The Big Dirty Secret Every Doctor Knows

–Eminence-based medicine is not the exception. It’s the rule.

Lately I’ve been writing about eminence-based medicine (here, here, and here). In response to these posts Saurabh Jha, a well-known radiologist and health-policy critic, asked me on Twitter: “How do you find these utter gems?!”

I was surprised by Jha’s question. At first I thought it was a silly question. The evidence for this phenomenon— eminence-based medicine trumping evidence-based medicine— is overwhelming.

But then I realized Jha’s question was legitimate, because there’s actually remarkably little hard proof, though I suspect it really is a big dirty secret that every doctor knows in his or her heart.

For this reason I think Bernhard Meier, the interventional cardiologist I’ve been writing about, deserves praise for, at the very least, being so honest and forthright. In his article in European Heart Journal and in his response to my questions he was perfectly willing to explain and defend his position. One of the refreshing aspects of Meier’s positions is that he readily admits that his actions fly in the face of evidence-based medicine. In his EHJ article he specifically states that randomized controlled trials are an artifact of the past. His beliefs and practices, he explains, are developed from his long experience at the pinnacle of interventional cardiology.

By contrast, most eminence-based medicine is dressed up in the guise of evidence-based medicine. The distinguished thought leader will provide a ceaseless barrage of statistics, of which he (or she, but usually he) will have an unparalleled mastery. At each step of the argument the logic will appear flawless, even brilliant. But, in general, the entire purpose of the talk will be to “prove” the thought leader’s opinion despite the complete lack of genuine reliable evidence or disprove the actual evidence that exists because it fails to support that opinion.

But the responsibility for eminence-based medicine goes well beyond the elite coterie of experts. The real problem is the culture of medicine which rewards the hubris of eminence and actively punishes or offers subtle disincentives to anyone who question this process.

In this respect medicine mirrors the rest of life. Medical training is disturbingly similar to military training, where immediate and unreflecting obedience is the goal. Both basic training and residency are designed to break down the mindset and instincts of a young person in order to mold them to the needs of the profession. In both the submission to authority is a central tenet.

It is the rare exception when a physician questions the practice of another physician. I’ve been told by several cardiologists that large portions of the Maryland cardiology community had been aware for years that Mark Midei implanted stents in patients who didn’t need them. No one said anything. In my career as a journalist I’ve stumbled across many similar cases.

Last year Annals of Internal Medicine published an extremely disturbing essay describing several outrageous cases of sexual assault during operations witnessed by trainees. I don’t want to equate eminence-based medicine with sexual assault, but the continued existence of both depends on a submissive medical culture that has no tolerance for questioning the established hierarchy.

The Annals piece was shocking, but even more shocking was a comment from one physician: “I suspect that the real challenge would be to find anyone in health care who does not have a story to tell about such witnessed abuses.”

If physicians can’t stand up against sexual assault how can they be expected to resist the far subtler problem of eminence-based medicine?

I invite readers to share their stories about this topic. I’m particularly eager to hear stories about successful challenges to authority.

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  1. This guy stays on my mind … How many doctors knew damn well what the eminent Farid T. Fata, M.D., was up to?

  2. The best way to deal with this is with 360-drgree reviews. Associates of each doctor are asked to evaluate his performance anonymously, and then the subject doctor is given the results of his reviews. This sort of thing was going on at NASA before I retired in 2014, and it has been used in the province of Alberta for at least 15 years. I would push this one further and make the results public after the first couple of years of feedback to the subject doctor. The evaluators should also include service leaders, nurses, and patients in addition to colleagues. You would be surprised how many acts would get cleaned up.

    • John Kauchick,RN,BSN says

      I introduced this at a hospital I worked at. It cleared the research committee but was dead in the water once it advanced to nursing administration.Recall that IOM compared healthcare culture to Challenger era NASA. I have tried to get leadership in organizations to look inward but their view is fallibility only exists with the front line. To quote a CEO regarding a very famous example: “We have no systems problems.”

  3. Great stuff.

  4. John Kauchick,RN,BSN says

    One thing there is plenty of is literature to document the effects of rigid authority gradients on patient safety. Try getting these types of discussions on the agenda at a conference.There are a few wrongful termination lawsuits that perfectly illustrate the entrenched culture and how aggressively hospitals will attempt to thwart the whistleblower. We almost had a lawsuit that would have had enough worldwide public interest to get the media off of the election, but true to the usual MO, the hospital system was aware of this and added 000’s to the settlement to forever keep its dirty secrets thanks to non disclosure: The Nina Pham Ebola lawsuit.

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