Medical herdology

Lawrence R. Huntoon, M.D., Ph.D. The desire for acceptance and approval by others is an innate human trait that naturally leads to individuals associating with one another in groups. As social beings, we are all creatures of the herd. A herd provides a certain level of comfort and protection in return for individuals relinquishing some of their independence and conforming to the ways of the herd. The seeming contradiction of highly independent physicians joining herds is probably explained by the strong attraction to the path of least resistance to the money. The herd effect manifests itself in many different ways, some good, some bad. These effects are often quite powerful and may not be readily apparent to individuals in the herd. In medicine, most of the herd effect is bad. The nature of our training is such that we spend many years of our lives learning the same material as our colleagues and performing in much the same way. Although this is the means by which the art and science of medicine have been passed on from generation to generation for thousands of years, it inevitably leads to a high degree of conformity among members of the profession. And, although this herd effect produces physicians who achieve a certain level of competence, it can also have negative consequences depending upon the direction the herd takes. In recent years, for example, the direction of the herd has changed, moving away from individual-based patient care to society-based patient care. Many residency programs today, in fact, have graduate medical education competency requirements in “systems-based care.” Priumum non nocere has thus been transformed by this herd effect into: Do the best you can for the greatest number–even if it means harming some individuals. The path of least resistance to the money has also led many doctors to participate in Medicare and managed-care arrangements that require physicians to defer their clinical decision making to untrained medical bureaucrats. These third-party shepherds demand a high degree of conformity, often subjecting the physician herd to a plethora of bizarre and nonsensical rules and regulations that have little or nothing to do with patient care. Clinical pathways, guidelines, ICD-9 - CPT linking, and DRGs all force the herd into accepting a one-size-fits-all philosophy of patient care. Play or no pay is the electrified prod that is used to keep any potential strays in line. And, in recent years, the criminalization of medicine has developed as a further means of instilling fear in members of the herd so as to increase unquestioning compliance. Despite all of this pressure to conform, however, there are still individuals who challenge the thinking of the mainstream herd in various ways. In this edition of the Journal, for instance, Dr. Thomas Gold looks at the consequence of the herd effect on scientific research and progress in his article “The Effect of Peer Review On Progress.” Professor Gold astutely points out that those who demonstrate thought processes consistent with those of the herd are routinely rewarded (grant money, invitations to speak, tenure, etc.), whereas those who propose ideas that challenge the status quo are often shunned. In another article, “Did Litigation and Junk Science Help Bring Down The World Trade Center?”, AAPS General Counsel Andrew Schlafly looks at the herd effect that resulted in the “hysteria about asbestos” as a possible factor contributing to the fall of the Twin Towers in the terrorist attack on September 11, 2001. And, in an era in which “fast food” establishments are threatened with lawsuits for making people fat and certain specialty societies are indignant if anyone dares question the safety of vaccines, the Journal offers “The Retreat of the DietHeart Hypothesis” by Dr. Uffe Ravnskov and “A Case Control Study Of Mercury Burden In Children With Autistic Spectrum Disorders,” by Dr. Jeffrey Bradstreet, et al. No discourse on the herd effect would be complete without considering what happens to those who are targeted for extinction by virtue of their nonconformity. In his article, “Sham Peer Review: Napoleonic Law In Medicine,” Dr. VernerWaite points out that solo physicians, physicians who don’t join the Medicare and managedcare herds, and independent physicians who refuse to be cowed by control-minded hospital administrators are particularly vulnerable to this type of attack. And, despite the utter viciousness of many of these sham peer review attacks, one of the most appalling features of the herd effect is that most other members of the herd simply continue to complacently “graze” nearby, totally unfazed, while one of their own is violently dismembered. Inescapably, the herd is a force to be reckoned with in all of our professional lives. We must be prepared to travel with it or alongside it, to one degree or another, without being trampled or singled out for extermination.And, for those few physicians who still believe in individual-based medicine practiced according to the principles of Hippocrates, and in watching out for one another when one of our own is attacked, fortunately we have the AAPS. We are a fellowship of “different doctors,” and the distinctionis apparent. Lawrence R. Huntoon, M.D., Ph.D., is a practicing neurologist and Editorin-Chief of the Journal of American Physicians and Surgeons. Journal of American Physicians and Surgeons Volume 8 Number 3 Fall 2003