#543 - Newborn Hip Exams, Avoiding Fallacies of Logic, Retirement Party?

Follow-up:  Note from a Reader – ADHD Diagnosis:

After reading my recent Pointer on diagnosing ADHD, our residency program’s lead Behavioral Scientist, Laura Kurdila, PhD, worried that my sentence, “Thoughtful use of readily available tools in primary care is frequently all that is needed” might mislead readers. She emphasizes that the tools reviewed are starting points for a clinical assessment of medical and behavioral history, family and social context and clinical examination – all of which can be done, of course, in primary care. Simply relying on the tool itself for diagnosis is inadequate. And, if there is uncertainty about the diagnosis or the response to treatment, a referral to a behavioral health specialist for a comprehensive evaluation is certainly indicated.

From the JAMA Rational Clinical Examination Series

1)  Newborn Hip Exams Work

Developmental dysplasia of the hip (DDH) is rare (0.4-2.3% prevalence) but catching it before three months of age is essential to enabling a simpler treatment plan of bracing and avoiding surgery and prolonged rehabilitation. The most recent installment in the JAMA Rational Clinical Examination (RCE) series is a systematic review of basic clinical examination methods for DDH, including physical examination techniques. RCE articles apply all the systematic review methods to the evidence on physical examination techniques. The review covered the following tests: Galeazzi (looking for difference in femur length when flexed and adducted), limited hip abduction of one side on active ROM testing, “clicking” of either hip on range of motion, Barlow (downward pressure on the flexed abducted hip causing posterior dislocation) and Ortolani (anterior relocation of a dislocated hip upon abduction of the flexed hip). The Barlow and Ortolani tests are meant to be performed together. Ultrasound using the standard Graf grading method was used as the reference standard for diagnosis.

Results:

LR pos: likelihood ratio for a positive test, 1-2 poor, 2-5 fair, 5-10 good, >10 excellent.

LR neg: likelihood ratio for a negative test, .5-1 poor, .2-.5 fair, .1-.2 good, <.1 excellent

The authors note that out of 1000 hips (not children) screened with Barlow and Ortolani maneuvers 4 (95% CI, 2-6) dislocations will be picked up. There will be 9 (95% CI, 1-30) unnecessary ultrasounds, but also still 5 (95% CI, 3-8) missed diagnoses. In higher prevalence locations (Austria, Norway) or with a family history, screening with ultrasound may be a better choice.

John’s Comments:

Our training on the Barlow and Ortolani tests can be somewhat variable in quality. This article has nice diagrams to describe the test techniques, and the authors point out that periodic retraining would benefit clinicians. It’s a rare case where thoughtful physical examination is proven to be a useful screening technique (despite its limitations), so this is one we should be good at.

Reference:

• Singh A, Wade RG, Metcalfe D, Perry DC. Does This Infant Have a Dislocated Hip?: The Rational Clinical Examination Systematic Review. JAMA. Published online April 15, 2024. Link

From the Literature and “Healthy Skeptic School”

2)  Honing Your Critical Thinking Skills:  Avoiding Fallacies of Logic

In the April 26 Take 3, we highlighted the importance of recognizing and managing common cognitive biases in order to prevent diagnostic error, and cautioned how prevalent these biases are in clinical care.

This week we continue our theme of sharpening our critical thinking skills by examining the phenomenon of logical fallacies.  Note that cognitive biases and logical fallacies are different.  Cognitive biases are rooted in the way the brain actually works whereas logical fallacies are errors in reasoning that occur in the moment.  Individuals can be trained to avoid logical fallacies, but as noted last week, cognitive biases, because they work as part of our cognitive “operating system,” must be consciously managed.  

Fallacies of logic confuse correlation, coincidence, and causation, otherwise known as “False Cause.”  In deductive logic (and hence in deductive arguments), fallacies are errors in the structure of the argument such that the conclusion does not necessarily follow from the premises. In inductive logic, fallacies are unjustified claims that the arguer tries to use to support an inference between evidence and a conclusion.

With This, Therefore Because of This (Cum Hoc Ergo Propter Hoc)

When two things seem to happen in correlation or at the same time with each other, many will mistakenly think that one thing caused the other when no such causal relationship has been established.  For example: “Many people who have strokes are on blood pressure medications.  Those blood pressure pills must be causing strokes."

Post Hoc Fallacy (Post Hoc Ergo Propter Hoc)

A precedes B, therefore A caused B. It is subtly different from the previous fallacy because in this case, the ordering of the events is key and appears to be integral to the causality.  The fallacy lies in coming to a conclusion based solely on the order of events, rather than taking into account other factors that might rule out the connection.  For example: "I get these symptoms at the same time every year and antibiotics are the only thing that works.”

Appeal to Authority (Argumentum ad Verecundiam)

None of us can know everything.  We rely on those with in-depth experience to help provide additional necessary context, particularly when it comes to the recognition and management of rare or serious manifestations of disease and the use of new medications, diagnostic tests, or procedures.  But specialists and generalists are two different kinds of experts that have two different ways of knowing things.  Neither of them should be looked at as authority, but as complementary approaches to the applied science of medicine.  Unfortunately, specialists are often treated as authorities on decisions that may better use a generalist approach – interpreting diagnostic tests in a primary care population, evaluating the right management course in a patient with multi-morbidity, and weighing available treatments in the context of the patient’s values and circumstances.  Our “healthy skeptic antennae” should be active when we hear appeals such as: “In my experience…”, “Dr. X, the world-renowned cardiologist always uses this with her patients…”, “This is the way we do it a Z Medical University …”  This doesn’t make the conclusion necessarily wrong, just that it should be consciously scrutinized.

The Bandwagon Effect (Argumentum ad Populum)

Also known as the “appeal to popularity,” this is a variation of the appeal to authority. In this case the "authority" is popularity or “the masses.”  There is a subtle “peer pressure” effect that occurs with this appeal.  We are often quick to jump on the bandwagon when we are afraid of looking as though we're not as up-to­ date as our colleagues.  The use of GLP-1 agonists (for everything?!) would be a present example of this.  As with other fallacies, the conclusion is not necessarily false, but the conclusion’s premise is wrong.

The Slippery Slope

The arguer tries to convince others that one action will lead to a series of events that will eventually lead to an ultimate, usually unwanted, consequence.  This is fallacious if it is unlikely that each intermediate step will necessarily follow the preceding one.  This argument is used regularly in political debate and ethical arguments in healthcare. 

The Appeal to Nature

This is perhaps the most prevalent fallacy used in the health and wellness industry.  It occurs when something is claimed to be good because it’s perceived as natural, or bad because it’s perceived as unnatural and is the basis for claims such as “all-natural ingredients” and “free from chemicals.” 

Mark’s Comments:

These fallacies occur regularly in the course of clinical care and are used quite commonly in medical advertising.  The first step in honing one’s critical thinking skills is acknowledging that we are susceptible to such fallacies of logic and regularly listening for them in the course of our daily work.  For those interested in learning more about the many fallacies (there are many more), this Link to "Skeptical Medicine" provides a good overview and some wonderful video clips. 

References:

• Shaughnessy AF, et al.  Separating the Wheat from the Chaff: Identifying Fallacies in Pharmaceutical Promotion.  J GIM 1994. 9 (10): 563–568. Link
• Tiller N.  The Skeptic’s Guide to Sports Science:  Ten Health and Wellness Fallacies Every Skeptic Should Know.  September 23, 2022. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Time for a “Retirement Party” From Competitive Suffering?

“Saying someone shouldn’t feel sad because someone else may have it worse is like saying someone can't be happy because someone else may have it better.”                                                                                                                                                  Unknown 

 

If you’re like many who work in healthcare, as you care for people who are facing significant health challenges, you’ve likely found yourself at times thinking, “Who am I to complain when there are so many who have it so much worse?”  There may even be a voice or voices from your past joining in that chorus.  The psychological literature has coined this common mindset as “comparative suffering.” 

Comparative suffering is when one feels the need to contrast one person’s suffering with the suffering of others.  Those of us in healthcare have generally been socialized to believe that our struggles and/or suffering are not legitimate or can wait because it is our job to care for the many others in distress.  We often even take it one step further and find ourselves participating in a process termed “competitive suffering,” in which we assign all suffering, both ours and that of others, a “legitimacy score” along some sort of self-created legitimacy scale.  And those of us in healthcare usually judge our own by much more stringent criteria – a phenomenon commonly known as minimizing ….       

Recently I found myself doing this very thing when I experienced some “twinges” similar to those of a serious and quite painful back injury I had three years ago for which I was unable to walk without assistance for a period of time.  While the symptoms in this case were fortunately transient (and likely unrelated), I found myself “joking” with a colleague “it’s just a little PTSD” (legitimacy scale) when the fact is there is rarely a day that goes by when I don’t think about that injury, usually when lifting something, and in the process, experience a “twinge” of both gratitude for my healing and fear of recurrence.  

Some might conclude that comparative suffering is a healthy pattern of thinking.  Afterall, isn’t “counting your blessings” encouraged throughout the well-being literature (and by me)?  And no one wants to be labeled a “whiner” or a “victim.”  But being grateful is not the same as pretending that you don’t have struggles, and one can express their struggles in constructive ways, such as sharing them with a trusted friend.  In fact, denying or suppressing your suffering rather than addressing it can actually cause greater suffering because the distress doesn’t magically go away, and we then also feel ALONE with it.  The consequence is a diminished ability to be compassionate, both with others and oneself.    

So remember, we can live our most authentic life by both keeping our struggles in perspective AND allowing ourselves and others to feel and express them in healthy ways.  Afterall, no one goes through life without them, so why not practice validating what you feel and then decide the story you will tell.  Perhaps you can even take it one step further, letting your PeerRx partner serve as your “becoming more human” practice partner as you officially announce your retirement from competitive suffering.  I’d welcome the opportunity to attend your “retirement party” … and would love for you to come to mine!

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org