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| Research of a holiday kind |
*Geriatrician, Halifax, NS; Cognitive neurologist, Montréal, Que.
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Abstract |
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How best to assess cognitive function of physicians is controversial. The Royal College of Physicians and Surgeons of Canada's Maintenance of Certification Program offers no assessment of cognitive function per se, beyond the ability to add up hours of continuing medical education. Even these simple tabulation tasks suggest that many physicians have trouble with basic arithmetic. What is more, this deficiency is so widespread as to be uninformative, although it has allowed generations of financial planners to observe that "a physician and his money are soon parted."
Technological advances, notably the cellular telephone, may be the key to assessing cognitive function in physicians. Many of the typically disruptive behaviours of people who answer cellular telephones in public are similar to the behaviours exhibited by patients with frontal lobe damage. We sought to determine whether physicians' behaviour in relation to their cellular telephone use at medical meetings would allow surreptitious assessment of their frontal lobe function, which is essential to the cognitive performance that society expects of physicians, especially older ones.
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Methods |
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Results |
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Interpretation |
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Our study had limitations. We did not use functional magnetic resonance imaging (MRI) to correlate our observations. The current state of technology does not allow for economical use of MRI-compatible cellular phones. In addition, the study was cell-phone biased. However, no one exhibiting aberrant social conduct was without a cell phone. (The converse was also often true.)
Some might object to the conceptual basis of our study. Given the increasing use of guidelines-driven models of health care delivery, much of modern medical practice ideally is decerebrate. In consequence, some degree of frontal lobe dysfunction actually aids physician cookbook compliance by minimizing intrusive so-called "clinical judgment."
We recognize, too, that our many betters at the Royal "This Is a Deadline" College will be disappointed that our approach to assessing doctors does not include confrontational testing and ritual humiliation by fully certified physicians. All we can offer in defence is that no method of physician evaluation is perfect. We hope that truly competent, busy doctors will welcome a method with such obvious face validity that makes no demand on their time and is no more invasive of their privacy than current methods of audit.
We attempted to validate our method against more traditional assessments of frontal lobe function. In keeping with the surreptitious nature of our study, we tried to work in several frontal lobe tests as part of ordinary conference conversation. (We had imagined this to be a boon; there are only so many times — no more than 3, to be exact — that you can, in a single conversation, ask a long-ago acquaintance "So, how are you?") Often we had to retreat from such evaluation because of the high degree of frontal lobe impairment that it revealed. For example, in response to the question "How is a cauliflower like a turnip?" (a similarities question used to assess a person's conceptualization and abstract reasoning as part of the Frontal Assessment Battery4), we witnessed a range of aberrant behaviours. These included impaired social conduct (from withdrawal to verbal aggression and swearing) and echolalia (e.g., "You're a turnip!"). Similarly, requests to copy the Luria Hand Sequence Task ("Fist, Slap, Side") typically resulted in intrusion of a stereotyped hand-raising/ middle finger response (which we scored as "4" — equivalent to greatest impairment on that item).
We were split on whether reading the newspaper during a presentation was a sign of frontal lobe dysfunction. However, because academic rivalries are so common and because obvious disdain for what a speaker is saying is an accepted part of strategic one-upmanship at conferences, we felt it unwise to introduce this possibility of misclassification bias. In addition, a consensus of experienced speakers (grade C evidence) suggests that participants can be as inattentive as they wish, as long as they are quiet.
We recognize that the line between physiologically normal impaired social conduct and that which is pathological can be fine. One of us once gave a dinner talk to an audience of 14, 2 of whom groped each other through about half the presentation. Intense hormonal influences can overwhelm social behaviour, but these effects generally fade, so such activity should probably be labelled pathological only if it persists — say past age 17.
An important strength of our study is that our observations were not limited to audience members. Many of the aberrant behaviours were also exhibited by speakers. An invitation to speak provides brain-damaged individuals an opportunity to display poor social conduct and impaired executive function (even when speaking to executives). Notable among these behaviours was lack of planning, as evidenced by the use of unreadable, "busy" slides. Lack of self-monitoring and self-inhibition was commonly demonstrated by one speaker who repeated most of what the previous speaker had just said; this deficit is not mitigated by first saying "I don't want to spend time on what we've all just heard." Some speakers exhibited lack of planning and lack of empathy, as evidenced by their use of too many slides, which resulted in their speaking too quickly and cramming too much in. Severe frontal lobe dysfunction was demonstrated by speakers who went over time: even in a room with only 100 people, going over by as little as 5 minutes wastes a half-day of collective effort. Localization of this behaviour is complex; we acknowledge, too, that deliberate provocation cannot always be ruled out.
Medical conferences represent immense opportunities for the study of frontal lobe dysfunction. This paper inaugurates the field of neuroconferencology, a topic about which we are glad to speak, given suitable invitation ... by email. Please don't call.
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Footnotes |
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Competing interests: None admitted to by either author.
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