PEOPLE AND POPULATIONS:

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PEOPLE AND POPULATIONS HAVE WE LOST SIGHT OF THE
INDIVIDUAL IN EPIDEMIOLOGY AND PUBLIC
HEALTH? Leon Gordis December 13, 2006
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An Era of Depersonalization
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The Numbers Are Individual People
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(No Transcript)
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Macroenvironmental or Microenvironmental Factors
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Epi Demos
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THE INDIVIDUAL IN RESEARCH
- Studies of disease risk and etiology
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Comparison of Patients with Adenocarcinoma and
Matched Controls
cases
controls
p-value
Herbst et al, 1971
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THE INDIVIDUAL IN RESEARCH
- Studies of disease risk and

etiology - Health services research
and other evaluation
studies
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Use of Large Data Sets
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Advantages Of UsingLarge Data Sets

• Data refer to real-world populations, so that the
  problem of representativeness or
  generalizability is minimized
• Because data have already been collected,
  analysis can usually be completed quickly and at
  lower cost
• Sample size is usually not a problem except in
  specific cells

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Disadvantages of Using Large Data Sets - I
1. No data or limited data on many relevant
variables
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Disadvantages of Using Large Data Sets- II

• No data or limited data on many relevant
  variables
• Investigators may be tempted to let the
  data set determine what questions to ask

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DISADVANTAGES OF USING LARGE DATA SETS - III

• No data or limited data on many relevant
  variables
• Investigators may be tempted to let the data
  set determine what questions to ask
• Investigators become progressively more
  removed from the individuals being studied

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Depersonalization in Clinical Medicine
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The competent physician, before he attempts to
give medicine to his patient, makes himself
acquainted not only with the disease which he
wishes to cure, but also with the habits and
constitution of the sick man.
Cicero, De oratore II
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It is more important to know what sort of
patient has a disease, than to know what sort of
disease a patient has. William Osler, quoting
the older physician, Parry of Bath
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One needs very much to feel that the unique
individuality of ones spouse has not been lost
in the common symptoms of a clinical
condition. John Bayley Elegy for Iris
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Sickness or Illness
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Before the mid-20th century, what therapies did
physicians have to offer patients that elicited
so much respect, gratitude and veneration?
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Why does this patient have this disease at this
moment?
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CLASSIFY AND AGGREGATE
REFINE CATEGORIES AND REDUCE THE NUMBER OF PEOPLE
IN EACH
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CLASSIFY AND AGGREGATE
FEWER LARGER GROUPS
MORE SMALLER GROUPS
REFINE CATEGORIES AND REDUCE THE NUMBER OF PEOPLE
IN EACH
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To produce another Wolfgang Amadeus Mozart, we
would need not only Wolfgangs genome, but his
mothers uterus, his fathers music lessons, his
parents friends and his own, the state of music
in 18th century Austria, Haydns patronage, and
on and on, in ever widening circles. Leon
Eisenberg NEJM, 1999
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Without Mozarts set of genes, the rest would
not suffice But we have no right to the
converse assumption that his genome, cultivated
in another world at another time, would result in
the same musical genius. Leon Eisenberg
NEJM, 1990
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Under the current understanding of
evidence-based medicine, the individuality of
patients tends to be devalued, the focus of
clinical practice is subtly shifted away from
the care of individuals toward the care of
populations, and the complex nature of sound
clinical judgment is not fully appreciated. EBM
currently fails to provide an adequate account
of optimal medical practice. Mark
Tonelli Academic Medicine, 1998
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After 1970, medical faculties
generally followed the same approach they had
all century long encouraging house officers to
order more diagnostic tests, not less to do
everything that was available, not just what was
needed. The result was the
perpetuation of a profligate practice style in
American medicine that benefited neither
patients nor those who paid the bills.
Ludmerer, KM Time to Heal, pp. 324-325
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Roughly 25 of the average hospital bill was
accounted for by laboratory tests and radiologic
studies, yet only 5 of laboratory information
was actually used in diagnosis and treatment.
False-positive tests often resulted in costly and
sometimes harmful interventions. Excessive
dependence on laboratory information may have
fostered the deterioration of bedside skills, the
tendency to deal with patients as objects, and
the temptation to treat the laboratory numbers
rather than the patient.

Ludmerer, KM Time to Heal, pp. 324-325
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WHATS IN A WORD? EXAMPLES OF HOW THE
DOCTOR-PATIENT RELATIONSHIP IS REFLECTED IN THE
TERMS USED TODAY
Client or consumer instead of Patient Treating
instead of Caring Encounter instead of
Visit Shareholders, stakeholders, market
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WHATS IN A WORD? EXAMPLES OF HOW PRIORITIES AND
VALUES IN HEALTH CARE ARE REFLECTED IN SOME TERMS
HEARD LESS OFTEN TODAY
Health Outcomes Effectiveness of care Patient
benefit Patient improvement Quality of life
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When you take an idea or a concept and turn
it into an abstraction, that opens the way to
take human beings and turn them, also, into
abstractions. When human beings become
abstractions What is left?

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So maybe this is the lessonthat we could
learnWe must not see any person as an
abstraction. Instead we must see in every person
a universe with its own secrets, with its own
treasures, with its own sources of anguish, and
with some measure of triumph.
Elie
Wiesel, 1992
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HAVE WE LOST SIGHT OF THE INDIVIDUAL IN
EPIDEMIOLOGY, PUBLIC HEALTH AND HEALTH POLICY?