Book review: Most fascinating book of 2008: Bad Medicine

By Ron Baker

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 Medicine

The 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.

The Case Against Medicine

The 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.

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 (this is by no means an exhaustive list).

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.
  • 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.

Why is this relevant to accounting firms?

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 accounting firm?

The similarities between bad medicine, the billable hour, and Value Pricing are illustrative.

Even today the U.S. 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 CPAs 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 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?

About the author
Ron Baker is the best-selling author of "The Firm of the Future: A Guide for Accountants, Lawyers, and Other Professional Services;" "Pricing on Purpose: Creating and Capturing Value;" "Measure What Matters to Customers: Using Key Predictive Indicators;" and "Mind Over Matter: Why Intellectual Capital is the Chief Source of Wealth." You can reach him at (707)769-0965, or e-mail at Ron@verasage.com. Ron is a member of the AccountingWEB Bloggers Crew.

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