Friday, December 5, 2014

How nostalgia killed Dr Singer's capacity for rational thought


A Facebook friend recently has been sending around a 2013 article/toddler-grade tantrum by Dr Jeffery Singer, general surgeon/old man sitting on a park bench. Let me tell you, it's a tear-jerker:

These rules are being bred into the system. Young doctors and medical students are being trained to follow protocol. To them, command and control is normal. But to older physicians who have lived through the decline of medical culture, this only contributes to our angst.

One of my colleagues, a noted pulmonologist with over 30 years’ experience, fears that teaching young physicians to follow guidelines and practice protocols discourages creative medical thinking and may lead to a decrease in diagnostic and therapeutic excellence. He laments that “ ‘evidence-based’ means you are not interested in listening to anyone.” Another colleague, a North Phoenix orthopedist of many years, decries the “cookie-cutter” approach mandated by protocols.
God forbid you should go to work and find rules "bred into the system" that restrict your ability to do whatever the hell you feel like doing. I'm sure no one but doctors ever feels that pain.

This all seems very sad, but when a doctor opines that evidence-based medicine "means you are not interested in listening to anyone" you have to understand that as code for "You aren't listening to me." Because until startlingly recently, that's how virtually all medicine worked; the leading lights of the profession laid down the law, and that was the standard of practice.

There are now standardized grades of evidence, starting with multiple randomized controlled trials and extending downwards through observational studies and case reports and at the very bottom, "expert consensus" (i.e., this is what we believe but we have no proof of any kind.) This quality of evidence is known colloquially in the industry as GOB-SAAT. Good Old Boys -- Sitting Around A Table. Before evidence-based medicine, we had eminence-based medicine.

Dr Singer's hatred of protocols -- things like washing your hands between patients, pausing before surgery to confirm you're doing the right surgery on the right patient, or observing low-risk head injuries in children rather than irradiating their brains -- is common in physicians, but in Dr Singer, it has been amplified by ideology:
Ayn Rand’s philosophical novel Atlas Shrugged describes a dystopian near-future America. One of its characters is Dr. Thomas Hendricks, a prominent and innovative neurosurgeon who one day just disappears. He could no longer be a part of a medical system that denied him autonomy and dignity. Dr. Hendricks’ warning deserves repeating:

“Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.”
What are we to think of a man with a responsible job and most of his career behind him who has the intellectual interests of a socially stunted 14-year-old? These are questions I cannot answer.

To try and interest us in what is essentially an irrelevant paean to his own nostalgia, Singer's lards up his argument with predictions of disaster aplenty (All the doctors will quit! Except for the brain-dead younger generation weak enough to tolerate the intrusion of "so-called 'evidence-based medicine,'") some of which are really funny in their own right:
 In other words, we’re about to experience the two-tiered system that already exists in most parts of the world that provide “universal coverage.” Those who have the financial means will still be able to get prompt, courteous, personalized, state-of-the-art health care from providers who consider themselves professionals. But the majority can expect long lines, mediocre and impersonal care from shift-working providers, subtle but definite rationing, and slowly deteriorating outcomes.
Yes, if nothing is done, we will soon experience the universal free healthcare that delivers better health outcomes at half the cost in the UK and Canada -- a model so wildly popular in those countries that right-wind politicians get nowhere near office without swearing to protect and defend it.

But the real punchline here is his claim of "slowly deteriorating outcomes." The outcomes are better than ours, but in the confines of Dr Singer's Rand-poisoned mind, that simply means they are deteriorating too slowly for the terrible and inevitable decline to be evident to the causal observer.

Back in the reality-based community, things look rather different:
The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity. In this edition of Mirror, Mirror, the United Kingdom ranks first, followed closely by Switzerland (Exhibit ES-1).
Protocols have good and bad points. I deal with frustrating and clinically counterproductive protocols every day. If you are going to spend seven years training a doctor, you should probably leave room in the system for them to exercise their clinical judgement. But many protocols are proven to improve patient outcomes. So if they make our days as doctors a little less fun, so be it. And evidence-based medicine, like free speech, is best answered by more and better evidence, not nostalgia for the days when the stand of care was "I got a hunch." Fuck GOB-SAAT.