The Fallacy of Eminence in Medicine

Date: June 29, 2024 Reference: Herbert L. Fred M.D. (1998) Old-Fashioned Doctors, Hospital Practice. This is an SGEM Xtra episode. I was honoured to be invited by Dr. Fernada Bellolio to the Mayo Clinic and present to the Department of Emergency Medicine. They were kind enough to allow me to speak about any topic. I decided to talk about an article Dr. Herbert L Fred published in 1998. You can get a copy of the slides by clicking on this LINK. When I say the term “Old fashioned” what comes to mind? Every generation of adults has been critical of the younger generation. This goes back a very long time. There is a wonderful comedy sketch by Monty Python called Four Yorkshiremen. These successful old men talk about how hard it was when they were growing up. One man complained he “lived for three months in a paper bag in a septic tank. We used to have to get up at six in the morning, clean the paper bag, eat a crust of stale bread, go to work down t' mill, fourteen hours a day, week-in week-out, for sixpence a week, and when we got home our Dad would thrash us to sleep wi' his belt.” This prompts another man to say… “luxury”. If you have never seen the Monty Python skit you check it out on YouTube. There is also a 90-second video that illustrates older generations crapping on the younger generation for thousands of years (The History of Adults Blaming the Younger Generation). Now that we have discussed the concept of being old-fashioned in general, let’s talk about old-fashioned doctors specifically. Isaac and Fitzgerald in the BMJ 1999 described seven alternatives to evidence-based medicine (EBM). One of the alternatives they were suggesting with their tongue firmly in their cheek was an old-fashioned doctor practicing Eminence-Based Medicine (EmBM). “The more senior the colleague. The eminent physician with the white hair and balding patch are called the “halo” effect. They place less importance on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as ‘‘making the same mistakes with increasing confidence over an impressive number of years.” Dr. Herbert Fred This brings us to the article that this lecture is based on. Dr. Herbert L Fred wrote an opinion piece in the journal Hospital Practice in 1998. Dr. Fred was born in Waco Texas, went to medical school at Johns Hopkins, did his internal medicine at the University of Utah, served in the US Air Force and then went on to teach for nearly 6 decades at Baylor College of Medicine and The University of Texas Health Science Center at Houston. In his article, Dr. Fred commiserated by saying “In the 40 years that I have been a full-time medical educator, much has changed regarding what we teach and how we teach our students and house officers. As a consequence, I now confine myself to teaching basic medical principles-principles that should never change. But even so, today’s trainees tell me that what I say and do is old-fashioned.” It sounds like a little bit of ageism from his students. His article responded with what could be interpreted as some ageism about the students. Reading the article it can come across as condescending and paternalistic giving off a strong "OK Boomer" vibe. After Dr. Fred makes a dozen complaints, he concludes the article with “If so, then I am proud to be old-fashioned.  And I believe that if more doctors today practiced medicine the old-fashioned way, our profession might regain some of the nobility and respect it once enjoyed.” I posted this article to social media asking if others considered themselves “old-fashioned”. The vast majority of people responded with positive comments and emojis. However, some pointed out another valid perspective about the condescending tone and ageism expressed in the article by Dr. Fred.