Lately I've been writing about eminence-based medicine (here, here, and here). In response to these posts, Saurabh Jha, MBBS, a well-known radiologist and health-policy critic, asked me on Twitter: "How do you find these utter gems?!"
I was surprised by Jha's question, because the evidence for this phenomenon -- eminence-based medicine trumping evidence-based medicine -- seems overwhelming.
But then I realized Jha's question was legitimate, because there's actually remarkably little hard proof, though I suspect it really is a big dirty secret that every doctor knows in his or her heart.
For this reason, I think Bernhard Meier, the interventional cardiologist I've been writing about, deserves praise for, at the very least, being so honest and forthright. In his article in European Heart Journal and in his response to my questions he was perfectly willing to explain and defend his position. One of the refreshing aspects of Meier's positions is that he readily admits that his actions fly in the face of evidence-based medicine. In his EHJ article, he specifically stated that randomized controlled trials are an artifact of the past. His beliefs and practices, he explained, were developed from his long experience at the pinnacle of interventional cardiology.
By contrast, most eminence-based medicine is dressed up in the guise of evidence-based medicine. The distinguished thought leader will provide a ceaseless barrage of statistics, of which he (or she, but usually he) will have an unparalleled mastery. At each step of the argument, the logic will appear flawless, even brilliant. But, in general, the entire purpose of the talk will be to "prove" the thought leader's opinion, despite the complete lack of genuine reliable evidence, or to disprove the actual evidence that exists, because it fails to support that opinion.
But the responsibility for eminence-based medicine goes well beyond the elite coterie of experts. The real problem is the culture of medicine, which rewards the hubris of eminence and actively punishes or offers subtle disincentives to anyone who question this process.
In this respect, medicine mirrors the rest of life. Medical training is disturbingly similar to military training, where immediate and unreflecting obedience is the goal. Both basic training and residency are designed to break down the mindset and instincts of a young person in order to mold them to the needs of the profession. In both, the submission to authority is a central tenet.
It is the rare exception when a physician questions the practice of another physician. I've been told by several cardiologists that large portions of the Maryland cardiology community had been aware for years that Mark Midei implanted stents in patients who didn't need them. No one said anything. In my career as a journalist, I've stumbled across many similar cases.
Last year, Annals of Internal Medicine published an extremely disturbing essay describing several outrageous cases of sexual assault during operations witnessed by trainees. I don't want to equate eminence-based medicine with sexual assault, but the continued existence of both depends on a submissive medical culture that has no tolerance for questioning the established hierarchy.
The Annals piece was shocking, but even more shocking was a comment from one physician: "I suspect that the real challenge would be to find anyone in health care who does not have a story to tell about such witnessed abuses."
If physicians can't stand up against sexual assault how can they be expected to resist the far subtler problem of eminence-based medicine?
I invite readers to share their stories about this topic. I'm particularly eager to hear stories about successful challenges to authority.
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