Taxicab Medicine and Diagnostic Errors by Jeffrey Dach MD
Last week JAMA published a study by Dr. Auerbach entitled “Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care”, finding diagnostic errors were common in patients who had bad outcomes, who died in the hospital or required transfer to the ICU. Dr. Auerbach writes:
Among hospitalized adults transferred to the ICU or who died in the hospital, diagnostic errors were common, harmful, and had underlying causes, which can be used to design future interventions. (1)
I look upon this report as merely one small indicator of a larger problem, the multi decade “race to the bottom”. Institutional medicine has been transformed into “Taxi-Cab Medicine” .
What is Taxicab Medicine ?
Let us say you owned a taxi cab company and you needed drivers. Let’s not be too picky. Anyone with a driver’s license will do. Is there a problem with a driver? Just get rid of them, and any other driver will do as a replacement. This is what has happened to the practice of medicine in our major institutions. Skilled doctors have been transformed into automatons forced to mindlessly follow hospital guidelines. If the doctor has a problem with the hospital guidelines and insists on a different treatment, the doctor is fired and replaced, just like the taxi cab company. This is called “Taxicab Medicine”.
Drs. Paul Marik and Pierre Kory
An excellent example of this is the case of Drs. Paul Marik and Pierre Kory, both highly skilled and published ICU critical care doctors working within institutional medicine. These prestigious doctors refused to follow hospital guidelines which called for use of ineffective toxic drugs such as remdesivir. Instead, the two doctors treated their covid patients with Ivermectin, a highly effective and safe drug. Because of their refusal to follow the absurd hospital guidelines, based on optimizing hospital profit, both doctors Drs. Paul Marik and Pierre Kory were promptly fired and replaced by more obedient doctors. This is called “Taxicab Medicine”. How many doctors met a similar fate? Probably thousands. (10-11)
Skilled Doctors Are a Rare Breed
The net result of decades of Taxicab Medicine is this: all the older gifted and skilled doctors, who are a rare breed, have disappeared, and have been replaced by new inexperienced doctors who lack the skills needed to take care of sick hospitalized patients. They are not required to have any skills. Instead, the only requirement is to obediently follow hospital guidelines. Deviation with creative thinking is not allowed. (13-16)
Diagnosis Requires Deliberate Reflection and Clinical Reasoning
In 2023, Dr. Sílvia Mamede reviewed the thinking process required to make a correct medical diagnosis, ie: the use of deliberate reflection and clinical reasoning to reduce errors, writing:
Several approaches based on reflection have been proposed to reduce clinicians’ errors during diagnostic reasoning…
(1) Deliberate induction, that is: returning to the problem to gather more information in search of alternative explanations besides the initial one considered;
(2) Deliberate deduction, exploring the consequences of these new explanations through predictions of signs and symptoms that should be present if the diagnostic hypothesis generated for the patient problem were correct;
(3) Testing these predictions extensively against the data present on the problem at hand, which would lead to either hypothesis confirmation or falsification;
(4) Openness towards reflection, an attitude that makes a physician tolerate uncertainty and engage in thoughtful reasoning when confronted with a challenging problem; and
(5) Meta‐reasoning, the willingness to reflect upon one’s own thinking processes and critically review assumptions and conclusions. (16)
How to Master the Art of Diagnosis
In 2023, Dr. Taro Shimizu provided twelve tips for doctors to master the art of medical diagnosis, writing:
Tip 1: Apply basic medicine knowledge to diagnosis.
Tip 2: Learn cognitive psychology.
Tip 3: Learn the various phenotypes of each disease.
Tip 4: Practice, practice, practice.
Tip 5: Maximise analytical thinking.
Tip 6: Develop and utilise diagnostic thinking strategies.
Tip 7: Integrate new technologies in relation to diagnostic decision making.
Tip 8: “Visualise” patients’ history and physical findings.
Tip 9: Nurture the ability to extract information appropriately.
Tip 10: Apply three reflections for calibration.
Tip 11: Consider both Safety 1 and 2.
Tip 12: Apply adaptive expertise training. (13)
Conclusion: Medical Diagnosis involves a complex cognitive process applying medical knowledge to the patient, the patient history, examination, laboratory and imaging studies etc. Making the correct diagnosis is difficult and errors can be made. For the new inexperienced doctor in training, the practice of medicine is a highly complex undertaking requiring many years of mentorship under older, and more experienced physicians. This is a long and arduous process giving rise to a generation of gifted and skilled physicians. This has been squandered, and Institutional Medicine has been transformed into Taxicab Medicine. Do you want to take a taxi ?
Jeffrey Dach MD
7450 Griffin Road Suite 180/190
Davie, Fl 33314
954 792 4663
Articles with Related Interest:
Is This the End of Medicine in America?
Medical Conspiracies that Came True
Why Are One in Six on Psych Meds ?
Header Image Taxi Cab Courtesy of Wikimedia Commons
References
1) Auerbach, Andrew D., et al. “Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care.” JAMA Internal Medicine (2024).
Among hospitalized adults transferred to the ICU or who died in the hospital, diagnostic errors were common, harmful, and had underlying causes, which can be used to design future interventions.
2) Carver, Niki, Vikas Gupta, and John E. Hipskind. “Medical errors.” StatPearls [Internet]. StatPearls Publishing, 2023.
3) Kohn, Linda T., Janet M. Corrigan, and Molla S. Donaldson. “Errors in health care: a leading cause of death and injury.” To err is human: Building a safer health system. National Academies Press (US), 2000.
4) Donaldson, Molla S., Janet M. Corrigan, and Linda T. Kohn, eds. “To err is human: building a safer health system.” (2000).
5) Neelamma, P., et al. “An evaluation of medication errors among staff nurses working in medicine intensive care unit of tertiary care hospital.” National Journal of Physiology, Pharmacy and Pharmacology 12.12 (2022): 2061-2065.
6) Singh, V. P., and Gautam Biswas. “Disclosing Medical Errors: Why, When and How?.” Legal Issues in Medical Practice (2020): 31.
7) Costa, Claudia Regina de Barros, et al. “Strategies for reducing medication errors during hospitalization: integrative review.” Cogitare Enfermagem 26 (2021).
8) Gray, Serajaddin, et al. “Medication Errors and Reducing Interventions: A Mixed Study in a Teaching Hospital.” Journal of Pharmaceutical Care (2021): 3-12.
9) Graber, Mark. “Diagnostic errors in medicine: a case of neglect.” The joint commission journal on quality and patient safety 31.2 (2005): 106-113.
10) ACADEMIA’S WAR ON DR. PAUL MARIK
World-renowned Critical Care Specialist, Dr. Paul Marik, joins Del to talk about the harrowing fight to keep his medical license, after treating critically-ill Covid-19 patients with lifesaving early treatments that were against hospital policy. Fellow FLCCC co-founder, Dr. Pierre Kory, joins the conversation to reflect on their first battle against Academia; the shocking struggle with a corrupt medical system to utilize a life-saving, cheap, and safe protocol for sepsis, the leading cause of death in the world.
11) How I Lost Three ICU Jobs During the COVID-19 Pandemic – Job 1
Prior to COVID, I was a nationally known expert in Pulmonary & Critical Care Medicine. Despite the massive need for specialists like me across the US, I had to leave 3 different US medical centers. Pierre Kory, MD, MPA Jan 18, 2022
12) Mamede, Sílvia, and Henk G. Schmidt. “Deliberate reflection and clinical reasoning: founding ideas and empirical findings.” Medical Education 57.1 (2023): 76-85.
13) Shimizu, Taro. “Twelve tips for physicians’ mastering expertise in diagnostic excellence.” MedEdPublish 13.21 (2023): 21.
14) Mamede, Sílvia, et al. “Think twice: effects on diagnostic accuracy of returning to the case to reflect upon the initial diagnosis.” Academic medicine 95.8 (2020): 1223-1229.
15) Brush, John E., Jonathan Sherbino, and Geoffrey R. Norman. “Diagnostic reasoning in cardiovascular medicine.” bmj 376 (2022).
16) Mamede, Sílvia, and Henk G. Schmidt. “Deliberate reflection and clinical reasoning: founding ideas and empirical findings.” Medical Education 57.1 (2023): 76-85.
According to the findings, a reflective physician would tend to show:
(1) Deliberate induction, that is: returning to the problem to gather more information in search of alternative explanations besides the initial one considered;
(2) Deliberate deduction, exploring the consequences of these new explanations through predictions of signs and symptoms that should be present if the diagnostic hypothesis generated for the patient problem were correct;
(3) Testing these predictions extensively against the data present on the problem at hand, which would lead to either hypothesis confirmation or falsification;
(4) Openness towards reflection, an attitude that makes a physician tolerate uncertainty and engage in thoughtful reasoning when confronted with a challenging problem; and
(5) Meta‐reasoning, the willingness to reflect upon one’s own thinking processes and critically review assumptions and conclusions.
Jeffrey Dach MD
7450 Griffin Road, Suite 190
Davie, Fl 33314
954-792-4663
my blog: www.jeffreydachmd.com
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