not fit all of them. Ice cream shops should have a selection of scoops that scoopers could try. It would only take a little more awareness and effort to prevent the ice cream licker’s pleasure being the ice cream scoopers’ pain.

Max Kamien is an Emeritus Professor of General Practice and Senior Honorary Research Fellow at the University of Western Australia