[ed. note: Michael Jorrin, who I like to call Doc Gumshoe, is a longtime medical writer (not a doctor) who writes about non-financial health and medical issues for us a couple times a month (past submissions can be found on his author page here). Like all of our authors, he chooses his own topics and his words and opinions are his alone. Enjoy!]
This subject has been simmering in my mind for a while, but it just came to a boil a few days ago, when I read a piece in the New York Times Magazine. The magazine is the good grey newspaper’s attempt to do something a bit more trendy and appeal to a younger readership, perhaps. There’s a weekly section entitled “The Ethicist” where readers pose supposedly ethical questions to a supposedly wise individual with the credentials to offer supposedly ethical advice.
In this particular case, the unidentified questioner in New Jersey was wondering what he/she should do, if anything, about a physician who “just might be a quack.” The case the questioner posed was this: he/she personally knew 12 persons who had been diagnosed with Lyme disease by this single physician. Several of these persons had previously seen other physicians, characterized by the questioner as “Lyme disease experts” – presumably infectious disease specialists – and had been assured that they did not have Lyme disease. But the possibly quack physician, relying on a test that had to be sent “out of state,” diagnosed these 12 individuals as having Lyme disease and prescribed courses of treatment costing about $35,000, which could not be covered by insurance. The questioner, moreover, commented that according to the CDC, the incidence of Lyme disease in New Jersey was 29 per 100,000 population, so it was highly improbable from a statistical perspective that he/she would be personally acquainted with 12 persons with Lyme disease, noting that, based on the 29/100,000 incidence (or 0.0029%), he/she would need to know about 40,000 residents of New Jersey to come up with 12 that had Lyme disease.
The “ethicist,” Mr Kwame Anthony Appiah, who teaches philosophy at NYU, dedicated about half of his answer to a frail statistical quibble, based on the probability that the number of Lyme diagnoses is about one-tenth the number of actual Lyme infections in the community, and that the CDC incidence might be for a four-year period, so the questioner would only need to know about a thousand New Jersey residents to make it somehow statistically not impossible that 12 of them might have Lyme disease. Mr Appiah did not address the likelihood that these 12 individuals would all have been diagnosed by the same physician.
Mr Appiah then went on to make several points. One, that the physician might genuinely believe that the test she is using catches previously undiagnosed Lyme, that the condition is underdiagnosed, and that in that way she is actually helping these patients.
That’s possible, of course. But then Mr Appiah goes further. He asserts that these patients would have been grateful for the Lyme diagnosis, and that the questioner would likely get nowhere voicing his concern about the physician’s potential ethical transgression to the relevant New Jersey authorities. He then implies that these patients may have been “doctor shopping,” which he asserts is common among the “more affluent.” And finally, that those patients may be hypochondriacs.
At this point I boiled over and resolved to write a letter to the magazine (which they almost certainly will not print), in which I pointed out that if the Lyme diagnoses were incorrect, which they probably were, this physician was doing real harm to these patients: first, by preventing them from finding the real cause of their symptoms, and second, by consigning them to a lengthy and costly course of treatment that would likely bring about significant adverse effects. And I said that the suggestion that these patients were hypochondriacs was cynical and demeaning, and that Mr Appiah, by brushing off the questioner’s concern, had forfeited his claim to be an ethicist.
I do not know for a fact whether the physician in question is a member of the International Lyme and Associated Diseases Society (ILADS), whose guidelines list no fewer than 25 very common conditions which they claim may be due to Lyme disease. The list begins with fatigue, low grade fever and chills and proceeds through just about every common symptom to headaches, light-headedness, and dizziness. ILADS proclaims that Lyme disease can be present despite negative ELISA and Western Blot assays, and that individuals with negative results on those tests are just as likely to have Lyme disease as individuals with positive results.
Chronic Lyme is certainly a reality. There are instances in which a person ignores the initial symptoms of Lyme and does not receive treatment, in which case the pathogen, an elusive spirochete called Borrelia burgdorferi persists and may cause a range of symptoms. These nasty little bugs tend to wend their tricky ways to parts of the body where antibiotics find it hard to penetrate. But the symptoms listed by ILADS as being related to Lyme are much more likely due to other causes, and jumping to the Lyme diagnosis without some kind of positive identification of the pathogen is a huge disservice to patients.
Are patients grateful for a diagnosis, even if it’s wrong?
The answer to that one is YES! Here’s a little story: a friend of my wife had been experiencing