Despite having worked in health care for the last 18 years, I am still constantly in awe of what modern medicine is able to do. One of my favorite patients is a man who sustained cancer of the esophagus (the organ responsible for the involuntary portion of the swallowing mechanism that smoothly massages food down past the vital organs in the chest and into the stomach). Esophageal cancer is associated with a very high rate of morbidity and mortality, related to both the disease process itself and the invasive treatments that are needed to eliminate the disease. In the case of my patient, I am grateful to his physicians and surgeons, who were able to not only remove the cancer but reconstruct his esophagus so that he can eat normally. He tells me that the only difference in his quality of life is that he needs to sleep sitting up a bit, or else the acidic contents of the stomach can leak up into the esophagus, creating irritation of his neo-esophagus. All in all, simply surviving the cancer would have been enough of a feat, but the fact that he can live a reasonably normal life is something I find incredible.
One of the two edged swords of being able to do such amazing things in medicine is that there is an expectation that we can fix everything, which is simply not the case. “So much for modern medicine, they can cure cancer, but I still have this headache.” As I’ve said before about the reality that even normal shoulders can be painful at times, so we have to reject the premise that the goal of modern medicine is to completely eliminate pain and suffering. If we think that blissful immortality is possible, or even desirable, we will not only fail in our attempt to reach it, but we will be unnecessarily distracted from achievable goals like improving accuracy of diagnoses, minimizing the risk of treatment options, and optimizing the means by which the best treatments are chosen. Time and energy are limited resources for the grant mechanisms that fund research, the scientists that perform the studies, and the clinicians that use the information to recommend treatment options. The challenge is that it is impossible to know a priori which paths will lead to the next MRI machine, drugs like Imatinib, or surgeries like the hip replacement; therefore, it is necessary to explore avenues of exploration that may not necessarily lead to practical applications in the short, or potentially even long term.
For all new innovations, each member of the health care world has a role to play in making sure that we are able to innovate and move the industry forward, while at the same time being mindful of the associated risks and costs of new technologies. Unfortunately, even if there is no overt charlatanism, there is a subconscious bias that we all have that keeps us from recognizing limitations of our points of view.¹ This means that if we are the one with the opinion, we should be aware of this limitation in ourselves, and if we are the ones being offered an opinion, we should be thoughtful about what kind of implicit or explicit bias is inherent in the opinion that is being offered. It surprises me how often friends and family members ask me whether I support a certain treatment that they have heard advertised on TV or on the radio; I tell them that it may not be a hard and fast rule, but as a general guideline, I would say that anything that still needs to be advertised directly to patients is unlikely to be an antifragile intervention that has withstood the test of time.² It surprises me just as much how often patients will insist that they need an intervention like surgery or a cortisone shot, when I have told them that this is not something that I would recommend for them. As someone who makes money from doing what it is they are asking for, I should not necessarily be trustworthy if I offer the treatment, but there is no reason for me to be suspected for saying that something that I get paid to do is not helpful in their specific situation.³
We must accept the reality that human nature cannot be circumvented, and none of us is immune to the risk of thinking we have all the answers. We also do not want innovation to be stifled by a never ending suspicion of anything new. The discernment of which new ideas are worth exploring is a constantly moving target, and we all need to correct ourselves appropriately, knowing ourselves as either eager early adopters that need to slow down, or risk averse conservatives who need to be open to new things. When it comes to medical treatments, it is my opinion that the current tools that we have are not adequate to tell us what actually works versus what is just being marketed in a convincing way, without any actual data supporting the opinions being offered. In my next and final post in this series, I will offer a novel mechanism of tracking quality care delivery in an episode of care … yes, you should be suspicious that I think this idea is really much better than it really is, but maybe you’ll like it anyway.
- Lotto, R B. Deviate : the science of seeing differently. New York: Hachette Books, 2017.
- Taleb, Nassim N. Antifragile : things that gain from disorder. New York: Random House Trade Paperbacks, 2014.
- Taleb, Nassim N. Skin in the game : hidden asymmetries in daily life. New York: Random House, 2018.