More Deadly Doctor Gambits: Mortality Rates and Doctors on Strike

Mainstream medicine and medical doctors are increasingly under attack. Homeopaths, naturopaths and other groups pretend to have real medical knowledge and subject vulnerable and sick people to fake “treatments” that has never been scientifically tested or has been tested and shown not to work.

Concerned parents think that a few hours spent reading blogs written by medically unqualified individuals without any credible sources gives them more knowledge and diagnostic skills than medical doctors. Cranks on the Internet who are literally making stuff up about avocados, sun-staring and bleach as a cure for all diseases amass an audience of millions for their nonsense assertions that fly in the face of rational thinking and published scientific evidence.

Even more sinister, quacks attempt to portray medical doctors as a dangerous threat to the health and life of patients. This is often done by deploying the so-called deadly doctor gambit (originally discussed by C0nc0rdance) by falsely claiming that doctors are more dangerous than guns. In reality, this argument falls apart when you realize that there are 33 million hospitalizations per year in the U. S. so the relative risk from guns is much higher than doctors. As an analogy, there are more people who die from car accidents than from motor cycle accidents, but since there are many more people driving cars than motor cycles, motor cycles are more dangerous per capita drivers.

Thus, many of the hateful alternative medicine proponents that would say almost anything to make doctors seem evil really just ignorantly misunderstand and abuse basic statistical considerations.

Recent developments

A new member of this deadly doctor gambit category recently became popular on pseudoscientific websites. Like its predecessor, it involves the claim that medical doctors are highly dangerous to people and that people are safer when doctors are not around. This time, however, the anti-medicine crowd mischaracterizes mortality data from doctors on strike and claim that overall mortality drops when doctors are on strike and the deaths that would have happened can be directly attributed to those allegedly evil doctors.

This is taken as absolute proof that doctors are dangerous and you do best to avoid them. It is rare for doctors to go on strike and even rarer for large strikes to break out among doctors. This is because they play such an important role in society and thus cannot easily strike without risking core functions. However, there have been data collected from a number of strikes.

A review paper by Cunningham, Mitchell, Narayan and Yusuf (2008) took a closer look at five doctor strikes. Let us go over some of their principal findings for the Los Angeles (1976), Jerusalem (1983), Spain (1990), Jerusalem (2000) and Croatia (2003) doctor strikes.

Los Angeles (1976)

The Los Angeles strike (initiated because doctors were angry at too high malpractice insurance premiums) lasted one month in early 1976 and involved about half of all doctors. Mortality did decline and number of deaths was reduced by about ~55-155. This was attributed to the reduction in elective surgeries being carried out. This was based on (1) considerable rise in number of deaths as soon as elective surgeries and (2) infant mortality rates (a measure of general health of a population) were unchanged. Due to the fact that the strike was short and only involved half of all doctors, it is hard to draw any other firm conclusions.

This analysis was based on the original papers James (1979), Roemer and Schwartz (1979) and Roemer (1981).

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Jerusalem (1983)

This strike was longer and persisted 17 weeks and involved ~73% of doctors due to salary disputes. Although initial anecdotes claimed that mortality decreased, actual research found that there was no effect on mortality rates at all, either during or after the strike. The proposed mechanism for why there was no difference was the presence of a large absolute number of doctors in the city. Despite over 7 in 10 doctors going on strike, there were so many doctors that they could efficiently serve their patient populations. Some doctors also opened special aid stations. Although they were technically on strike, many of them did not stop helping people.

This was based on the original publications Slater and Ever-Hadani (1983) as well as Steinherz (1984).

Spain (1990)

Virtually all doctors in teaching hospitals in Spain (with the exception of family care physicians) went on strike for nine days that were not consecutive. There was no differences detected in mortality rates at the emergency departments: there were 0 deaths on average per day during the strike and 1 death on average per day during the control period. The strike was short, data only comes from the emergency department and personnel was replaced by staff physicians. Thus, this strike probably does not provide that much useful information about the effects of doctor strikes on mortality.

The primary publication here is Salazar and colleagues (2001).

Jerusalem (2000)

This strike was three months and involved public hospital physicians due to a conflict between the medical association and the government on salaries. Elective surgeries were cancelled, but all emergency services were kept open. Data is sparse, coming from reading about funerals in the local newspaper. There was a decrease in the number of funerals and this was attributed to cancellation of elective surgeries.

Original paper is Siegel-Itzkovich (2000).

Croatia (2003)

The final strike covered by the review paper occurred in Croatia during 1 month and involved most doctors. The researchers found no difference in either mortality rates or cause of death distributions.

The original data can be found in Erceg, Kujundzic-Tiljak, Babic-Erceg, Coric, and Lang (2007)

Miscellaneous

Although outside the focus of the review, the authors also found some data on strikes involving nurses, either showing no difference or a decline. The three papers for this was Stabler and others (1984), Allebeck (1985) and Belmin and colleagues (1992).

There is also a Straight Dope article on this topic.

Conclusion

For most strikes that we have data for, mortality is either unchanged or declines.

When mortality is unchanged, it is typically because there are enough doctors around to do their jobs even if some of them go on strike or doctors just being on strike on paper while continuing to do doctor services in other places.

For the strikes where mortality decreases, this is typically due to the cancellation of a lot of elective surgeries. Since there is always a risk of dying from these, mortality rates go down. In addition, such strikes involve only a minority of doctors and so most emergency surgeries and treatments can be carried out, and these strikes are at most a few months so the long-term negative effects rarely comes into play.

Pseudoscientific quacks, on the other hand, falsely interpret this as “fewer doctors, fewer deaths” and that this means that doctors are dangerous to human life. They are wrong.

Reference:

Allebeck, P. (1985). The general labour conflict in Sweden 1980: effects on the mortality in Stockholm County. Public Health, 99(1), 10–17.

Belmin, J., Chatellier, G., Bellot, P., & Moulias, R. (1992). Effect of two French nurses’ strikes on mortality in a geriatric hospital. American Journal of Medicine, 93(2), 151–156.

Cunningham, S. A., Mitchell, K., Venkat Narayan, K. M., & Yusuf, S. (2008). Doctors’ strikes and mortality: A review. Social Science & Medicine, 67(11), 1784-1788.

Erceg, M., Kujundzic-Tiljak, M., Babic-Erceg, A., Coric, T., & Lang, S. (2007). Physicians’ strike and general mortality: Croatia’s experience of 2003. Collegium Antropologicum, 31(3), 891–895.

James, J. J. (1979). Impacts of the medical malpractice slowdown in Los Angeles County: January 1976. American Journal of Public Health, 69(5), 437–443.

Roemer, M. I. (1981). More data on post-surgical deaths related to the 1976 Los Angeles doctor slowdown. Social Science & Medicine, 15C(3), 161–163.

Roemer, M. I., & Schwartz, J. L. (1979). Doctor slowdown: effects on the population of Los Angeles County. Social Science & Medicine, 13C(4), 213–218.

Salazar, A., Corbella, X., Onaga, H., Ramon, R., Pallares, R., & Escarrabill, J. (2001). Impact of a resident strike on emergency department quality indicators at an urban teaching hospital. Academic Emergency Medicine, 8(8), 804–808.

Siegel-Itzkovich, J. (2000). Doctors’ strike in Israel may be good for health. BMJ, 320(7249), 1561.

Slater, P. E., & Ever-Hadani, P. (1983). Mortality in Jerusalem during the 1983 doctor’s strike. Lancet, 2(8362), 1306.

Stabler, C., Schnurr, L., Powell, G., Stewart, B., & Guenter, C. A. (1984). Impact of a province-wide nurses’ strike on medical care in a regional referral centre. Canadian Medical Association Journal, 131(3), 205–210.

Steinherz, R. (1984). Death rates and the 1983 doctors’ strike in Israel. Lancet, 1(8368), 107.