Monday 19 August 2013

Hiding in the herd

I had a conflict of interest while operating the other day. I had a patient with a hip fracture that needed surgery, and a knee fracture (on the same side) that would normally be fixed surgically but according to my criteria (decent evidence), it wasn’t necessary. I would not have been criticised for doing the surgery (in fact, my trainees had already consented the patient, thinking that I would). Further, I expected some criticism for not doing the surgery, and I would have felt terrible if the result of my non-operative treatment had been poor. The conflict? I would have been paid a lot of money to do the surgery, and got paid nothing for treating it non-operatively. I was tempted to hide in the herd.

It is just too easy to do what everyone else is doing. Not that the herd is always wrong, in fact it is probably mostly right, but that’s why it’s such a good place to hide.

Herd behaviour is one cause of the perpetuation of poor practice. Think back to blood letting; that took a few thousand years to stamp out and was driven largely by herd behaviour. So what are the causes?

Let’s face it; it is simply easier to do what everyone else is doing. And when everyone else stops doing it and moves on to the next fashionable treatment or the latest device, join in. This is how many doctors learn and practice medicine, and it explains a lot of the regional variation in medicine. Again, the herd is probably right most of the time, but sometimes a little more scientific enquiry would reveal holes in the way we practice. Unfortunately, bucking the trend is hard work, leaves you exposed, and takes effort to justify.

Secondary gain
I think there is a problem with the way surgery is funded in the private system in my country, and in many other countries. Surgeons get paid very well (often thousands of dollars) to operate, and very little (often nothing) not to operate. If an operation is common practice, no one is going to look too hard at the evidence so as not to spoil the party.
Why is the medical intervention rate for procedures like coronary surgery and stenting in Germany and the USA five times higher than in the UK? The people aren’t that different, but the funding model is.

Nobody wants to be out of fashion. We want to keep up with fashion, and some want to set the trends. New is perceived as better. Innovation is accepted as improvement, by default.

Lack of external control
There is a problem with autoregulation of the professions. Who is going to protect the public from overtreatment? Not those already doing the overtreating; they are biased by their own perception, not to mention financial and professional conflicts of interest. But in this regard, doctors are no worse than any trade or profession. Do you really think lawyers don’t overservice?

Lack of scientific rigour
This is related to laziness (rather than look something up, just go with the flow), but there is also a general lack of understanding of the scientific method and the biases that influence our treatment decisions. Even when an effort is made to find the evidence, many doctors do not have the necessary skills to properly appraise the studies they find. And this is separate from the lack of scientific rigour in the studies themselves, which leads to an overestimate of the treatment effect.

The bottom line
There are multiple problems here: doing what has been done by tradition, doing what everybody else is doing because it is easier and pays the bills, doing what is in fashion, and a failure to recognise the biases that drive overtreatment and persistent ineffective treatment. With so many driving forces and little to stop it, ‘standard practice’ becomes a very big ship to turn around, or a very big herd to corral. 


  1. Dr,

    I deal with this everyday in the therapy world. My colleagues are content with living in the wild west of no evidence past and continuing with the same old treatment paradigms just to keep the money flowing.

    When I do clash professionally about what I am doing (following what the evidence and science suggests), it is almost as if I am speaking to a child. No thought whatsoever is given to what the evidence (how many times can I say that word?) says, but rather only to what is supposed to be done, i.e. following the herd.

    It's enough to give a young clinician a headache.

    Rant over. Good post.

    1. you are not alone - gets 'older' therapy clinicians too. Does that make us a sub herd?!

  2. 'Hiding in the herd', (actually all posts on this blog) are painfully relevant to me and reflect my experience following the elective 'cosmetic' procedure to 'cure' sweaty palms (sympathectomy) when I delved into the literature and realised the extent of fabrication, lies and deceit that goes on. The misrepresentation of this procedure and the extent the medical professionals can get away with the 'medical myth' as scientific fact is mind boggling.
    I am taking legal action due to lack of INFORMED CONSENT, wilful misrepresentation and injury caused by this procedure, and was hoping that you would be willing to apply your medical expertise and skepticism to review the procedure and the literature.

    My recurrent experience with medical professionals is that when they are asked to comment, they go back to the 'herd-mentality' and are reluctant to scrutinise the pompous silliness that is pretending to be a scientific fact. Sadly these have been repeated so many times, that most (all?) seem to be unable to think critically and question the credibility or validity.

    I would love to have you on my case as my medical/surgical expert. Please let me know if you are willing/able to provide a medico-legal expert opinion.
    Mia (at)

    1. Thanks, somebody had mentioned this procedure to me once before and I briefly looked it up. I will put it on my ever-expanding list of procedures to write about but because it is not my field, I would not be qualified to provide an expert opinion.
      Your blog is interesting and there are many links there to get me started on a blog for this topic.

    2. I only discovered the reply. Thanks for responding.
      You raise interesting issues in your answer, the issue of competence. Sympathectomy is performed by vascular or thoracic surgeons (in rare circumstance by neurosurgeons, but you would have to look hard to find someone from within that speciality offering this procedure). I wonder how much training and understanding these specialties have of the ANS and it role in other contexts (apart from hyperhidrosis or blushing)? While they might be trained to navigate within the thoracic cavity, they are hardly experts in the field of neurology and the ANS. And that is why when reading the rationale for this procedure, most of what you find is half-truths and fake science to justify the procedure.
      NICE recently updated their guidelines on the procedure, but all they consulted in the process were the British Thoracic Society, Vascular Society of Great Britain and Ireland, and Association of Surgeons of Great Britain and Ireland. This not only ignores the above point but fails to take into consideration the inherent bias and conflict of interest.
      The advice on treatment (and sympathectomy) varies greatly once it is not from the surgeons who directly profit/benefit from promoting and offering the intervention. For example the British Association of Dermatologists has a different 'take' on the procedure and does not seem to ignore the literature that has been published on the subject:

      Please consider writing on the subject of this surgery, as even medical professionals (who would be expected to advise the public on this issue) are often not knowledgeable about these procedures, and the best they do is reach for an article or two that was published by a surgeon intent to promote his brand and success. The fake science should be exposed, and the advertising of these procedures better monitored.


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