Expert Opinions are Not Facts

Remember the patient that I mentioned in my last post, who signed up for a tendon transfer? Turns out that his rotator cuff was repairable, and he has done very well with his recovery … so far. As someone who is scientifically minded who wants clear answers from his craft, this frustrates me because I wish the human body were more predictable. As someone who cares very much about this patient and wants him to have a great outcome, this worries me because I share with him the hope that the decisions we make together will result in a good outcome for him. Whether I am evaluating the situation with my mind or my heart, I am dissatisfied with the uncertainty of my advice, which is inescapable since I am giving people my expert opinion and not facts from a book. If we were giving people facts, they could look it up on Google or WebMD. If we are giving people our expert opinion, then that has to be taken by both the giver and the receiver of the advice as better than the average opinion … but still an opinion.

Epistemology, the study of the nature of knowledge, justification, and the rationality of belief, is a very interesting branch of philosophy, and it becomes applicable to medicine every time a clinician gets asked by a patient, “how do you know that this is the correct diagnosis?” We can quote studies, our degrees, our experience, or any of a number of other things that justify why we are qualified to give an expert opinion, but the reality is that if the patient is not convinced, it becomes our responsibility to explain to the patient that they fall into one of the following categories:

1. Some people do not have a diagnosis because their shoulder is normal. This does not mean their shoulder does not hurt, since even normal shoulders hurt sometimes. In my opinion, there are many people who come to see me that are better off doing a proper shoulder exercise program, rather than exposing themselves to unnecessary risk in “treating a shoulder” that just hurts because it is lacking in the standard preventive maintenance that any shoulder should have. We understand this to be the case for dental care that is mostly preventive, and intended to keep people from needing “treatment.” We mostly understand this to be the case for nutrition, which is best thought of as eating healthy on an ongoing basis rather than “treating” weight gain with a diet or other short term intervention. We should, therefore, understand this to be the case for many musculoskeletal problems that are a result of disuse or improper use.
2. Some people do not have a diagnosis because their shoulder problem is not identified yet by the medical field. Whether the clinician knows “all that there is to know” is not the question here, since we have to be aware that even the most experienced clinician still has a gap in their knowledge compared to the sum knowledge of all current specialists. The most helpful clinician is not the one that knows the most, but rather the one who is most aware of the difference between what they know, what they don’t know, and what is not knowable. For example, if someone comes to see me for a joint that is not their shoulder, I will tell them “I do know something about this, but I don’t know as much as a specialist of that joint, so why don’t we start with some simple things, and if you need something more complex, then we can figure out whom you can see next.” Even if they are seeing me for their shoulder, I will tell them when I do feel that there is something that I am missing, and it may be beneficial to get a fresh perspective from someone else. Despite this commitment to getting people the best possible opinion, there are some things that fall outside the current scope of all that is known.
3. Some people do have a diagnosis that just makes no sense, even for the person explaining it. Fortunately, in the world of shoulder problems, most things make sense. It is fairly easy to explain to tell someone when something is broken, torn, or inflamed. Unfortunately, even for my fairly straightforward specialty, there are times where I have to tell people “yes, I know this makes no sense, but life does not always make sense.” One example is why AC joint arthritis eventually stops hurting, since arthritis of almost every other joint in the body gets gradually worse and worse with time. It may be because if the joint arthritis gets so bad that the joint stops moving, then you continue to move your shoulder with only a mild limitation in your range of motion, but without any further pain. Yes, I know this makes no sense.
4. Finally, we have a group of people who have a diagnosis that the clinician understands well, is usually fairly successful in explaining, but for some reason in this case the message does not seem to be clear enough to satisfy the patient’s inquisitiveness. Before you jump to conclusions, let me tell you that this scenario does not usually happen because the patient is not smart enough to understand. The professions that usually find themselves at risk of being in this group are doctors, nurses, and engineers. It is not because they don’t know anything, but because they are used to knowing things at a much deeper level than is possible for certain problems that have an inherent fuzziness in their decision making, like rotator cuff tears. I was very impressed today with a patient that was able to share with me what she learned from researching her frozen shoulder, including a healthy skepticism for what seemed to be questionable information. Most people are not able to do that, and they get lost in the sea of information, without any context within which to discern which treatments are reasonable for them, which are not indicated, and which are potentially dangerous.

Before I go any further, let me admit I struggle with this last group sometimes. It’s getting easier as I my experience, confidence, and reputation grows with time; however, there is always a bit of self-doubt and self-consciousness that is sometimes difficult to suppress when you have someone in the room that simply does not accept what you are saying, despite your best efforts to make sure they are heard, evaluated, and counseled properly. It has helped me, lately, to simply admit to these patients that expert opinions are not facts. They have scheduled an appointment, showed up, and paid a copay for my opinion. If they were here for facts, it would be a waste of their time since computers and books are much better than humans at spitting out facts. Even if the opinion being offered were formulaic, I would defer to computer algorithms and artificial intelligence as being either currently or eventually better equipped to say “these are the possible treatments and their likelihood of success.”

What these patients and their surgeons need to realize is that a key part of the relationship is the trust required for a empathetic and therapeutic encounter. If clinicians try to escape the tension of the uncertainty, we will find ourselves with an ego-protective overconfidence in our own opinion, or we may even distance ourselves from the patient intellectually or emotionally. The former sounds something like “well, this isn’t something you’ll be able to understand,” while the latter sounds something like “well, I don’t think there is much else I am able to do for you here.” Instead of leaving the patient behind to protect our egos, I invite us to lean in and stay vulnerable. Even if we say something to the effect of “I’m not sure if I’m doing a bad job explaining this, but I’m not sure if I can do much better,” this allows the patient to ask themselves if they really need more information, or if they are willing to move forward with what they have already heard.

The dangerous thing about knowing so much about something is that this gives us the false impression that we know everything, which is definitely not the case, and that is ok. It is ok to tell the patient we don’t know something. It is ok to tell ourselves that we don’t know something. It is ok for our mom to find out that we don’t know something. It is actually helpful to people that they know we we are human, and that we care enough about them to study for years, listen to their problem, and apply what we know to what we have heard to help them make the best decision possible, even in the face of uncertainty.