200 Being a Doctor After Being a Patient
tendency may contribute to these physician-patients seeking more ag-
gressive treatment.
Trainees in particular seemed overly influenced by observations of
rare but severe complications of treatments or disease in patients, though
the odds of such events remained small. For example, Suzanne, who had
bipolar disorder, refused to take a drug because of its risk of causing
Stevens-Johnson syndrome, which she had witnessed in a patient.
My psychiatrist suggested Lamictal, but my answer was ‘no,’ be-
cause of Stevens-Johnson syndrome: I met one patient who can’t
move her arm now. That’s enough for me!
Because she had less clinical experience, such an event may have
influenced Suzanne more than it would older physicians. In fact, the
statistical likelihood of Lamictal causing Stevens-Johnson is very low.
However, as Tversky and Kahnemann (2) have described, individuals are
biased in assessing risks, using, for example, an ‘‘availability heuristic’’
through which they disproportionately weigh vivid personal experiences
of bad outcomes more than the actual probability of such outcomes
occurring.
Trainees appeared to have particular difficulty integrating observations
of rare but serious complications with epidemiological data that such
extreme complications may in fact be highly unusual. It is not surprising
that ‘‘medical student disease’’ results among trainees, who ignore base-
line rates of conditions in assessing minor symptoms. The degree to which
such misassessments hamper subsequent treatment decisions is not clear,
and needs to be probed by researchers. But the fact that a rare but trau-
matic event occurred can shape views among physicians (particularly
if young) of the odds of its recurring. Indeed, extended, cumulative clin-
ical experiences can counter tendencies to overweigh uncommon but
traumatic events.
Some doctors felt fatalistic about their own condition, seeing their
disease kill their patients. Stuart, the internist with HIV who was now
teaching at the university, felt less sanguine about his own prognosis than
he would have otherwise. ‘‘It was a problem seeing a lot of sickness with
patients. So I was pretty pessimistic about my own outcome. I assumed
that in five years, I’d be facing severe disease and death.’’
These doctors had strong views as to whether they would ‘‘overcome
the odds’’ or fall victim to