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The role of devil's advocate in medicine

Hippocrates (Father of medicine)

“I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone”- Hippocrates

 

Healthcare is one of the noblest professions as it ensures the well-being of everyone. The abovementioned Hippocratic oath holds the true spirit of this field and outlines the moral commitment of every person in the field of medicine. In order to ensure that the best decisions are made in the health sector, a lot of decision making happens in groups of medical professionals. It is of no surprise that this creates a problem of confirmation bias and group thinking affecting the decisions made by such groups and even leads to a failure of obligation to the oath. In this blog, I would like to highlight some of the existing problems in the medical field caused by group thinking and confirmation bias like the practice of defensive medicine and what can this field learn from an age-old practice of the catholic church.

Before you read further, let me make it clear that my intention is not to promote suspicions about the efficacy of the medical prescriptions or procedures you might be recommended next time you go to a doctor. Your health professional knows better about what to do with your medical problems, the goal here is to highlight some of the documented trends and encourage a healthy debate about certain practices in medicine and how those practices can be avoided.

 A 2010 Gallup survey showed that around 73% of the healthcare professionals admitted to be recommending unnecessary diagnostic tests and invasive procedures, as well as therapeutic prescriptions and hospitalisation [1]. This practice has its own name called defensive medicine and it has two types, assurance behaviour and avoidance behaviour. Assurance behaviour is the group of practices as described above and avoidance behaviour is when doctors avoid the treatment of critical patients altogether.

Defensive medicine is a form of confirmation bias that is found to be widely practised as Other studies done by Harvard Medical school and Jackson Healthcare showed similar and sometimes even higher percentages [1]. The reason for it is solely to avoid litigation or criticism from medical societies. Due to such fear healthcare professionals often avoid personal clinical judgment at expense of increasing the cost of healthcare for the patient.

 At this point one might raise a question, “What is wrong with being extra vigilant about patients health, nothing could cost more than the life of a patient” right? But, one study done in 2014 about such practices estimated that the increased cost of healthcare due to the bane of defensive medicine was estimated to be $46 billion [2]. It is not just about the staggeringly expensive medical procedures but the quality of outcome of patient’s health as well. Studies have concluded in the past that the overall quality of patient’s care is decreased due to the practice of defensive medicine [3].

 At the macro level, healthcare organizations can also foster a sense of group cohesion that prioritizes unanimity and group harmony over effective decision making [4]. This can be observed on all levels of organizational hierarchies of any healthcare organization from top-level managers to clinical teams down at the bottom. Such group thinking leads to poor decisions, and combating it depends in part on health care organisations' capacity to foster proper 'open' cultures and create supportive working settings where it can be avoided [4].

 Here, I would take a brief pause from talking about the healthcare sector and turn towards history to contextualize a suggestion about the problems mentioned above. In 1587, the Catholic Church created a new position of "Devil's advocate" to improve the scrutiny in the process of sainthood declaration [5]. The job of the person responsible for being a devil's advocate was to present differing viewpoints and counter the selection of the deceased person as the saint. No matter how favorable a candidate was for sainthood, the selection was meant to be transparent and free from biases or group thinking. There is a lesson to be learned here for the existing healthcare system and medicine in general.

 Healthcare organizations can benefit from adopting the role of a devil’s advocate within their ranks. Take a medical board for a patient for instance, by introducing the role of a devil’s advocate, better decisions could be made about whether a set of prescriptions or tests must be recommended to the patient or not. In this manner, It can be better assessed if the recommended line of action is being taken purely for the wellbeing of the patient or some innate fear for the litigation and/or criticisms from the medical boards. The findings of this discussion amongst the medical board could help the governing boards to assess the rigor of the decision making about a patient’s health and wellness.

References:

	[1] M. S. Sekhar and N. Vyas, “Defensive Medicine: A Bane to Healthcare,” Annals of Medical and Health Sciences, p. 295–296, 2013.
	[2] M. B. Rothberg, J. Class and T. F. Bishop, “The Cost of Defensive Medicine on 3 Hospital Medicine Services,” JAMA Internal Medicine, 2014.
	[3] M. L.DeKay and D. A. Asch, “Is the Defensive Use of Diagnostic Tests Good for Patients, or Bad?,” Society For Medical Decision Making.
	[4] R. Mannion and C. Thompson, “Systematic biases in group decision-making,” International Journal for Quality in Health Care, vol. 26, p. 606–612, 2014.
	[5] “Devil's Advocate,” Wikipedia, [Online]. Available: https://en.wikipedia.org/wiki/Devil%27s_advocate.