
The case for being a medical conservative - bookofjoe
https://www.amjmed.com/article/S0002-9343(19)30167-6/fulltext
======
Gatsky
I only know anything about one of the authors of this (Prasad). The history
leading up to this article is relevant. His modus operandi is to severely
criticise clinical trials to an audience that is only peripherally or not at
all involved in the field. You can see why this works - being extremely shrill
about something to people that don't have any idea tends to garner agreement,
since they can't evaluate your claims and you seem so adamant about it. It
creates the illusion of someone that is 'telling it like it is' and not just
following the norms of the profession.

The problem is that this doesn't generate anything of actual value, except for
Prasad. It is easy to criticise medicine. It is easy to criticise any complex
and difficult human endeavour. He takes the practice of critical thinking
about studies and results and what they mean, something which all doctors do
and are taught to do, and turns it into a blood sport which plays to the
masses. There are plenty of academics who do what he does, and publish in well
respected journals. At any conference where a major result is presented,
people in the audience get up and ask questions about the value of the
intervention, the conduct of the study etc, just the kind of things Prasad
rants about. The difference is that Prasad has monetised this practice by
pretending that he is the only one doing it. He writes books, publishes
endless articles which are mainly reviews and rehashings of other's work and
the person that hired him to a faculty position openly admits they chose him
because of his propensity for scathing criticism.

This article therefore, I find largely self-indulgent and in some parts sheer
nonsense. The authors style themselves as custodians of some higher art, a
priesthood of common sense and clear thinking. They pull the trick of trying
to cement their importance by defending themselves against a bogeyman, the
force of 'commercialisation'. Of course, there is no single person or group
who is causing this commercialisation, so there is nobody to question them.
They also bizarrely say that they are better placed at evaluating medical
evidence than the people who know most about it ('content experts'), because
the experts are too enthusiastic.

~~~
DoreenMichele
Thank you for your comment.

 _At any conference where a major result is presented, people in the audience
get up and ask questions about the value of the intervention, the conduct of
the study etc, just the kind of things Prasad rants about._

For people with incurable conditions, "dread diseases" and very deadly
conditions, the current system is already too conservative. They denied
approval for a non-drug treatment for cystic fibrosis because some
participants had lung bleeds. Lung bleeds are common with CF. CF is extremely
miserable and has a very short average life expectancy.

There are many stories like this out there. People with horrible conditions
hear the news that some new drug they were hoping would get approved has been
denied by people who seem to be comparing it to some internalized standard for
someone relatively healthy and not actually comparing it to "Is it better for
_this_ group of people than what they currently have?"

There are very, very expensive drugs and surgeries that get approved at times
and that's a whole other issue for such communities. But it's a very real
problem that some people are dying and drug approvals don't seem to actually
take that into account. I've seen people say things like "Just let me live the
additional five years that it takes to get these horrible side effects instead
of dying before then. I will worry about the horrible side effects then."

Most people want to live, even when that involves terrible suffering. Most
people want that chance. And our drug approval process is often maddeningly
conservative already in the eyes of people with various terrible conditions
who would be happy to be a guinea pig to have some kind of shot at survival.

It's a logic that makes sense to the people enduring these diseases, but one
the medical establishment recoils from.

~~~
leereeves
My grandmother was killed by an FDA approved drug, so my experience is that
sometimes the current system is not conservative enough.

What's worse, the company reportedly knew about the danger of the drug, and
didn't tell anyone.

Eventually the drug was removed from the market, but not before hurting
thousands of people.

This particular story is about Baycol (1), but perhaps, while reading this,
you may have been thinking about another similar story. It's happened many
times.

If "medical conservatives" can help prevent this from happening even one time,
they are creating something of value. I think it's ridiculous to claim, as GP
did, that protecting people from harm does not "generate anything of actual
value".

1: [https://www.nytimes.com/2003/02/22/business/papers-
indicate-...](https://www.nytimes.com/2003/02/22/business/papers-indicate-
that-bayer-knew-of-dangers-of-its-cholesterol-drug.html)

~~~
roenxi
The medical system is always going to be an ongoing series of tragedies.
People are going to die stupidly in the medical system because it is run by
humans who make mistakes. The human body is not a controlled and repeatable
environment like an aircraft; it is a mess, a lot of the parts look accidental
and it is a miracle it works on a good day.

"A mistake was made so we must adjust the system to stop that happening" isn't
a workable philosophy in this specific instance. There is no scenario where
mistakes don't happen. A strategy that attempts to achieve the impossible is
not a good idea. Tradeoffs will be made that are bad.

I can acknowledge that your story is horrible and unfair; but if that thinking
takes hold in medicine (which realistically it probably already has) then
people will suffer for no reason in a predictable way. It is better that at
least people suffering is a surprise or at least somewhat unexpected.
Decisions must be made using statistics and risk assessments rather than
grasping hopelessly at certainty and happiness. We must tolerate a few bad
drugs slipping through.

~~~
leereeves
According to the FDA itself (1), adverse drug reactions (ADRs) "are one of the
leading causes of morbidity and mortality in health care" and may be the
_fourth_ leading cause of death.

We need people willing to speak up and be skeptical. And whatever small reward
they may obtain by doing so is trivial in comparison to the billions that
pharma and their sponsored scientists stand to gain by unjustified
cheerleading.

It's laughable to question the motives and incentives of skeptics like Prasad
while ignoring the immeasurably greater perverse incentives in favor of
approving drugs too quickly.

I can understand the desire, the hope, that a new drug might be the miracle
we've been waiting for. But precisely because we so desperately want new drugs
to be helpful, it's crucial to remain rational and evaluate new drugs based on
what they actually do, not based on our hopes or on the claims made by pharma
companies.

1: [https://www.fda.gov/drugs/drug-interactions-
labeling/prevent...](https://www.fda.gov/drugs/drug-interactions-
labeling/preventable-adverse-drug-reactions-focus-drug-interactions)

~~~
roenxi
But the statistic you cite might just as likely be evidence that the system is
working very well. If the drugs being approved are 99.999% perfectly
efficacious and 0.001% deadly then nearly all the deaths would be attributable
to when the drugs fail. We aren't going to do better than that.

The better the system works and the more effective the medicines, the more
deaths will be attributed mainly to adverse drug reactions. That is why we
must tolerate them. We can't work towards a system where nobody dies in
hospitals; but we can work to one where the leading cause of death is failure
of medical care as opposed to natural causes.

The better our healthcare gets, the more likely the leading cause of death
will be "nurse didn't follow the checklist", "the machine broke" or "the drugs
made their body go haywire" and similar. Something has to be the leading cause
of death. As we become gods unto our own bodies that cause will be human
factors and mistakes.

~~~
leereeves
In that hypothetical world, life expectancy would be rising. In fact, it is
falling.

~~~
roenxi
I promise I'll stop being argumentative after this, but in the meantime - not
necessarily. Simpson's Paradox might get triggered where better healthcare
encourages more marginal people to have children/migrate to the better
healthcare/whatever. There is no single statistic or even a small batch that
is safe to make uninformed decisions on.

This is optimising a complex system. It needs to be done slowly, holistically
and with statistics and science. Just because one part is failing doesn't mean
that the system is out of control. It might be out of control, but the
evidence needs to be quite deep to conclude that because the system is very
complicated. A response powered by emotions, anecdotes or silver bullet stats
probably feels right but is likely to do more damage than good. This is a
field where high-functioning sociopaths should be given a lot of room to make
decisions; they are the ones who can make hard decisions and get to a
greatest-good-greatest-number style outcomes despite that fact that gut-
wrenchingly unfair and tragic thing happen every day in the world of
healthcare.

What it comes down to is people die and often suffer. The fact that people are
observed to die in the hospital system is _not_ evidence. Even aggregate stats
getting worse is not necessarily a problem. Arguments have to talk thoroughly
about what the costs and benefits of any change is likely to be and we have to
accept that death is a cost that the healthcare system is going to pay whether
we like it or not; because that really is an elephant in the room with these
sort of decisions.

~~~
leereeves
What I don't understand is why you'd want to shut down the discussion. Why
object, not merely to a specific statement a "medical conservative" made, but
to their very existence?

Why should we trust the system to high-functioning sociopaths, as you said,
and not listen to both sides and have a vigorous and ongoing debate?

You're right that people die, and will continue to die, in medical care. And
it's a difficult and emotional subject. And people don't always make the best
decisions. But I'd still rather have public discussion about every little
detail rather than trust insiders (with their own, sometimes perverse,
motivations) implicitly.

~~~
DoreenMichele
I don't want to debate it with you because you led with stating that your
grandmother died. You made it emotional and personal from the very first
sentence and in a manner such that arguing with you looks like emotional
cruelty.

Nothing can bring your grandmother back. The closure you desire is unlikely to
be found in trying to protect others from her fate.

I have a form of cystic fibrosis, as does my oldest son. It's just as personal
for me as it is for you. No good ever comes from trying to argue whose hurt
feelings or personal suffering trumps the other's.

I've been talking about medical stuff a long time. I sometimes make comments
that do decently well. I also still make comments that bomb, such as this one
from this same discussion that was quickly downvoted to the negatives and
still remains there:

[https://news.ycombinator.com/item?id=22042276](https://news.ycombinator.com/item?id=22042276)

I'm only responding now to this comment of yours because it makes me
completely crazy when I can't get engagement, I get downvotes and the silent
treatment and people act like I'm too emotionally fragile to have a reasoned
discussion with.

I'm responding in hopes that something I say will help you more effectively
find your way forward in future discussions. I still have zero plans to debate
you in this one.

~~~
leereeves
I apologize for making it emotional. I didn't mean to; I only offered my
grandmother's story as a cautionary anecdote. The truth is, it happened a long
time ago and I've already found closure.

I hope you find medications that help you.

------
_bxg1
> A conservative is someone who stands athwart history, yelling Stop, at a
> time when no one is inclined to do so, or to have much patience with those
> who so urge it.

Identifying yourself as simply a conservative or an anti-conservative in any
context _as a rule_ , without regard for circumstance, is just absurd to me.
It's like identifying as someone who walks northward or southward. Or someone
who prefers large numbers or small. There is no useful across-the-board
argument that can be made for either changing things or not changing things.

~~~
GuiA
I agree with you. That said, my reading of the article is that they do
identify themselves as conservatives within a context - that of medical care
in the US in 2020. They make their argument on the basis of a utility
function, which one can debate the merits of, but the whole arguemnt seems
very contextualized.

~~~
_bxg1
By "context" I meant, in this case, a specific medical decision/direction of
research/etc. An entire field isn't sufficient context to make a judgement
call.

------
caycep
To be honest, I think they are trying to make a "thing" where in day to day
practice, and both in academic centers and in the private practice realm, I
haven't really seen much distinction. Most physicians I know are aware of the
major studies, and debate with colleagues and amongst themselves regarding
efficacies and appropriateness of treatments. In so much that yes, there are
variations between different practitioners and schools of thought, but I
haven't seen a binary line in the sand saying "this is conservative medicine"
vs. "this is liberal medicine".

There is "conservative vs. aggressive" medicine, which is more based on
individual wishes of patients and familes, and also, well, "current" practices
versus "out of date" ones that have fallen out of favor due to new research
and data, for sure, but to color/frame it on political conservatism vs.
liberalism is a bit of a stretch.

~~~
ska
Further than that, medicine in general tends to the conservative by nature.
I'm not sure this is a distinction with much value.

------
cjhveal
I agree with this in that I believe that many industries (esp. health care)
are being harmed by hyper-financialization, which is reducing transparency for
consumers and creating massive waste.

What worries me is the part about judging the worthiness of an intervention
based on a hypothetical homo economicus' decision to pay for it. These kinds
of cost-benefit analyses end up feeling really strange when applied to things
with strong "intangible" value.

Even if set up in a well intentioned manner, I could see these kinds of
analyses themselves becoming victims of regulatory capture and being used to
restrict access to care rather than improve it, similar to how the Office of
Information and Regulatory Affairs[0] has used economic arguments to gut
regulations on coal ash, vaping, and prison rape.

[0]: [https://mattstoller.substack.com/p/did-economists-stop-
congr...](https://mattstoller.substack.com/p/did-economists-stop-congress-
from)

~~~
gowld
I don't understand how the analysts could put a price tag of $300K+ on a
prison rape, multiply by the number of rapes, and still conclude that it's not
worth investing in prevention. Or, you know, if their argument is that the
cost of preventing a rape is less than the cost of compensating victims, why
the law isn't compensating victims. As it is, it's levying massive tax on
victims of crimes. Same for the car backup camera law. OIRA is economically
incoherent, by optimizing for supposed total utilitarian benefit without any
regard for _who_ gets the benefit. They block laws because they claim the cost
to society is greater than the benefit to victims, and therefore rule that
victims of catastrophes should get nothing. Under their own economic model,
it's blatant theft from the poor to give to the rich.

Here's the NYT trying to be "fair and balanced", but at least linking to a
critical report, and a much later Reuters article with more critical detail.

Naturally, since this malfeasance occured in the Democratic Obama
administration, almost no one cared, and Twitter wasn't ablaze with complaints
that Obama was killing children.

[https://www.nytimes.com/2012/08/04/science/earth/cass-
sunste...](https://www.nytimes.com/2012/08/04/science/earth/cass-sunstein-to-
leave-top-regulatory-post.html)

[https://www.reuters.com/investigates/special-report/usa-
regu...](https://www.reuters.com/investigates/special-report/usa-regulations-
oira/)

------
KaiserPro
> the actual benefit derived by an individual can be far less than what is
> advertised or publicized

which is why the UK has NICE to evaluate everything. THe individual GP/family
doctor/specialist simply does not have the time to evaluate every single
treatment.

Basically the author has described what NICE does, but without knowing what
NICE does. (for reference, NICE evaluates the evidence of new drugs and
techniques and works out if they are safe, effective and worth the money.
Where they cost lots of money and show marginal efficacy, they do not get
approved.)

However despite protestations to the opposite, the author appears to be
calling for a political judgement ("The expert is just very enthusiastic, but
this isnt real progress") instead of an evidence based authority with clearly
defined thresholds.

Dangerous twaddle basically.

------
svat
See also (with no overlap in authors): The case for medical nihilism and
“gentle medicine” (Richard Smith's review of book by Jacob Stegenga):
[https://blogs.bmj.com/bmj/2018/06/04/richard-smith-the-
case-...](https://blogs.bmj.com/bmj/2018/06/04/richard-smith-the-case-for-
medical-nihilism-and-gentle-medicine/)

> Most practising doctors are, I believe, instinctive medical nihilists even
> if they would never use that term: they know the limitations of magic
> bullets, are highly sceptical of claims for new drugs, and recognise the
> importance of the human as opposed to the technical. Some patients and
> politicians are also medical nihilists, but most are not. They are the group
> who would benefit the most from this important book but also, sadly, are
> perhaps the least likely to read it.

------
simonsarris
> We believe this is the ideal approach to patient care.

There's the rub: Ideal for the patients? Or for the doctors/nurses? The
incentives are not at all aligned.

Reading everything we can about birth as my wife is pregnant and it's
astonishing the amount of interventionism that the field gets into. It seems
like things are implemented first and then dialed back only if they backfire
in an obvious way. You end up with hundreds of dubious interventions:
[https://elifesciences.org/articles/45183](https://elifesciences.org/articles/45183)

But the incentive is almost never towards respecting the precautionary
principles, and almost always towards billable services.

------
duckMuppet
A great listen..

EconTalk: Keith Smith on Free Market Health Care
[https://www.econtalk.org/keith-smith-on-free-market-
health-c...](https://www.econtalk.org/keith-smith-on-free-market-health-care/)

~~~
wang_li
And:

[https://www.econtalk.org/adam-cifu-on-ending-medical-
reversa...](https://www.econtalk.org/adam-cifu-on-ending-medical-reversal/)

[https://www.econtalk.org/adam-cifu-on-the-case-for-being-
a-m...](https://www.econtalk.org/adam-cifu-on-the-case-for-being-a-medical-
conservative/)

Both with one of the authors of the linked paper, Adam Cifu.

~~~
kyleee
I recall enjoying both very much. The health/medical realm is so hard to
navigate as a layperson

------
undecisive
It would be interesting to quantify the psychological effect of concrete
actions compared with the feeling of impotency, separated from the placebo
effect.

I understand the absolutist monetary argument: If a treatment is not
consistently effective, yet costs a lot, services such as the NHS - and the
pockets of those on lower incomes in other countries - suffer avoidable
losses.

But for an individual with a disease with no good prognosis, the feeling of
doing something positive about this thing they have no control of will
certainly have beneficial effects on their mental state, and provided it is
not harmful, their body.

A good example recently is in remitting / relapsing MS - patients have for a
long time been prescribed large doses of Vitamin D. It turns out that Vitamin
D is useful for MS sufferers, much as it is for the rest of the population
(maybe a little more as a common side effect, photosensitivity, means they are
likely less exposed to sunlight) but that actually they don't need anywhere
near as much as they are being prescribed.

(It is still being researched, so that study may yet be wrong.)

My point is, if I told you "There's some evidence to say that this massive
dose of Vit D will reduce the frequency of your relapses," you will feel like
there is a positive step you can take to beneficially impact your situation.

If, instead, I say "Take some vitamin D because it's good for you" that only
leaves the crushing sensation of seemingly inevitable defeat.

So I guess my point is, there is value in hope. Where there are major side
effects, or the costs are wildly prohibitive, that's a very different equation
and I'd probably follow the OP's conservatism on that. But I'd like to see
some mention of the mental effects of this policy, as well as the positive
impact on research that real-world use of new drugs has.

------
jhpriestley
questionable choice quoting a notorious segregationist and homophobe like
Buckley.

------
stretchwithme
omg. If you did everything a doctor suggests you do without a critical ear,
you'll probably die younger.

You just care an lot more about the results and have more time to focus on
researching just one person's condition.

But you're also a lot more likely to be kidding yourself than a medical
professional is. But I think sometimes they just keep that to themselves
sometimes because it's too hard to challenge an idea a patient has locked on
to.

No easy answers.

~~~
p1necone
I get the impression that Doctors prescribe things/give advice under the
assumption that most patients don't care about the details, and aren't likely
to stick to any long term plans. I wish there was an easy way to communicate
to a doctor that I'm willing to research things, and to stick with better
diets/excercise in the long term if that's the best fix for me.

~~~
Sacho
I don't know how medicine is practiced in other countries, but finding a
doctor that shares your philosophy about treatment and sticking to them seems
like a problem best solved at a local level.

In my country, you are assigned a GP, but can switch with a specific
administrative form. There are several well-known(via word of mouth) GPs in my
town that have people deliberately switching to them due to the way they
practice medicine - less short-term treatment, conservative prescription of
medicine(especially antibiotics and painkillers), focus on lifestyle/diet
changes and regular check-ups to catch serious ailments early. The GPs will
also recommend particular specialists who have a similar philosophy.

Mind you, this kind of treatment is far from controversial. I've talked to
some of these doctors and a common problem they have is justifying their costs
- e.g. a patient comes over, they listen to the symptoms and examine them and
prescribe...toughing it out and maybe changing your diet a bit. People feel
like they're not getting their money's worth("I already know that!"). There's
also plenty of people who are looking for a quick fix - e.g. I'm under so much
stress at work now, I just need a pill, I'll fix my life later.

There's also plenty of people who think they can follow a strict regime and
make lifestyle changes, but just can't, and it ends up being a resentful
relationship with the doctor(the doctor feels like the extra time they put in
is wasted, the patient may rationalize the failures as the treatment just
being ineffective, etc).

All of this points to me that this is something best decided on an individual
basis, when the doctor and patient have a good relationship.

------
DoreenMichele
_We see true medical progress as slow and hard, in large part because nature
has provided the human body with inherent healing properties.

The wisest of conservative physicians understand and embrace how little effect
the clinician has on outcomes._

Blah blah blah.

Now if only more doctors/medical researchers were intensely curious about how
to better support the body's "inherent healing properties" effectively. Then
we might see a real sea change that is both dramatic and actually, in fact,
honors the pledge: _First, do no harm._

Edit: Would people be happier if I said "This is nonsense." instead of "Blah
blah blah"? (Serious question here. It says the same thing to me and someone
else has made much the same point and been upvoted for it.)

~~~
undecisive
In answer to your edit, probably downvoted because your post seems to have no
point, other than to say "this is nonsense". Also, at a glance it sounds like
the prelude to a homeopathy advert - doctors aren't listening to our bodies,
they should be more in tune with their [insert pseudoscience rubbish here].
And given the narrow focus of the original post (talking about bias in
economic trade-offs) fairly off-topic.

Also:

 _honors the pledge: First, do no harm._

Alas, in many places that pledge (and various variants) while studied, and not
imposed upon students as an oath - other than through medical malpractice
legislation

 _how to better support the body 's "inherent healing properties"_

That's almost exactly what most drugs are designed to do. Vaccines don't kill
maladies, just hint at your body to prep for a siege. Painkillers don't kill
pain, just hint at your body to ignore it. Antibiotics are an exception to
this I believe (though happy to be corrected). So I'm pretty sure the majority
of drug research is exactly what you've said that more doctors should do.

~~~
AstralStorm
Painkillers do kill pain, but pain itself is rarely a problem. And as there
are different kinds and causes of pain, as many types of painkillers exist.
Pain is only a symptom, but better quality of life is often worth the side
effects.

Likewise antiinflammatories, though sometimes inflammation itself is one -
mostly autoimmune or to reduce damage when other treatment is curative.

Most drugs are in fact designed to work on their own, but are insufficient due
to their laser focus, this the rest of body's mechanisms are required. Or they
are directly messing with the chemistry doing either exactly as they should or
otherwise known side effects due to relatively simple causation.

The about only place where it does not apply is carcinogenic or teratogenic
effects.

Probably the only place where those remarks about "working with the body"
apply is where we know next to nothing, such as psychiatry and very deep
metabolic changes such as obesity.

Careful with analogies and broad generalizations.

~~~
undecisive
_Painkillers do kill pain, but pain itself is rarely a problem. And as there
are different kinds and causes of pain, as many types of painkillers exist.
Pain is only a symptom, but better quality of life is often worth the side
effects._

As much as I appreciate a technical debate (and before I fall off Mount Stupid
[1]) I feel like maybe we're approaching a non-question at different ends.
Questions like "What is Pain?" "What does it mean to 'kill' pain?" "What
constitutes working with the body?" and "If a head is cleaved in the forest,
does it make a noise?" are all questions I'd love to spend hours debating, but
the answers to these probably have little bearing on my original point.

The only reason I piped up is that I know how crappy it is to be downvoted
with no explanation, because what you said sounded perfectly reasonable in
your own head.

Apologies if I accidentally promulgated a misinformation bugbear!

I will be more careful with my analgesics and my broad general anaesthetics ;)

[1]
[https://www.urbandictionary.com/define.php?term=mount%20stup...](https://www.urbandictionary.com/define.php?term=mount%20stupid)

------
Ericson2314
I thought these going to be about doubting those new results that say X time
honored surgery or other big procedure has no evidence of efficacy.

------
ImaCake
I think calling themselves "medical conservatives" is a massive homegoal. If
the goal is to populise this term they have immediately made a lot of people
more skeptical of it than they need to. Why not search for a more neutral word
than "conservative"? The anti-science "skeptics" certainly were thinking in
the right way by co-opting that word for themselves.

~~~
kyleee
Little 'c' conservatism is a very reasonable guiding principle within the
realm of healthcare, so on the contrary I think it's a well chosen word here.
I am generally tired of the marketing/PR mindset that leads to perfectly good
words from being marked as off limits due to various optics

------
iron0013
I wish the authors would just make their point instead of bandying about
florid prose (which is extra out-of-place in a medical journal!) and
inappropriately invoking political conservatism. It takes them until the 5th
or 6th paragraph to even start to describe what they mean by "medical
conservative"

~~~
downerending
The reference to political conservatism (little 'C') seems quite apt. The
quote describes the idea well--I'd summarize it as: not everything that's new
is good, and we would do well to think hard before making major changes that
might cause serious harm.

Those old-timers that did those old-time things? Sometimes they did them for
very good reasons, even if they've since been forgotten.

~~~
homonculus1
Conservatism is essentially the philosophy of Chesterton's Fence, as opposed
to Move Fast and Break Things.

~~~
downerending
Link:
[https://en.wikipedia.org/wiki/Wikipedia:Chesterton%27s_fence](https://en.wikipedia.org/wiki/Wikipedia:Chesterton%27s_fence)

