Saving Normal

Mental health and what is normal.

Hippocratic Humility

Uncertainty beats false certainty

The greatest doctor who ever lived was a very humble guy. Hippocrates is the father of medicine because he introduced the naturalistic conception of disease—you got sick because your organs weren't working properly—no spirits, no curses, no angry gods.

But he also set a precious example of physicianly humility too often since forgotten. On a nearby Greek island, the doctors treated their patients aggressively—in ways that often did more harm than good. This led Hippocrates to formulate the most robust and enduring finding in all of medical history- the 'rule of thirds' states that one third of patients get better on their own; one third don't respond to treatment; and just one third really benefit from it. This has been part of medical student lore for almost 2500 years and holds up remarkably well across time, specialties, and diseases.

It follows that the goal of medicine is to diagnose and treat only when there is a favorable risk/benefit ratio- to let people heal themselves when they can; to console those for whom there is no effective treatment; and to reserve risky treatments for those who need and can benefit from them.

It is, of course, difficult to predict course- and treatment response is often trial and error. But the obvious conclusion of Hippocrates' teaching is to be humble about the doctor's ability to treat and prevent illness. First and foremost- Do No Harm.

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Dr Diane O'Leary, an author and philospher, believes physicianly humility is now in short supply. She writes:

"Hippocrates’ sense of humility is valuable for all physicians- as a matter of principle and ethics, but also of simple number crunching."

"There are roughly 30 million people in this country with rare diseases. That’s roughly 1 in 10 Americans asking their doctors for help with ailments likely to lead to diagnostic uncertainty. This is twice the number of people with cancer."

"Since there are nearly 7000 rare diseases on current listings, it’s not humanly or statistically possible for doctors to be familiar with most of them. Without humility—without awareness that diagnostic knowledge is always limited—doctors can’t begin to care for the 1 in 10 people with rare disease.”

“Given these numbers it should not be easy for doctors to assume that symptoms they are unable to explain have psychiatric causes—but it is, in fact, easy. It is standard practice."

"Because common diseases do also present in unusual ways, easy psychiatric explanations can be threatening not just for those with rare diseases, but for everyone. When doctors treat their inability to understand symptoms as evidence of patients’ psychiatric problems, lack of humility stands in the way of sound diagnostic reasoning.”

Dr O'Leary's specific call for physician humility in the face of 'unexplained' medical problems' touches on the broader need for humility in all aspects of medical and psychiatric treatment.

  • The poorly conceived DSM 5 Somatic Symptom Disorder substitutes a false psychiatric certainty that misleadingly covers medical uncertainty about the appropriate diagnosis. It is better to admit what we don't know than cover it with meaningless labels.
  • Psychiatry needs to contain its recent enthusiasm for diagnosing as mental disorders all problems of life.
  • Researchers need to trim their exaggerated claims that we will soon solve the elusive mystery of how brain makes mind and behavior. The process of translating the exciting results of basic neuroscience into accurate diagnostic tests or improved treatments will be a very slow and lead up many blind alleys.
  • Doctors need to stop making snap diagnoses and starting premature treatments after first meetings with people they have just met and barely know. Watchful waiting beats intrusive diagnostic and treatment exuberance whenever the patient's problems are mild and bearable.
  • Primary care doctors need to accept their limitations in delivering psychiatric treatment- it makes no sense for them to be prescribing 80% of psychiatric medicine. Not every patient has to leave the office with a pill.
  • And patients need to accept physician uncertainty and humility. Don't push doctors for quick answers that will be wrong and harmful. Don't you expect or ask for a pill for every problem. Trust to time, resilience, and support from family and friends to solve the expectable and transient problems of life.

Psychiatric diagnosis and treatment are often life changing events—usually for the better, sometimes for worse, sometimes a tie score. Sorting out who is who in the rule of thirds requires patience and humility—both currently in short supply.

 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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