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The Animals of Medical Thinking

I want to introduce you to a fundamental principle: the difference between a hedgehog and a fox. A hedgehog knows a few things well and tries to grasp underlying principles. Foxes are more intellectual. They live in a nuanced world, ruminate on many deep thoughts, and tries to understand every complexity. My readers understand by now that I am a hedgehog.


In a room full of physicians, I am rarely the brightest person, but I strive to understand issues in the most basic terms. When I communicate, I try for clarity. For example, I spent the last six months re-editing my book to make it easy to read. You may have heard about the grade-level writing scale. This can be measured by cutting and pasting 1000 to 2000 words at a time into certain websites. I got much of my book down to a ninth-grade reading level, which is difficult for medical writing.


To understand these intellectual animals better, consider COVID. Here, foxes see an enormous panoply of detail. They worry about infection rates, testing incidence, symptoms of the disease, and many other issues. They have many points of view, but they believe all this analysis is vital.


Hedgehogs might perceive only the most global questions, such as how much we are spending to save each person. If we assume, for example, that we have saved the same number of people who have died in America (doubtful), and if we assume we have spent $5 trillion on the effort, each of the 200,000 people saved has cost us $25 million. (I had to use Google to divide these numbers.) If we assume we spent only a trillion dollars, and this is low as you know, it was still $5 million per life.


Physicians believe that lives saved by medication or medical care are a reasonable “buy” at about $1 million each. Supposedly, we might reasonably spend up to $200,000 for each year of life saved. These are also doubtful propositions, because if we had to save the life of every person in America, at $1 million each, it would cost far more than the entire gross domestic product of not the USA, but of the world. And were we to spend even $100,000 per year of life saved, and we had to spend this much every year for everyone in the USA, it would cost a multiple of the gross domestic product of the world.


Even if you believe that above ideas make sense, the COVID effort is costing us five to (more likely) 25 times more than cancer treatments, vaccines, and other medical items for each life we save. It is hundreds of times more expensive than feeding hungry people. This makes no sense at all to a hedgehog. The foxes, however, seem to buy the story and want to spend more still.

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Otis Brawley wrote, “After dispassionate analysis is completed and all the facts are laid bare on the table, emotion can rule. Forget subtlety, forget decorum, forget dogma, loyalties, niceties, sacre

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