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.

I wanted to go through ten of his comments and show how these things are not necessarily old-fashioned or new-fashioned but rather timeless axioms of good medical practice.

1. Time With Patients

“Is it because old-fashioned doctors spend whatever time it takes to obtain a good medical history and physical examination?”

Seriously, we all would probably like to spend more time with our patients. Back in the 1960’s the emergency room was literally a ROOM. There was no specialty of emergency medicine (EM). The physician could take time and sit at the bedside longer and focus on the one patient in the only room.

Things have changed significantly and it is now an emergency DEPARTMENT (ED). There is also the current reality of metrics forcing doctors to move faster, be more “efficient” and “meet ‘em, greet ‘em and street ‘em”.

Then there is the dumpster fire of COVID-19 leading to the entire healthcare system seemingly signing out to the ED. We are expected to do primary care, manage post-op complications, be mental health experts, substance use disorder specialists, etc, etc, etc.

Wanting to spend more time with most patients is usually something we all want whether you are a young or old doc.

2. Patient Records

“Is it because old-fashioned doctors routinely seek all of the patient’s previous medical records, not just the discharge summaries?”

Previous records were sometimes only one index card for General Practitioners or pediatricians. The addition of electronic health records (EHRs) has led to a huge increase in the length and redundancy of medical records. It has been for a variety of reasons including medical-legal and billing purposes. This problem has been coined the “Note Bloat” and there are initiatives to try and address this problem (Rule et al. JAMA Network Open, 2021).

How can you possibly find the signal in all the noise? Finding the information you need can be like trying to find a needle in a haystack. Systems are now being explored to use Large Language Models (LLMs) of narrow Artificial Intelligence (AI) to find relevant information clinicians need.

In addition, EHRs have been identified by physicians as one of the top reasons for burnout (Budd J. 2023 and Alobayli et al 2023).

3. Sophisticated/Expensive Tests

“Is it because old-fashioned doctors do not order sophisticated, expensive studies when simpler and cheaper procedures can supply the needed information?”

It’s pretty easy not to order sophisticated/expensive tests when you don’t have them. Who wants to go back to tasting urine to diagnose diabetes? Has anyone in this room done a diagnostic peritoneal lavage lately? Residents are using point-of-care ultrasound (POCUS) more and more.

CT scanners are better than plain X-rays for diagnosing head, neck and abdominal injuries. They can also find surgical abdominal pathology missed on the exam or even missed ultrasounds. Sure, we can be too quick to pull the trigger on the donut of truth but diagnostic imaging has often improved our ability to diagnose people correctly.

4. Brains and Hearts

“Is it because old-fashioned doctors use their brain and their heart, not an army of consultants, to manage their patients?”

This comment misses the mark. In 30 years of practice, I have seen wonderful caring young physicians who don’t rely on an army of consultants to manage their patients. Can anyone validate that with their experience? Have you worked with smart and kind residents?

For the residents, have any of you worked with an older physician who was unkind to a patient and seemed to consult on every patient?

I think brains/hearts have less to do with age and more to do with the individual’s practice styles and personality types.

5. Treat Patients Not Numbers

“Is it because old-fashioned doctors treat patients, not numbers?”

I agree that we should treat patients, not numbers. Treat patients as people, not statistics. However, did old-fashioned doctors treat patients as people?

  • 14th Amendment: This is when black people were finally recognized not as property (1868) yet 150 years later we still see racial disparities in the House of Medicine. There continues to be racial bias with multiple lines of evidence supporting this claim.
  • 19th Amendment: Women got the right to vote (1920) yet 100 years later female patients are still treated differently in the house of medicine. Hysteria/hysterical used to describe neurotic conditions in people (women) with uteruses.
  • American Psychiatric Association (APA): In 1973 the APA removed the diagnosis of “homosexuality” from the second edition of its Diagnostic and Statistical Manual (DSM). There was a lot of stigma around gay male patients especially in the late 1980s and 1990s during the height of the HIV/AIDS epidemic. Were these men treated as patients, not numbers?

Now we have trans and non-binary people fighting against discrimination. I would advocate that physicians treat every patient as a person with kindness no matter what size, shape, colour or how they identify.

6. Pill for Every Ill

“Is it because old-fashioned doctors do not blindly administer a ton of drugs in an attempt to alleviate every possible ill?”

This is another case of it being easy not to treat patients with lots of drugs when we had few defined diseases in the past and very few medical therapies.

In 1899 Bayer Aspirin was patented. However, the medicinal properties of salicylic acid go back to 4,000 before the common era (BCE). Over the last one-hundred, we have had several wonder drugs that can prevent illness and save lives. Sure, some patients deny any medical history and then bring out their medications. But if you had a heart attack in the past you would get aspirin, morphine and nitroglycerine. Now you will also likely get dual anti-platelet therapy, ACE-I, Beta-blocker and statin. These have been shown to improve outcomes after an ST-elevated myocardial infarction (STEMI).

Yes, there is over-testing, over-diagnosing, and over-treating. But some pretty amazing drugs can save lives. Vaccines, antibiotics, diabetic drugs (insulin, metformin, flosins, GLP-1), antipsychotics (lithium), birth control pills, asthma drugs (beta-agonists, inhaled corticosteroids). Modern medicine has contributed to the dramatic increase in life expectancy.

7. Intervention Bias

“Is it because old-fashioned doctors recognize that doing nothing is, at times, doing a lot?”

Intervention bias has existed forever. It is part of human psychology and not unique to young doctors.

As an example, USA President George Washington died in 1799 at the age of 67 after suffering from a fever, lethargy, sore throat difficulty swallowing and breathing. The old-fashioned physicians did bloodletting and removed ~40% of his blood.

Bloodletting was the standard of care. In addition, Washington gargled with molasses, vinegar and butter; he inhaled a steam of vinegar and hot water; and his throat also was swabbed with a preparation of dried beetles. It is possible he would have survived if his physicians just stood there or skipped all these things and just did a tracheotomy.

Another example of intervention bias from the past involves another president. George W. Bush was considered physically active and fit at age 67. Asymptomatic coronary artery disease was discovered at his annual physical. As a result, the physicians put in a stent despite a lack of evidence of benefit compared with initial medical therapy for the prevention of death, nonfatal myocardial infarction, unplanned revascularization, or angina.

Intervention bias is not a new-fashioned or old-fashioned doctor problem but rather human psychology that biases people into action rather than inaction. I learned from my mentor Dr. Jerry Hoffman to be on guard for intervention bias. To do things that have been demonstrated to benefit patients. Without sufficient evidence, the advice is “Don’t just do something, stand there”.

8. Natural History of Disease

“Is it because old-fashioned doctors understand that patients often get well despite what we do, not as a result of what we do?”

Also, I’ve seen “old-fashioned” docs claim someone got better because of what they did. This can be a logical fallacy, specifically, post hoc ergo propter hoc (after this, therefore because of this). Think of giving people ketorolac for renal colic. Shortly after administration of a non-steroidal anti-inflammatory (NSAID), the pain subsides. Is that because of the treatment or the natural history of colic? I’ve seen both young and old physicians commit this logical fallacy when the intellectually honest answer would be we don’t know if the improvement was caused by our actions.

The first known systematic study of logical fallacies was by Aristotle (Sophistical Refutations). He listed thirteen types of fallacies.

9. Kindness

“Is it because old-fashioned doctors realize that good rapport with their patients is their best protection against lawsuits?”

This one speaks to me about kindness. We should be kind to all our patients, staff and ourselves. If one of the secondary things is less likely to be sued then fine, but this should not be the primary reason to have a good rapport with patients.

We often know so little about our patients’ lives and experiences. Many are fighting a hard battle we know nothing about.

I do like this quote from Aldous Huxley: “It is a little embarrassing that, after forty-five years of research and study, the best advice I can give to people is to be a little kinder to each other.”

This is not old-fashioned or new-fashioned. It is just an axiom, a truism, a timeless piece of advice that we should be kinder to each other.

10. I Don’t Know

“Is it because old-fashioned doctors are aware of their own fallibility and are never afraid to say, “I don’t know”?

Maybe it is safe for a senior physician to say I don’t know because they are privileged. This is different than a resident acknowledging a knowledge gap or their fallibility.

We as attending need to create an environment where it is ok to say “I don’t know”. It is our job to help them find the fallibility. It is an unrealistic expectation for learners to get every question right. Medical knowledge has expanded so much since we were going through our training as older physicians. New physicians can’t memorize everything. We should focus more on teaching residents how to think, rather than what to think. Give them the critical appraisal tools to evaluate evidence. Make a safe space for them to be wrong and explore their knowledge gaps.

There are some great quotes by physicist Richard Feynman. This is one of my favourites. “We need to teach how doubt is not to be feared but welcomed. It’s OK to say, I don’t know.

At the end of the day, it is not about being old-fashioned or new-fashioned. It is more about being on what I like to call Team Patient. It starts with patient care and ends with patient care. Our decisions should be centred around what is in the best interest of the patient. Some things are timeless: Providing patients with the best care, based on the best evidence and with kindness.

The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence.