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?

Laziness

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.

Fashion

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.