Michel Accad, MD. 140 pages. College Station, Texas: Green Publishing House, LLC; 2017. Paperback: US $12.99; eBook US $9.99. ISBN: 9781634320306. Available from Amazon.com and Barnes & Noble; E-Book also available via Kobo and iTunes.

Field of Medicine: All who treat patients.

Format: Paperback book. Trim size: 5.5 × 8.5 inches.

Recommended Readership: Anyone interested in the limitations of population medicine, presented in a cerebral, lively, and entertaining format.

Purpose: To “question” Dr. Geoffrey Rose, one of the intellectual founders of the population health movement, by examining his writings. Using the Socratic method (and an imagined Socrates), the book highlights the confirmation bias, logical errors, and internal contradictions that make population medicine—and its offshoot, evidence-based medicine—ethically indefensible treatment approaches for individual patients.

Content: 140 pages of text divided into 7 chapters, with an Introduction and an Epilogue.

The Introduction discusses the early influences on Geoffrey Rose's theories, all predicated on the concepts that, for most diseases, risk factors within a given population are distributed in a bell-shaped curve, and that substantial benefits to public health can be achieved by “moving the mountain” of the bell curve to the left side of the graph. Michel Accad notes that these ideas were quickly adopted by medical schools and organizations around the world. He then proceeds to his imagined Socratic dialogue.

In chapters 1 through 7, Accad's Socrates probes the foundations of Rose's theories, the “sick population” hypothesis, the relationship between risk factors and disease, and Rose's opinions on the social determinants of health, including the inherent conflict between mandated health care for a population and individual patient choice.

In the Epilogue, Accad, speaking again in his own voice, notes that, in the 25 years since the publication of Rose's The Strategy of Preventive Medicine, the number of articles that use the term “population health” has increased exponentially, from almost none in 1992 to more than 16 per day by 2016 (reviewer's calculation from Accad's graph, p. 102). Its rapid rise, Accad argues, resulted from the confluence of 3 factors: the economics, the science, and the ethics of health care, each of which he discusses in detail.

Summarizing his arguments, Accad concludes by denouncing population medicine as no more than an egalitarian social movement masquerading as a medical treatment model. He predicts that, because of its inherent shortcomings in effectiveness and ethics, it must eventually fail, and physicians will once again be able to treat “one patient at a time.”

Had Accad opted to choose among philosophers (ancient to modern) to establish his fundamental point—that individuals cannot be treated as merely interchangeable members of a population—he would have had a wealth of choices. He could have used Plato, Duns Scotus, Leibniz, and many others; for that matter, even second-tier philosophers in Socrates' time understood that, from the point of view of philosophy, “a bird” is not the same as “a flock of birds.” His choice of Socrates, however, is particularly apt for several reasons:

  • According to Plato, Socrates described himself as an αλογóμυγα—a gadfly—whose purpose in life was to stimulate the citizens of Athens, through his stinging public questioning of their beliefs, to reexamine themselves. (Famously, of course, they were so unappreciative of his efforts that he was convicted on trumped-up charges of impiety and condemned to drink hemlock.)

  • Socrates' style was particularly galling: he asked a series of seemingly naïve questions, forcing his adversary to ultimately agree that the adversary's stated beliefs were merely conventional, poorly thought-out, and self-contradictory “alternative facts.”

  • Accad's Socrates is more humane, humorous, and playful than Plato's, but Accad is equally serious about getting to the truth.

  • The book is scrupulously fair to Geoffrey Rose and his ideas as articulated in Rose's articles and books—usually Accad has Rose speak in quotations from his works, so there can be no error through paraphrase.

  • Even though the conversation is supposedly taking place in Purgatory, Accad's Socrates has some advantages that Rose does not: critically, he seems to have access to the Internet, because he cites studies through 2016. (For the record, there was no Purgatory in Ancient Greek religion, and, in any case, Dante later placed Socrates not in his Purgatorio, but in the Inferno, where, presumably, the Internet connection was not as good.)

Strengths: Tightly reasoned and intellectually rigorous, this is a well-presented investigation of the internal contradictions, evidentiary shortcomings, and ethical failures of population- and evidence-based medicine. I also appreciated the final implicit “twist”—Accad's use of a philosopher to question the “rule of statistics” that governs population theory. Physicians who follow Rose's guidelines need do only “what the numbers say” to treat their patients. In contrast, physicians who treat patients by following Socrates' guidelines—and those of Hippocrates, Galen, and Sir William Osler—must do what philosophers do: think.

Weaknesses: Aside from a few typographical errors, none.

Overall Grade: