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Some Thoughts on Herd Medicine
Farmer Bernie has 1,000 cows on his dairy farm. He learns that if he adds a certain new antibiotic to their feed, he is likely to experience a 10% higher yield of milk. Unfortunately this antibiotic causes a potentially fatal allergic reaction in about 0.005% of cows. There is a test he could do to identify the allergic cows ahead of time, but the testing is expensive. Also, separating out the allergic cows each day at feeding time would be impractical. What will Farmer Bernie do?
We all know what he will do. He and his Progressive friends are doing it right now, in their administration of our increasingly centralized healthcare system. And in doing so, they have firmly established a set of ethical precepts that perhaps we had better stop and think about.
I am not really a student of philosophy so maybe I am mistaken about this, but I trace the lineage of our current generation of medical ethicists back to Jeremy Bentham. Bentham formalized modern utilitarian ethics and attempted to make it scientific. First, he said, deciding on the ethical path is a simple matter of determining which decision will lead to the greatest good for the greatest number. And second, he insisted that the technique that should be used in making this determination is based on straightforward mathematics. (He called it “felicific calculus,” that is, performing the calculations that will reveal which choice will maximize felicity for society.)
It should go without saying that in the traditional practice of medicine, utilitarian ethics is anathema. Through history, medical doctors have taken oaths to always do what is best for the individual patient in front of them. The doctor’s relationship to the patient is supposed to be the same as the lawyer’s to the client — strictly defending the patient’s individual interests. Without their personal expert acting in a fiduciary role, a patient (like an accused felon) has little chance against the awesome competing interests of society. So according to classical medical ethics, above all else, doctors are obligated to advocate for the interests of their individual patients.
But in an era where healthcare expenditures are collectivized, that is, where society is footing the bill, classic medical ethics no longer make sense. Making the decisions that would optimize medical outcomes for each individual patient obviously would be prohibitively expensive for society. Equally as obviously, such decisions can no longer be permitted.
So, for at least three decades doctors have been trained to make decisions based on utilitarian ethics. I’m not sure the average American doctor would recognize this fact, because their Progressive leaders insist it’s not true, and the utilitarian decisions doctors are coerced into making are disguised sufficiently that, by employing generous portions of cognitive dissonance, many doctors can convince themselves it’s not the case.
As Bentham carefully described, much of the process has been reduced to math. We no longer call it felicific calculus (though I wish we did). We call it the randomized clinical trial.
Your average doctor will tell you that we rely on RCTs because they are the only way we can achieve scientific truth in clinical medicine. And while a well-designed RCT can indeed tell us things we would be hard-pressed to learn by any other method, RCTs do not actually distinguish truth from falsity. More accurately, RCTs allow researchers to do a study that more effectively incorporates the particular bias they wish to incorporate.
Most of the time, what medical researchers (at least the ones working at the behest of the central authority) are interested in is purely utilitarian — determining how to get the most benefit for society for the least money. So this is the bias they build into their research.
Let us do a thought experiment. Assume that you are the chief administrator of Medicare-For-All. Through the actions of evil automaker lobbyists, Congress determines that seat belts are an aspect of preventive healthcare, and therefore, if seat belts are to be required, automakers would have to be reimbursed for them by MFA.
This could be a massive hit to your budget, and suddenly you view seat belts in a whole new light. Fortunately, it is up to you to determine if seat belts are reimbursable. So you set up a study to see if they actually do any good.
You mandate that, of the next million cars sold in the US, seat belts will be randomly removed in half of them at the dealership — after the sales contract is signed, but before they leave the lot. (As the chief administrator for everyone’s healthcare, you are endowed, like Lincoln, with awesome power.) You then wait five years and count the dead people.
The results of this study are reasonably predictable. Auto accidents will account for a pretty small proportion of all the deaths that occur among the people who own those million cars, seat belts or not, and seat belts will likely not significantly reduce the overall mortality of this population. Seat belts will be declared “ineffective” according to the authority of your randomized trial, and you are off the hook.
You could have biased your study differently if you wanted a different result, of course. You could have compared results only in people who had auto accidents (instead of the whole population), in which case you would be far more likely to show a benefit from seat belts. But why would you want to do that? The greatest good for society, obviously, is saving money by not spending it on useless crap.
The game is established. First, mandate that, in order to remain a physician in good standing, doctors have to follow formal guidelines in treating their patients. Second, mandate that, in order for a therapy to be included in the guidelines, one or more RCT has to conclude that it is safe and effective. Third, gain control over designing the RCTs. The first two steps are largely in place. Medicare For All will finally complete step three.
Practicing medicine for the good of the individual, instead of for the good of the herd, would look very different. If seat belts were an option in cars, many would choose to buy them for the sake of their family, regardless of negative results of an RCT. Women with advanced breast cancer might choose to buy a new chemotherapy that has a cure rate of 5%, even though it might not significantly reduce the mortality of the whole population.
But as long as we insist on collectivizing our healthcare expenditures, those kinds of options will become less and less available. The distribution of medical care necessarily will be made on a purely utilitarian basis — to do what’s best for society as a whole — no matter how our overseers attempt to dress it up.
Published in Healthcare
You should submit some version of this as an article for the WSJ opinion section.
The health care system is becoming like the education system.
Good bit of logic there. And let’s not forget that tests under socialized medicine become serialized, each with its own waiting list, because diagnostic equipment costs money and must be rationed. A friend of mine in Canada had a health issue, which was eventually diagnosed as brain cancer. The doctor put her on a waiting list for a test. She had the test with negative results. The doctor put her on a waiting list for another test. She had the test with negative results. Repeat a few more times. She finally was diagnosed months later. By then, they said she was too far along to do anything. It was a very nice funeral.
I broke my back about a decade ago. I had in one day most of the tests she had spread over months and months. Had she been in the US of the time, she might still be alive today.
So, when someone says socialized medicine, remember that diagnostic tests cost money that Medicare-For-All has to pay for. Paying for the funeral, you’re on your own.
Depends on some of the variables (how expensive is the testing and how long will it take to determine), but feed ’em the antibiotic. On a population of 1000 cows a 0.005% rate means he can expect a reaction in 1/20th of a cow. That means that the possibility of a catastrophic reaction (enough cows to put him out of business) is miniscule. Supposing that he feeds ’em the antibiotic and one cow is affected. If it dies it’s still probably covered by the 10% milk yield. If it doesn’t then sell it or slaughter it and don’t bother with an impractical separation.
This gets harder if you assume it’s a real world problem, where real world factors apply. Maybe that 0.005% rejection rate is applicable to a particular strain of cow genetics, in which case a failure would probably affect multiple cows in his herd. Maybe if he goes through with it he’ll find out the salesman was lying and he gets (at best) a 2% increase in yield. Maybe no one wants to buy cows that aren’t roundup-ready.
The salient point is still that cows aren’t people. One may make the cold calculation that risking the life of one cow is acceptable. Unnecessarily risking the life of one person isn’t.
I don’t know where to begin with this.
In treating a patient, my only obligation is to that patient (excepting cases where there is a danger to others, such as homicidal mania or an STD). Perhaps my hospital’s administrators and the insurers and the policy-makers feel otherwise, but it is still the truth. My only obligation is to the patient. I will order whatever labs and meds she needs. I once left a generally-crappy but very easy and secure job because my supervisors faulted me for doing too much imaging. Screw them, I order the tests that I need to take good care of my ladies. My patients’ needs trump my supervisors’.
My patient’s insurer may not approve these tests or meds, but that’s not under my control. She can pay for them out of pocket if my appeal fails.
Every therapy has a risk. The uncommon risks of a therapy are often unrecognized in the RCTs that lead to said therapy coming into use, because RCTs are usually tightly devised to address a clearly defined population. The RCT of seat belts and overall population mortality posited above would be a really lousy study because the index event is so rare. I have never been in a collision in my 62 years.
I have a problem with “scientific” medicine in that statistics apply to populations yet are applied to individuals. Take one of my bêtte noirs, the use of thyroid hormone in patients with subclinical hypothyroidism. RCTs show no benefit to the population of patients with subclinical hypothyroidism, so most endocrinologists eschew such therapy. I embrace it, because SOME patients will respond to this therapy (see #4) and the therapy is essentially harmless. You can’t hurt a cooperating adult with 25 micrograms of T4 daily.
What else? The third paragraph from the end is a little strong. My professional societies have practice guidelines but no Doc is obliged to follow them. If you hurt someone, get brought to the State Board, and show that you have followed professional guidelines, you are pretty certain to be found not at fault.
I’d write more but I just heard Mrs Doctor Robert drive in and I would like to say hello to her. Cheers.
Yes, we Old Farts are more likely to cling to the old ethics we grew up with than are our Whippersnaper colleagues, most of whom have been fully indoctrinated with the social justice and single-payer mantra. The central authority can probably afford to wait us out. (But they do have alternatives.)
Regarding guidelines, I’m extrapolating a bit into the future. There are guidelines and there are guidelines. Professional guidelines are a mixed bag; often they’re designed to foster the prejudices of a particular specialty (I’m thinking of cardiology, my area) rather than those of the central authority. Federal guidelines, I submit, will be a different animal. Under Obamacare, for instance, the pronouncements of the USPSTF have been converted to “must follow” from “ought to be considered.” As nearly as I can tell this aspect of Obamacare has not yet been enforced, but it’s in there in writing when the time comes. As it is (as you point out) there are already plenty of incentives, when in doubt, to be guideline-compliant.
I realize that this is analogy, but there are many other factors that come into play.
If people realize they don’t have seat belts, they can buy their own (in this case, alternative medicine) or drive more carefully (eat well, exercise, lose weight, etc.) to avoid accidents. So adjusting for these variables makes the study even more problematical.
In short, socialism never works in the long run, even though it might seem appropriate to many.
Cows aren’t people. Agreed. What about the reverse?
The convenient thing about “felicific calculus” is that it’s just math. Doesn’t really matter whether you’re dealing with people, cows, or widgets; the calculations are the same. The kinds of trade-offs Farmer Bernie is thinking about with his herd are the same kinds of trade-offs public health experts think about when they decide to urge every human person to restrict their sodium intake to unheard of (and I would argue, unphysiologic) levels. Sure, a few of them may go into renal failure, but you’ll lower the population’s average blood pressure by 3 mm Hg.
So open wide and say, Moo!
There are two trends creating tension. The first is the one you mention and I agree with you. The second is the advances in knowledge regarding the genome which have, to a limited extent, and may, to a great extent, allow for individualized treatment strategies to a much greater extent than in the past. Will the general utilitarian drift under centralized medicine obliterate the potential for person-specific treatments?
I see it as you do. There is already a battle afoot between herd medicine vs. individualized healthcare, the latter enabled by technology (not only genomic medicine, but also things like physiologic sensors tied to personalized processors). It’s an aspect of the more generalized battle we’re seeing regarding whether rapidly advancing technology will enable individuals to protect themselves from centralized control, or rather, empower central authorities to control individual lives.
I fear that our Progressive friends are more alert to this critical issue than we are, since it goes to the very heart of their plans to arrange a perfect, centrally-controlled society. In the (very) long run, however, I am betting on the recalcitrance of human nature, and against final submission.
This is diabolical! It’s so easy to manipulate numerators and especially denominators in order to get stats that express the desired results.
I’m scared enough. Please stop the nightmares. Please. I don’t want my daughter to live that way.
It won’t stop, will it? Sigh.
This happens in sports now. The behind the scenes analytic guys try to calculate the “probably” of winning at any point in the game, or succeeding in a particular play, and therefore what a coach should decide to do, based on league-wide averages.
Hence the sacramentizing of the RCT.
I agree 100%. Even though if that drug is an antibiotic, there is a small but real conflict between the interest of your patient and the future interest of all patients:
Once you correctly determine that your patient has no better alternative than a course of antibiotics, you prescribe them and the interest of your patient outweighs an unintended result: the incremental increase in the speed of the approach of the day when total or near total antibiotic resistance by many pathogens will be the new reality and antibiotic therapy will no longer be available to a future patient. Yes, OK, new science might come soon enough. But let’s not bet the farm on that we don’t have to.
Speaking of farms, your hypothetical farmer is employing a lifesaving drug or a relative thereof for industrial purposes… and we now know that this comes with a substantially greater increase in the spread of antibiotic resistance than does your patient’s treatment. OK, the farmer increases his profit margin, but he also adds an increment of risk to every human being who might potentially benefit from an antibiotic in the future.
He may provide milk (with federal milk price policy that’s not the cleanest example but let’s ignore that) at a slightly lower cost. In doing so he profits, which is fine but he does so by damaging a common good: the utility of antibiotics.
It won’t stop at least until some critical mass of people understand what they’re doing.
I have to confess I was a little confused by the Bernie-and-his-cows analogy. I didn’t “know what what he [would] do.” Antibiotics in cattle feed is an environmental hot button issue. At first I thought that, because of his progressive ideology and the absolute authority of the FDA, Bernie would most certainly not be giving his cows antibiotics.
After reading the whole post and all of the comments, I realized I was 180-degrees wrong. Bernie actually has autonomy, and in fact is a medicare-for-all proponent for cows. Bernie’s cost-benefit analysis says “dose the whole herd.”
Please tell me I’ve got it now.
There does tend to be significantly fewer high tech diagnostic equipment in advanced nations that have socialized medicine. Here is a list by the CDC of the number MRI units and CT scanners per capita in various nations.
There are probably many long-term implications of Farmer Bernie’s decision I have not considered. But why should I worry about it any more than public health experts did when they insisted that trans fats be added to our food, or that we cut out all dietary fat, or that we severely restrict our salt intake? If things turn out badly, they just indignantly move on to the next thing as if it never happened.
You’ve got it now.
The public health literature is fully corrupted with utilitarian thinking, presumably because the government already is the dominant player in the healthcare system. A complete takeover of healthcare by government will only exacerbate this but we’re already far down that road. In the meantime, each citizen must take on a greater responsibility to learn about relevant drugs or treatments: their efficacy and dangers. Unfortunately not everyone is up to the task of reading NEJM, JAMA, The Lancet, PLoS Medicine; that’s why people hired physicians to do that work for them: division of labor. The only other solution, for those who can afford it, is to hire a physician somewhat outside the system, e.g., concierge practice. As usual, socializing a private function leads to more stratification of access to quality service, not less.
Apropos of this comment: http://ricochet.com/547592/charmed-substances/
It’s a serious medical issue. Both the medical use (and, unfortunately, abuse*) and the agricultural use of antibiotics contribute to the spread of antibiotic resistance but agricultural use is by far the greater problem. Barring a brand new, much hoped for, and not yet discovered approach to treating bacterial infections, the era of reliable antibiotic miracles is reaching its expiration date and is may not even outlast the centennial of the first clinical use of penicillin.
*One of the more egregious examples is giving antibiotics for a diagnosis of the common cold. This has been going on in the face of scientific and academic objection for many decades.
There are busy physicians might diagnose a cold and prescribe antibiotics (which is lousy medicine) and busy physicians who think the patient had a concurrent or concomitant bacterial infection, prescribe antibiotics and fail to enter the rationale for that in the chart. Which is lousy medicine for another reason. The latter dereliction will tend to confound chart review type studies of outcomes for patients with colds given antibiotics.
Using them in clinical medicine does some potentially quantifiable harm (spread of resistance; for this discussion not considering allergies, etc.) but the probability of wider harm done for one course of antibiotics for one patient is very small.
That said, having antibiotics available that are likely to be able treat life-altering or life-ending illness in a properly selected patient – or, as in the case of, say, anthrax exposure prevent such illnesses is a much greater good – so they ought not to be used frivolously. If you’re in your 60s, you’ve been seeing journal articles decrying the prescription of antibiotics for a diagnosis of “common cold” for your entire career, and there are still clowns who are doing it. Herd organizations like Kaiser and its fanboys come down on crap like that.
In any case, I’m contending that that the continued wide clinical utility of antibiotics is, in a sense, a commons. Herd use of the Farmer Bernie type is demonstrably damaging this commons.
This has been a concern of mine for decades, now. Population-centric medicine means that only the central area of the distribution curve is being treated effectively– say, two standard deviations, at best. The outliers (~5%) are not. .. and everyone is probably an outlier in some dimension/characteristic.
There was a House episode that illustrated this. The doctor cured a patient but was fired for not following guidelines that would be more probable to cure the most people. Liability avoidance behavior, perhaps.
I tried to express this thought to my PCP once. We obviously did not communicate clearly.
As an ER doc, I believe I could publish a study that shows that seat belts cause accidents.
When patients present to the ER after an accident, nearly 100% of the patients report they were wearing their seat belt.
But studies show that only about 70% of people wear their seat belts while driving.
QED seat belt wear correlates with higher accident rates.
Ain’t statistics fun?
What’s also an interesting exercise is to look at people who made sound nutritional recommendations when the herd of independent minds was going another way.
Weston A. Price is one, and he wasn’t just more right than Keys about macronutrients. In 1945, Price asserted that there was something present in certain foods which was involved in calcium metabolism, which was fat soluble, and which was not vitamin D. He called it “Activator X,” and the existence and identity of Activator X was an ongoing topic of discussion among Price’s followers for decades.
Masterjohn presents a convincing argument that Price was describing vitamin K2.
It’s voodoo math.
The evidence that the use of antibiotics in domestic animals such as cattle and chickens is causing human resistance to antibiotics is controversial. It seems as though it would be a problem, and so the practice is a popular target for concerned citizens. But the reality is that the jury is still out on this issue. My daughter did a research paper on this practice vis-a-vis mastitis in cows. She wrote the paper ten years ago. I haven’t read it lately, and I forget how she and her fellow researchers reached their conclusion. But it had something to do with the kind of antibiotics used in agriculture versus human health care.
The biggest problem in the use of antibiotics was caused by the medical profession and the pharmaceutical companies. From the day they made their appearance in health care, doctors have always known that resistance would be a problem. That was why they removed tonsils that potentially stored strep bugs rather than prescribing penicillin five times a year. Now doctors don’t take tonsils out. That means there are more strep bugs in circulation. The herd medicine model at work.
There is a herd immunity benefit from the use of antibiotics. I find it bizarre that we talk about it in terms of immunizations but not in terms of antibiotics. It was not the Spanish flu that killed millions of people. In actuality, it was a bacterial pneumonia bug that was traveling along with the flu and infecting the flu-weakened people.
Furthermore, originally, within my lifetime, doctors would take sputum samples and send them to a lab for analysis. The lab tech would open up ten Petri dishes with different antibiotics in each one and administer a drop of the sputum in each one. Then watch. In whatever dish the antibiotic worked against the microbe in the sputum, that was the antibiotic that was prescribed. The medical world did this to prevent superinfections from gaining ground. They handled antibiotics with great care.
Then came along “broad-spectrum antibiotics.” These eliminated the delays and expenses that went with culturing sputum or body tissue. But they may be also partly responsible for the rise of superbugs. They are a great drug to use if time is of the essence and we need to treat someone without knowing what bug is causing the problem. But for most other nonemergency uses, we need to go back to culturing the infection and giving patients the right antibiotic.
Not treating infections with antibiotics is not a good answer. There were 172 child deaths related to the flu in 2018. That is just plain unacceptable. The flu kills very very few people. These deaths were caused by secondary infections. Infections in children or other patients who are already weakened by flu or some other problem move fast. These bacteria are nature’s decomposers. They multiply and overwhelm their target astonishingly fast.
Blanket prohibitions against the use of antibiotics will lead to unnecessary deaths.
A postscript to my comment 29 above: I question the prevailing notion that doctors overprescribe antibiotics. Granted, my experience with doctors is all I’m basing this question on. However, the Massachusetts doctors I have worked with in caring for my three kids, my husband, my mom, and me did not prescribe antibiotics until they were absolutely sure there was a true infection. And the antibiotics always worked. So they were right when they did prescribe them. I think there were quite a few times when they missed infections that should have treated with antibiotics. It would be easier in the state of Massachusetts to get heroin than to get an antibiotic prescription.
I’d be willing to be that the emergence of superbugs is not the fault of doctors’ overprescribing antibiotics to people who don’t actually need them. There is something else in play here.
Public opinion on medical care is often incorrect. I remember when I was a kid the thinking was that eating greasy food like potato chips caused acne. My poor sister suffered from acne, and people were always chastising her for what she ate. They constantly blamed her for the problem. When my own daughter had acne, I took her to a dermatologist who prescribed an antibiotic. My daughter took it when we got home, and the next morning, when she got up, her skin was perfectly clear. Son of a gun. It was a clogged skin pore that had become infected. The same thing happened with stomach ulcers. The medical professionals used to tell people to “calm down.” They blamed the patients for their pain. One day the researchers discovered it was actually a bacteria causing the ulcer to get inflamed. It wasn’t lifestyle after all.
I’m just saying that our desire to blame people for their problems can blind us to real causes. Now we’re trying to blame the doctors and patients for the emergence of superbugs. I’m betting there’s something else at work here.