Most Fascinating Book of 2008: Bad Medicine

By far the most interesting book I read this year is Bad Medicine: Doctors Doing Harm Since Hippocrates, by David Wootton.Wootton is a historian at the University of York. He's no medical profession basher, thanking modern medicine for saving his life and also admitting his daughter is a doctor. You can read more about the book at his Web site.Not only is the book incredibly well written—even if, like me, you have no particular interest in the history of medicine—it's a mesmerizing look at how a supposedly scientific and evidence-based profession rejected new innovations, knowledge, and theories, while stubbornly clinging to their old—and completely ineffectual, if not down right lethal—therapies.The parallels between this and moving beyond the billable hour and timesheets are uncanny.Bad Medicine Drives Out Good MedicineThe history of medicine begins with Hippocrates in the fifth century BC. Yet until the invention of antibiotics in the 1940s doctors, in general, did their patients more harm than good.In other words, for 2400 years patients believed doctors were doing good; for 2300 years they were wrong.From the 1st century BC to the mid-nineteenth century, the major therapy was bloodletting, performed with a special knife called a lancet. Interestingly enough, that is the title of today's prestigious English medical journal, The Lancet.Bad ideas die hard.Bloodletting had its opponents of course, but the debate was over where in the body to draw the blood from, not over its effectiveness.There's a wonderful story about Antonio Durazzini, a doctor who practiced in the small town of Figline near Florence, Italy. In 1622, he reported on an epidemic of a deadly fever, and began tracking the progress of those who could afford treatment and those who could not. The treatment was bloodletting. He concluded in his report:

More of those who are able to seek medical advice and treatment die than of the poor, who of course received no treatment.

Wootton wonders if Durazzini thought the poor were peculiarly robust.The Case Against MedicineThe author makes three devastating arguments.First, if medicine is defined as the ability to cure diseases, then there was very little medicine before 1865. Prior to that—a period the author calls Hippocratic medicine—doctors relied on bloodletting, purges, cautery, and emetics, all totally ineffectual, if not positively deleterious.The term iatrogenesis describes how doctors do harm while trying to do good. It is estimated that one-third of good medicine is a placebo effect, meaning medicine up to 1865 was less effective than placebos today.Second, effective medicine could only begin when doctors began to count and compare, such as using clinical trials.Third, the key development that made modern medicine possible is the germ theory of disease.We all assume that good ideas and theories will drive out bad ones, but that is not necessarily true, especially in medicine. Historically, bad medicine drove out good medicine.As Wootton explains:

We know how to write histories of discovery and progress, but not how to write histories of stasis, of delay, of digression. We know how to write about the delight of discovery, but not about attachment to the old and resistance to the new.

This is not to say that advances in knowledge were not made prior to 1860. Unfortunately, those advances had no pay-off in terms of advances in therapy, or what Wootton calls technology—that is, therapies, treatments, and techniques to cure.So until the 1860s doctors had knowledge of what was wrong but could only use it to predict who would live and who would die.Wootton describes how the advances in knowledge did not change therapies, in perhaps the most devastating conclusion in the book:

The discovery of the circulation of the blood (1628), of oxygen (1775), of the role of haemoglobin (1862) made no difference; the discoveries were adapted to the therapy [bloodletting] rather than vice versa....if you look at therapy, not theory, then ancient medicine survive more or less intact into the middle of the nineteenth century and beyond.Strangely, traditional medical practices—bloodletting, purging, inducing vomiting—had continued even while people's understanding of how the body worked underwent radical alteration. The new theories were set to work to justify old practices. [Emphasis added].

In a reversal of the scientific method, the therapies guided the theory, not the other way around.Diffusing a new theory into a population is no easy task, nor is it quick. Wootton describes in captivating detail how various innovations in medicine were rejected by the medical establishment.Examples of delay and resistance

• Joseph Lister is credited with positing germ theory in 1865, yet there was considerable evidence for this theory dating back to 1546, and certainly by 1700. Prior to this, infections were thought to be caused by stale air and water (even Florence Nightingale believed this).
• Even though by 1628 it was understood that the heart pumped blood through the arteries, the use of tourniquets in amputations didn't happen until roughly a century later.
• The microscope was invented by 1677—simultaneously with the telescope, which lead to new discoveries in astronomy—yet as late as 1820 it had no place in medical research, believed to be nothing more than a toy.
• Penicillin was first discovered in 1872, not 1941, as popularly believed. Its effectiveness was doubted for nearly 70 years.
• The theory that bacteria, not stress, causes stomach ulcers was met with considerable resistance for over a decade.
• Anesthesia was discovered to kill pain by 1795, first used on animals in 1824, then dentists. It wasn't used by doctors in surgery until 1846, in London, and it was degradedly labeled the "Yankee dodge."
• The thermometer was invented in the 17th century, but was not commonly used until 1850 in Berlin, then New York by 1865.
• The medical profession resisted the use of statistics and comparative trials for centuries. The first comparative study was conducted in 1575, but it took until 1644 for the next one. Then John Snow's 1855 account of transmission of cholera in the water was rejected for over a decade. The modern clinical trial dates from 1946.
• Puerperal fever or childbed fever caused one-half of 6 to 9 women in every 1,000 to die in the 18th and 19th centuries. In May 1847, Ignaz Semmelweis, a Hungarian doctor, advocated doctors wash their hand in between patient—and cadaver—examinations. The incidence of fever fell dramatically, but he didn't publish his findings until 1860, which by that time he was considered an eccentric, being confined to a lunatic asylum in 1865; two weeks later he died. (Interestingly, even he still believed the disease was caused by stale air).

Why the delay?Wootton believes the primary obstacle to progress was not practical, nor theoretical, but psychological and cultural—"it lay in doctor's sense of themselves." Consider the psychological obstacles:

Medicine has often involved doing things to other people that you normally should not do. Think for a moment what surgery was like before the invention of anesthesia in 1842.Imagine amputating the limb of a patient who is screaming and struggling. Imagine training yourself to be indifferent to the patient's suffering, to be deaf to their screams. Imagine developing the strength to pin down the patient's thrashing body.Imagine taking pride, above all, in the speed with which you wield the knife, in never having to pause for thought or breath: speed was essential, for the shock of an operation could itself be a major factor in bringing about the patient's death.To think about progress, you must first understand what stands in the way of progress—in this case, the surgeon's pride in his work, his professional training, his expertise, his sense of who he is.Anesthetics made the work of surgery easier. They were no threat to surgeon's incomes. [The] obstacle was the surgeon's own image of themselves.

The cultural obstacles, Wootton believes, are based on a somewhat counterintuitive observation: institutions have a life of their own.All actions cannot be said to be performed by individuals; some are performed by institutions. For instance, a committee may reach a decision that was nobody's first choice.This is especially true for institutions that are shielded from competition and hermetically sealed in orthodoxy. In a competitive market, germ theory might have grown up in a competing company, diffusing into the population much faster than it did within the institutions of the medical community.Wootton also cites Thomas Kuhn's book, The Structure of Scientific Revolutions, wherein he distinguished between periods of "normal science" and science that takes place during periods of crisis. Germ theory was adopted because the medical profession knew it was in crisis.Why is this relevant to PKFs VeraSage?In physics the key barriers to progress are most likely theoretical. In oceanography they might be practical.What are the key barriers to progress in the professional knowledge firm?The similarities between bad medicine, the billable hour and Value Pricing are illustrative.Even today the US Centers of Disease Control reports that 2 million people get infections in hospitals, of those 90,000 die. The largest cause? Failure to properly wash hands.If a supposed scientific and evidence-based profession is this slow to change, what chance do lawyers, CPAs, and other professionals have to move away from the discredited labor theory of value—the modern-day equivalent of bloodletting?In his book Better: A Surgeon's Notes on Performance, Atul Gawande, proposes three core requirements for success in medicine—or in any endeavor that involves risk, uncertainty, and responsibility:

1. Diligence
2. Do right
3. Thinking anew—a willingness to recognize failure, to not paper over the cracks, and to change.

Will CPAs and lawyers resist change for as long as doctors?Are the cultural and institutional legacies that entrenched? Do professionals really define themselves by how many hours they log on a timesheet?I don't know, but the evidence seems to indicate in the positive.Obviously, burying the billable hour and the timesheet is going to be a very long process indeed.Any predictions?