Change and the Case for Being a Medical Conservative:

When my favorite podcaster, the economist Tyler Cowan, asked Dr. Ezekiel Emanuel what nonobvious advice he would give to medical students today, the answer surprised me.

The famous bioethicist said: 

I do think that this is probably the most exciting time in American medicine in a century, since really about 1910, 1920. And it causes a lot of anxiety for people, so I want to be sympathetic to that….

…We would prefer no change. But I do think, if you can go with the change, this is a super exciting time when lots of things are changing, and you can have a real positive impact in shaping the future, probably for at least half a century.” 

I am not precisely sure what change he refers to, but you can feel change. 

  • Electronic records have replaced paper charts;
  • More patients contact me via electronic sources; 
  • I often crowdsource (with colleagues across the globe) difficult cases in real time;
  • Advanced practice clinicians are replacing physicians, especially docs without a specific procedure or skill;
  • Clinicians increasingly serve as translators of medical evidence.

But one thing that will never change about the practice of medicine is that there is a right way to do it.

Three colleagues and I recently described the right approach.

It is The Case for Being a Medical Conservative.[1]

My co-authors: Andrew Foy is an academic cardiologist at Penn State. He got it started with an outline. Adam Cifu, an academic internist at the University of Chicago, and Vinay Prasad, an academic oncologist at University of Oregon, made significant revisions. 

We felt that it was time to set out what it means to be a medical conservative because the rapid pace of innovation and the democracy of digital media have tested the resolve of slow-adopting skeptical clinicians. 

Here is a Twitter thread I did on the paper.

Some highlights: 

A medical conservative is not a nihilist; we adopt new therapies when the evidence is compelling.

Too often, medical evidence is hyped and the benefits to patients are small. The medical conservative, therefore, has to be skillful in assessing evidence. 

It’s not always easy to assess evidence. I recently co-authored a systematic review[2 ]that found that manipulative language, or spin, pervades the cardiac literature. I urge you to read this paper. You would think science would be dispassionate; it is not.

The medical conservative asks a simple question: 

Would an unbiased patient, who had perfect knowledge of an intervention’s tradeoffs, voluntarily choose to adopt it, and taking into account differing patient resources, pay for it?

Medical conservatives worry about the commercialization of medicine because too often medical progress occurs under the pretext of science without meaningful improvement in patient outcomes. 

This careful approach to “progress” sometimes puts the medical conservative at odds with content experts—who are often enthusiasts for the procedure that they do. 

Atrial fibrillation ablation proponents are a good example. Unlike me, many of my colleagues are so sure the procedure works that they oppose a proper placebo-controlled trial. Yet, every single study of AF ablation has been unblinded—patients and their doctors know the treatment assignment. This is nuts. No novel drug gets approved unless it’s proven better than a placebo. 

The medical conservative sees medical progress as slow and hard. That is because nature has provided the human body with natural healing properties. We understand and embrace how little the clinician affects outcomes.

Finally, the medical conservative does not oppose innovation, we simply place the burden of proof on those who innovate.

Dr. Emanuel is right; change is happening. But the conservative approach to medical practice remains a bedrock principle.

I am a proud #medicalconservative. 

JMM

Ref:

1.         Mandrola J et al.The Case for Being a Medical Conservative. Am J Med2019; 0(0). doi:10.1016/j.amjmed.2019.02.005.

2.         Khan MS et al.Level and Prevalence of Spin in Published Cardiovascular Randomized Clinical Trial Reports With Statistically Nonsignificant Primary Outcomes: A Systematic Review. JAMA Netw Open2019; 2(5): e192622–e192622. doi:10.1001/jamanetworkopen.2019.2622.

5 comments

  1. Change for good. Nothing is wrong with Medical conservative practice. To add what is nihilist, as not all can understand that medical term. Nihilism is the philosophical viewpoint that suggests the denial of, or lack of belief in, the reputedly meaningful aspects of life. We should never stop to learn and adopt the new technology to fasten our work load.

  2. Dr. Mandrola,

    I too am thankful you are willing to be strong voice on the side of medical conservatism.

    It is fascinating to me to compare your perspective to the information offered to (and willingly consumed by) a close family member who chose to have the Watchman procedure, for example. I think most of us non-medical types never even realize there may be that different perspective-we tend to defer completely, even here in 2019, to what the doctor says to do.

    I work in a politically sensitive position and know how challenging it is to speak up in a productive way about systemic, cultural flaws in a profession. Because of this, and because of my own harrowing experiences as a healthy person who found herself caught in a life-changing over-treatment spiral, I simply cannot thank you enough for your courage. Please keep it up.

  3. Dear Dr. John
    I have a question about PVCs. The PVC pulse that looks like a low pulse due to the extra beat, is that a very short activity in the rhythm of your heart or can it go on for very longer periods of time? I was told that it is short acting but I have had readings from 15 minutes to an hour of less than 40 bpm. I have recorded 37 for an entire hour. Can a PVC pulse last that long?
    I cannot seem to get a definitive answer.
    Thank you.

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