Social Media/Writing/Blogging

Deeper Worries in America

June 7, 2020 By Dr John

I worry about the coronavirus. It’s already killed more than 100,000 Americans. The recent protests have created a nerve-wracking public-health situation for the next weeks.

I really worry about racism. Not only racism in police systems but more systemic racism in our culture.

My friend Dr. Andrew Foy sent me this slide and post showing the large disparity in black and hispanic representation in medical education.

There can be no rest so long as a man like Dr. Otis Brawley, a distinguished professor of medicine,

“can get thrown to the ground, handcuffed and questioned at gunpoint for looking suspicious in a nice part of Montgomery County. That would be yours truly a few years ago.

My real offense: standing in the garage of my own home.”

****

But I think there may be another great threat to this country.

Last night I read a story describing a situation in which the writer Andrew Sullivan would not be allowed to publish his column on the protests in the New York Magazine.

Sullivan is not just forbidden from writing for the New York magazine about the riots; his contract means he cannot write on the topic for another publication.

From Wikipedia: Andrew Sullivan is an openly gay Roman Catholic conservative intellectual. He has voted for Bill Clinton, and endorsed Barak Obama. And in 2006, Sullivan was named as an LGBT History Month icon.

The reason I am writing here is that my colleague in cardiology Usman Qayyum asked ….with so many problems right now, how is this important?

There are so many problems right now, how is this important.
— Usman Qayyum MD FACC (@Uqayyum123) June 7, 2020

This is important because it indicates what could become a dangerous problem: the fall of classic liberalism.

If a sane calm intellectual like Andrew Sullivan can be silenced, what does that say for others?

Then there was the civil war within the NYT about the Tom Cotton editorial. I disagree strongly with the Senator’s view, but as a leading senator, should he not be allowed to make his argument?

Intolerance of ideas also extends into science:

Liz Neporent, the social media director at Medscape, had an important story on how YouTube initially removed a video on coronavirus from British oncologist and former chief of The WHO for violating guidelines. Initial efforts to have the video reinstated failed. It took more intervention from Medscape Medical News to get it put back up.

What was the problem? The scientist dared to express a view of the coronavirus that ran counter to the prevailing “consensus.” As if there could be any consensus with a months-old novel virus.

Hospital-employed doctors and nurses have grown used to not speaking publicly on anything contentious. So have many corporate workers.

But when this degree of illiberalism reaches the opinion pages of media, college campuses or social medial platforms, we have a big problem.

The obvious issue with deplatforming an idea is that if it can’t be debated, it cannot be proven wrong.

The late Christopher Hitchens, who we dearly miss now, once said or wrote: “time spent in argument is hardly ever time wasted.”

If the opposition to the current authoritarian regime, one that seeks to divide us, is an illiberal group that does not tolerate free public debate, I think we should be very worried.

JMM

P.S. After a thoughtful online discussion with Professor Alok Khorana, I have changed my choice of words in the seventh and eleventh paragraphs.

In the seventh paragraph, I changed the wording from ‘even greater ‘ to ‘another’ to define a threat to our country. In the eleventh paragraph, I changed ‘what could become a much more dangerous problem’ to ‘what could become a dangerous problem.’

By expressing my concern over the intolerance of ideas in policy and science, I did not intend to minimize racism.

P.P.S: Another edit. I cut the line “As a doctor, I am always looking for upstream causes of bad things.” I did not mean to imply the intolerance of ideas caused systemic racism.

Will the Uncertainties of COVID Science Resurrect Blogs?

May 9, 2020 By Dr John

Health news was popular before the pandemic. Now, almost all news is health news.

Itâ€™s not only a rapt audience contributing to the deluge of COVID19 news. Two other factors: 1) the availability of preprint servers, digital archives where a scientific paper can be published without formal peer-review and 2) the attention economy.

Attention is currency. Since the business model of both scientific journals, internet-based medical news sites and mainstream media is attention (citations, views), both groups are eager to publish all that is COVID.

The slew of COVID papers are outpacing the normal vetting process. It happened with hydroxychloroquine. In normal times, a study as weak as the one which launched this unproven drug would have never passed muster.

Media has the same problem as medical journals. They struggle to keep up with the public’s need for COVID information. Vetting was far from perfect before COVID, but there used to be more time to assess a study, seek expert opinion and add a bit of caution.

For instance, pre-COVID, journalists would often get an embargoed copy of a study days before it was published. The luxury of time does not exist during the pandemic.

Enter blogs

Blogs were hip 10-15 years ago, but have given way to Instagram, Twitter, and podcasts. Content consumption via the printed word seems quaint.

But these days I find myself increasingly drawn to the raw and candid nature of un-edited blogs. Here is why: A study gets covered in mainstream media. It fits an anointed narrative. Once one media site covers it, others feel like they have to cover it as well. Then Twitter and Facebook amplify it.

Boom, a message becomes accepted, often codified. If slow science pre-COVID was imperfect, the fast science of COVID can be deeply problematic. I’ve already mentioned hydroxychloroquine.

Another example is a study showing that cities that started social distancing earlier and stayed with it longer had better economic outcomes during the 1918 flu pandemic.

That narrative aligned well with the notion that stricter/longer lockdowns were the right choice. Keeping the virus from spreading is good for health and good for the economy.

Here’s the problem: other researchers could not reproduce it. When they tried, they found noise instead of signal.

Where did I read that? No, not in the NYT or WashPo or NPR; they don’t have the time or the incentive to correct a story. I read it on a blog from a distinguished professor of statistics at Columbia.

Professor Andrew Gelman writes;

The larger issue is that there seem to be more outlets for positive claims than negative claims. â€œWe found Xâ€ can get you publication in a top journal and major media coverageâ€”in this case, even before publication. â€œWe didnâ€™t find Xâ€ . . . thatâ€™s a tougher sell.

Another example, one which I may opine on in coming days:

A prominent group of researchers in cardiology published an observational study of patients with COVID who received clot-blocking drugs called anticoagulants. The top-line result was that patients who got the anticoagulants did better.

One of the authors of the study is the editor-in-chief of the journal that published the paper. He’s influential. Mainstream media covered the story. The WashPo used an upbeat headline and weaved a positive narrative.

This, too, fits with another common theme: keep socially distancing because if you get the virus later rather than sooner doctors will have found better treatments. And this may be true, but the study on anticoagulants was far too flawed to make any such conclusion.

Where did I get that? Well, since this is cardiology, I could critically appraise it myself. But say I wasn’t a cardiologist.

I, or you, or anyone, could have read the blog of intensive-care doctor, Josh Farkas, who writes on topics related to ICU medicine. Here is his assessment of the study’s fatal problem, including something technical called immortal time bias.

Numerous sources of bias exist.Â Perhaps most notable isÂ immortal time biasÂ â€“ patients who live longer may survive long enough to be diagnosed with DVT/PE and be treated with anticoagulation (whereas other patients may die rapidly, before being able to be prescribed anticoagulation).

You might wonder how one is supposed to know if information from a blog is reliable. This is where thinking comes in; it’s under-rated. You start with the content. Make a judgement.

You can also use meta-data: for instance, a blog with adverts for life-hacks or proprietary supplements might downgrade your confidence. Keep in mind, though, that many medical journals make you watch an ad before looking at a study.

One of my favorite American heroes, Mr Rogers, famously said when you are scared look for the helpers. I wonder… in this scary pandemic will more people start looking for help from the doctors, professors and thinkers taking time to write online. One of my recent favorites is Marginal Revolution.

Medical studies often get discussed on Twitter on the day of publication. Indeed, it is a great place for watching and conversing in realtime, but, as Doctor Bryan Vartabedian writes, in a blog, the ephemeral nature of Twitter makes it a lousy place to park ideas.

Finally, and this is big: science is not supposed to be held up as law; it’s supposed to be corrected. Being wrong in science is normal. Humility is essential. More and more, I am interested in how we communicate that core tenet to the public.

The tension, of course, is that the public can’t handle uncertainty.

I wonder if that is true. Perhaps it is the opposite: is it the faux certainty that bolsters distrust and division?

JMM

Can We Discuss Flatten-the-Curve in COVID19? My Eight Assertions

May 5, 2020 By Dr John

On Telehealth, an older couple asked me a tough question about COVID19. They asked whether this virus would either be gone or less dangerous in 6 months to a year.

It was a curious question. I replied, Why do you ask?

Doc, we have a big family with many children and grandchildren, most of whom live nearby. We miss them. We’ve been isolating, but it’s hard; we did it for 6 weeks. Doing it for a year or more would be miserable.

We saw on the news today that the battle with the virus would be long. A man called it a cruel new normal.

So doc, if you tell me the the virus will be gone in a year or it will be less dangerous to get infected later, then it makes sense for us to keep isolating. But if the situation will not be much different a year from now, we would just as soon see our family and take the risk. Of course, doc, we would still be sensible. We’d not visit if someone was sick; we would wash our hands and wear masks.

Indeed my patient was correct. Dr. Scott Gottlieb writing in the WSJ, did not mince words:

Hospitals and public-health systems will have to contend with persistent disease and death.

In essence, my couple asks whether flatten-the-curve policies save lives. Buried in that question are three other questions: namely, in one year, will the virus be 1) gone, or 2) less contagious, or 3) less deadly? If any of those three are true, then my couple could rationally decide to stay lonely for a year or more.

I study this new virus and this once-in-a-lifetime-situation every day.

I don’t think flatten-the-curve policies will change any of those issues. Let me explain my reasoning. I may be wrong; tell me if you disagree in the comments.

Flatten-the-Curve Purpose

You now know the famous curves–one with an early surge of disease, and the other flatter curve that spreads the infections over time. The y-axis is number of COVID19 cases.

In early March the COVID19 narratives were from Wuhan, Iran, Lombardy and Spain, places where surges overwhelmed hospitals. In the US, COVID cases spiked in NYC.

Early COVID19 surges were over-running some big-city hospitals. This was bad because it caused excess or preventable death–people who could have been saved were not saved because of shortages of ICU beds, dialysis equipment, staff and ventilators.

Social distancing policies and postponement of elective medical care were necessary to stop the excess deaths. These policies allowed time for hospitals to prepare for COVID19 cases and for doctors to learn how best to treat these patients. Exhibit A: not intubating patients early.

Social distancing worked. The number of cases slowed and the US got into the blue part of the curve. But now, months later, the narrative has changed.

Change in Flatten-the-Curve Narrative

What was once flatten the curve to prevent over-running hospitals has changed to flatten the curve to save lives. Some likened moderation of social distancing to human sacrifice.

That change in framing, I believe, is misleading. I will argue that the cumulative deaths from COVID19 will not be reduced significantly by flatten-the-curve policies. And that this virus will be as dangerous to vulnerable patients in 6 months to a year. We should be allowed to debate this.

My case has eight assertions.

First: the virus will not be contained. The chance for containment has long passed. The virus transmits before people know they have it and many patients never develop symptoms. It will be with us until an effective vaccine is both widely available and widely used. (See #6)

Second: Tests will under-perform. The high rate of asymptomatic disease, the low sensitivity of PCR tests (false negatives), imperfect specificity of antibody tests (false positives) and concerns over privacy mean that we should expect less from test and trace–even if proposed by a Nobel Laureate. Carl Bergstrom and others write persuasively on major barriers to contact tracing in the US.

Third: US hospitals are now prepared and in little danger of being over-whelmed. In fact, many hospitals are so dormant they are nearing financial ruin. Healthcare workers have been furloughed due to postponement of elective work. Iâ€™ve talked to numerous colleagues in the US and the message is clear: hospitals are under-capacity and prepared for a â€œpersistentâ€ number of COVID19 cases during the coming months/years. Hospitals now have COVID response teams.

Fourth: Americans are not stupid. Before governors enacted lockdowns, economic activity and travel slowed, the NBA, MBL, NHL stopped their seasons and medical meetings were cancelled. People socially distance not because police are bearing down on them, but because it makes sense. The pictures of spring-breakers in Florida and crazies-with-guns in state capitals bring clicks to news organizations but belie the majority of sensible people in this country.

Fifth: Public-health surveillance has improved. Tests may underperform but they will not be useless. Tests will help signal coming hot spots and that will allow communities to act locally. Other technologies may emerge that help prevent surges. One cool example is the use of resting heart rate apps that might signal health officials early on.

Sixth: (I need a few paragraphs): Social distancing will not lower the infection fatality rate or IFR. Remember the red and blue curves? The y-axis of that graph is number of infections. Due to the contagion of this virus, the area under these curves is likely to be the same at the end of two years. Ok, then, if the number of cases is similar at two years, then the number of people who cumulatively die will not likely change either.

The only way fewer people die from COVID19 over time is if the IFR declines. Here is where American exceptionalism misleads people. Politicians have a strong bias to pump up optimism on any potential medical advance–no matter how dubious. (Exhibit B- hydroxychloroquine.)

That is not how Medicine works. History is replete with examples showing that drug development is super hard. But leaving aside the challenge of developing new drugs against a new virus, the basic math of COVID19 creates a huge barrier for success: already, more than 99% of people infected with this virus survive. A therapy that has a massive 50% reduction in death from a disease with 1% mortality (high estimate) delivers only a 0.5% absolute risk reduction.

What about Remdesivir? This antiviral may help a little. But even if you believe its â‰ˆ 3% reduction of death was not due to chance (p = 0.06), the death rate in the remdesivir arm in that trial was 8%. Remdesivir is no game-changer.

COVID19 vaccine development is sobering. Most experts say a safe and effective vaccine is at least 18 months away. Again, the 99% survivability erects a huge safety barrier for vaccine makers. (I get that from Dr. Paul Offit.) Given society’s tension over vaccines, it would take only a tiny signal of harm to derail a coronavirus vaccine.

A slight hedge on the sixth assertion that IFR remains constant: some smart people say that getting the virus later may be better because doctors will be a little better at treating this disease. For instance, a year from now we may better understand how to use drugs that block clotting; we may have better vent protocols. These are big ifs. They may drive the IFR down a little but IFR is already low. Another benefit of infection in a year would be that most hospitals will likely allow family visitors.

Seventh: The more we test, the lower the IFR goes. Early estimates had it at 3%. Then it was revised downward to about 1%. Now most people put it at 0.1-0.5%. But that is still quite serious. Youâ€™ve probably read that 0.1% is similar to flu mortality. That is likely wrong. Dr. Jeremy Faust points out that flu mortality is grossly overestimated and is probably much lower than 0.1%.

Eighth: I wrote a piece on Medscape about the harms from COVID19 interventions. One of the points I made is that right now we count only deaths from COVID19. We stay riveted on day-to-day numbers. But the endpoint of this crisis is not next month but in 1-2 years. And when we get there, we have to count people who died from COVID19 and those who died from other causes.

This preprint from prominent researchers suggests a substantial proportion of excess deaths observed during the pandemic are not attributed to COVID19 and may represent an excess of deaths due to other causes.

In my column I cited an older study by Raj Chetty and co-workers that finds a strong association of lower income and lower survival. And that is the rub with COVID19 interventions: they make poor people even poorer. The rich just work from home. It is possible, therefore, that our social interventions will be especially hard on the disadvantaged.

I realize that no person overtly dismisses the harm from economic shutdowns. My friend Dr. Dan Morgan expresses my frustrations well in this thread. Why can one safely critique a drug for COVID19 but not massive public health interventions?

1/ It is strange being an epidemiologist, liberal, scientist who feels like we are making mistakes with absolutism of shutdowns. (and being lumped with antivaxxers, Trump etc. by my own people)
Many people out of workâ†’ anxiety & depression & social discord â†’ @VPrasadMDMPH
— Dan Morgan (@dr_dmorgan) May 4, 2020

Conclusion:

I did not have a clear answer for my couple. But after thinking and writing about this question it seems that the most reasonable approach in this crisis is transparent information–no matter how stark. And, crucially, we must have space for public debate.

I hate this virus. I wish it never came. But we can make it worse by avoiding hard discussions on tradeoffs, the limits of modern medicine and risk.

JMM

P.S. At 173 comments, I cannot keep up the moderation. Thanks for your interaction. I have closed the comment thread.

2020 Mandrola Update

January 4, 2020 By Dr John

Many things have changed in my life.

I still practice electrophysiology full-time in Louisville. I still write. And I still love endurance exercise.

You haven’t seen many blog updates because my writing has taken different forms.

One is academic writing. In 2019, I co-authored 21 academic papers. Here is a link to the papers on PubMed. This has been an exciting turn. I love being on the steep part of the learning curve for new stuff. Make no mistake: I am a beginner-academic.

Much of my academic work centers on the state of medical evidence. One of the studies I am most proud to have worked on is this evaluation of the prevalence of spin in the cardiovascular literature. Sadly, language designed to distract is damn common in medical science. Caveat emptor.

I am also grateful to Dr. Roderick Tung from the University of Chicago for inviting Baptist Health Louisville to participate in the first ever head-to-head randomized controlled trial of His-bundle pacing. This study garnered the big stage at the Heart Rhythm Society meeting and its findings were published in two leading cardiac journals–JACC and Heart Rhythm. (We kept the spin to a minimum!) Being part of an RCT was almost as nifty as pacing the his bundle.

A cool thing about the time we live in is the ability to have mentors all over the world. Here, Dr. Andrew Foy and his team at Penn State University in Hershey PA, deserve mention. Andrew is a true academic; he has helped me understand research methods. We have published many papers together, including my favorite: The Case for Being a Medical Conservative. Kudos and gratitude to the American Journal of Medicine for publishing our essay, and not putting it behind a paywall. Thanks also to the EconTalk podcast for devoting a show to the conservative approach to medical practice.

Another writing form that occupies a lot of my time is podcasting. Every week, I review the top 3-5 studies in cardiology. The podcast is called This Week in Cardiology. It’s produced and published by theHeart.org | Medscape Cardiology.

I was wrong about podcasts. Years ago, when my editor approached me about doing a weekly podcast, I was resistant. But now I hear from listeners all over the world. The strength of the podcast as a medical educational form has been stunning.

Malcolm Gladwell said (or wrote) that he started Revisionist History because he was afraid that if he didn’t, his writing would not reach younger people.

I think Gladwell was right. Most (but not all) the people who reach out to me to say they listen to TWIC are young. This makes me happy because I love teaching.

I still write for Theheart.org | Medscape Cardiology. You can find my columns at Musings From Mandrola. One thing you should know about Medscape is its professionalism. The news and editorial team have given me great faith in journalism. My columns may be called blogs, but the editorial oversight and fact-checking there far outpace most academic articles I have published.

The other major change in the way I create content is the lecture. In 2019, I was honored to speak in Park City, New Orleans, Phoenix, Vilamoura Portugal, San Fran, Chicago (at an oncology meeting), Paris, Venice, RzeszÃ³w, Poland, Edinburgh, Scotland, Los Angeles, Salvador Brazil and Philadelphia. Meeting colleagues across the world is a thrilling life experience.

Three special notes: doing real cases in Poland with Piotr, Pasquale, and Jaro.

And meeting in real life, the Professor Darrel Francis:

And to you Dr. Andrew Flapan: thank you to the power of ten.

Finally, on the exercise front, I have retired from criterium and cross racing. These are for the young. I still ride my bike but no more in anger.

To fulfill my exercise addiction, I have gone back to running. This year, while in Poland, I ran the RzeszÃ³w Maraton–an unforgettable memory. Thanks Arek, Magda and Piotr. This image is from the start. The image at the end is different. Hey Arek?

I know; the maraton is silly. But I will try another in 2020–to redeem myself for cracking in the last 10k in Poland.

Far smarter is a 5k run by the sea. Thank you, Dr. Luis Correia

If you don’t use Twitter, you should. It’s a brilliant medium for those interested in medical science. I am here @drjohnm

JMM

I am not quitting social media

January 26, 2019 By Dr John

I recently finished an academic review paper on the role of social media in medicine and cardiology. My co-author and friend Piotr Futyma (RzeszÃ³w Poland) and I focused mostly on the upsides of digital media. Itâ€™s not yet published but it is accepted.Â

I was an early and accidental adopter of social media. I used it to think publicly. I am glad I did, for it enhanced my love of medical practice, connected me with colleagues over the world, made me new friends, gained me a second job as a writer, and even launched me into academics.Â Â It turns out that despite trying to dodge research back at Indiana, the academyÂ is fun.

No doubt, though, social media has downsides. The Covington Catholic School controversy showed how social media can enhance the ugliness and lack of empathy in societyâ€™s embrace of identity over ideas.Â

A story in the Wall Street Journal today added to the chorus of voices calling people to quit social media. They interviewed a computer scientist who has never used social media. His argument is persuasive. As a professor, he notes social mediaâ€™s ability to distract learners from sustained focus. White screens also distract us from family and friends.

The social scientist Jonathon Haidt makes a compelling argument that social media is especially toxic to teenage girlsâ€”and may be on the causal pathway for increasing mental disorders and suicide.Â

Over the holiday season, I took a break from my favorite medium, Twitter. I read books instead of essays and Tweets. My three New Years’ resolutions were to read a book a month, learn more Spanish and act less like a cardiologist. (The latter has been a work in progress for decades.)

During the holiday break, I read Bork (Slouchingâ€¦), Dobelli (Thinking Clearlyâ€¦), Westover (Educated), Oâ€™Brien (â€¦Cacciato), Cottom (Thick), and Simler and Hanson (The Elephant in the Brain).

I have a Medscape column on the Elephant and the Brain publishing next week. The Elephant comes with a warning–you can’t unsee this stuff. The book is a must read for people interested in our massive problem of medical overuse.

My break with social media is over. I am not quitting social media. My Twitter feed makes me think. It leads me to great ideas. It expands my horizon past medicine. I missed my statistician gurus. My Facebook feed keeps me up with friends from high school and college. I get to see great pics of my grandchildren.

That said, my pause on social media showed me the value of airplane mode. And isnâ€™t this obvious? Social media, like anything else, is best when used with moderation.

Overuse of social media reminds me of the misthink on toxicity. For instance, people wrongly think certain drugs are â€˜toxic.â€™ The heart rhythm drug amiodarone, the beta-blockers, and the cardiac-event-reducing class of drugs known as statins are frequently referred to as toxic. This is stupid.

Toxicity is about dose. My athletic friends know that drinking too much water leads to low sodium levels and seizures. Last year, ICU doctors learned that oxygen, our life force, given in high doses increases death rates. See story number eight in my top-ten stories of 2018.

The rule with social media is the same as the rule of success in life: master the obvious and you will be fine.

Finding Truth: How Much Do We Need Experts?

June 10, 2018 By Dr John

I am planning a column on the role of experts in translating medical evidence. Evidence is important because it’s how doctors know they are helping not harming people.

It’s hardly news that the new (digital) democracy of information has changed the rules of influence in Medicine.

In the days of old, academic doctors generated, analyzed and translated evidence. We called these people key opinion leaders (KOLs). To become a KOL, you stayed in academics, published lots of studies, and crucially, you were not too critical of prevailing views.

If you did that, you could get invited to speak at meetings, write editorials and participate in expert guideline documents.

This vertical (or top-down) model still exists, but social media and the democracy of information is breaking it down a bit. More and more, ideas can garner influence based on their merit rather than their source. Resistance to expert views seems to be on the rise.

Some recent examples:

Neurology experts strongly recommend use of TPA (clot-busting drugs) in stroke. Many emergency doctors have looked at the same evidence and are not convinced. I’ve sided with the emergency doctors, but our analyses have been criticized mostly because we are not “experts.”
Cardiology societies have endorsed recent guidelines for treating high blood pressure. Family medicine leaders have looked at the same evidence and come to a different view.
The USPSTF (United States Preventive Services Task Force) are an independent voluntary group of scientists tasked with making evidence-based recommendations. Their look at the evidence has sometimes conflicted with those from professional societies–most notably in the review of screening for cancer.

My questions are:

How much a role should experts play in translating evidence?

Can non-expert clinicians come to a more balanced review of the evidence? Perhaps experts are too close to the topic at hand–e.g. AF ablation doctors writing guidelines on AF ablation?

The opposing viewpoint holds that one needs the context of being an expert to understand and translate studies of medical evidence.

A related question is that if you put 10 people on a writing committee for treatment of a medical condition, how many should be experts in the field and how many should be independent experts in evaluating medical evidence, like statisticians and epidemiologists? Now the majority are experts in the field.

Finally,

When I have written about using stents in patients with stable coronary disease, or TPA in stroke, or screening tests for cancer, some have said that I am an electrophysiologist and should “stay in my lane.”

I am interested in your thoughts on these questions.

JMM

P/S: Inherent in this debate is the matter of who is more expert: the hobbiest doctor who spends most of his/her time running trials or the doctor who spends all his/her time seeing and treating patients?

On the intolerance of ideas, and liberty …

April 22, 2017 By Dr John

I like thinking and learning.

Birthdays surely make one slower on the bike, but birthdays, it seems, do not have the same drag on the brain.

For me, birthdays have increased my appreciation of liberty. In the Constitution of Liberty, Hayek defines it as the absence of coercion. Such is a beautiful definition. Don’t coerce me to wear a bike helmet when I ride my Dutch bike to work. Don’t coerce an 85 year-old with life-limiting disease to stop smoking. And above all, don’t coerce people-without-complaints to have unproven tests in the name of health.

Piotr Skrabanek wrote in the Death of Humane Medicine that “the pursuit of health is a symptom of unhealth.” (That would be an apt blog title for this era of the quantified self.)

Birthdays have also brought me an appreciation of contrarian views. Christopher Hitchens famously said in Letters to a Young Contrarian that to be a contrarian is not to be a nihilist. When I question entrenched dogma, or a dubious new drug or the latest new toy for cardiologists, these views do not equate with nihilism. Hell, I sometimes ablate patients with dilated left atria and persistent atrial fib.

Medical culture shuns uncertainty. I like thinking about how little we know. Medical culture favors conformity. I find that tiresome and pretentious.

One of the challenges of being a medical writer is that embracing uncertainty and calling out hype can hurt one’s ability to function in the mainstream. You don’t get invited to the podium at medical meetings or ease through peer review if you highlight contrarian views: abuse of the p-value, financial conflict of interests, biased research and hyped results.

Illiberalism wise, cardiology is better than some areas of medicine. I will mention neither the less tolerant fields nor the specific no-go areas of medical topics–out of fear of public shaming.

Yet intolerance of contrary opinions in the medical sphere pale in comparison to the intolerance on many college campuses. Witness the Middlebury College and UC Berkeley incidents.

One somewhat fearless speaker on the matter of intolerance of ideas is the social psychologist Jonathan Haidt, now a professor of ethical leadership at the Stern School of Business (NYU).

Here are two interesting videos in which he contrasts opposing viewpoints. Gosh do we need more of this.

This is a lecture that belies its simple title.

This a discussion with Frank Bruni on the origins of intolerance on some college campuses.

I think we could use a Heterodox Academy in Medicine.

Think away readers.

JMM

I am changing…

December 18, 2016 By Dr John

Seven years have passed since I started this blog.

In that time…

I have learned some basics about writing. (I almost wrote, “I have learned to write,” which would have been foolish, since, writing-wise, I have plenty to learn.)

I have learned to stay upright on the bicycle. Concussions made me understand that the joys of criterium and cross racing don’t outweigh their risks. I still ride nearly every day; I’m a pretty fast bike commuter now. And I’ve shifted my endurance-sport goals to running, which is a far safer sport for the brain. My goal is to run 10k in less than 40 minutes.

The main thing that has changed about me is my views as a doctor, especially when it comes to dealing with people who complain of nothing.

Medicine is most pure when we treat people with illness. The infirmed come to us with a problem and we use our intelligence, experience and procedural skills to help them. It’s immensely gratifying. The joy of helping people still negates the stifling burden of administrative nonsense. I’ll do your damn corporate safety modules one more year because helping sick people get well feels so good.

But when people complain of nothing, our first job is to do no harm. I know prevention of disease is better than treating it, but the process of prevention gets dicey. When we prescribe things (screening tests, statins, aspirin, diabetes drugs etc) to people who complain of nothing, we should have the highest evidence these therapies deliver benefit. Too often, we cite eminence rather than evidence.

I’ve come to believe the medical profession is too paternalistic, too arrogant. I fear the medicalization of the human condition. These days, I order fewer tests. Medical tests put people into the “system,” on the metaphorical train of healthcare. This train accelerates quickly, and it’s often hard to get off. Even a simple echo scares me. I could tell you stories.

More often than not, I tell patients to stop checking their “numbers.” If they insist on health numbers, I favor three–the scale, the belt size and a Timex to measure walking speed.

A 2002 article from Dr. David Sackett (a pioneer of evidence-based medicine) perfectly captures my views on preventive medicine.

It’s called The Arrogance of Preventive Medicine. It’s worth a look, now more than ever.

Shortly after I tweeted the Sackett article, Harvard economist and professor Amitabh Chandra chimed in with this:

Spot on. "Prevention" is a scoundrels refuge…lazy, patient-blaming, overstated, superb tool to side-step real problems (ht @RogueRad) https://t.co/Iaj5y6nBrk

— Amitabh Chandra (@amitabhchandra2) December 18, 2016

JMM

P.S. For a longer and more polemic view of preventive medicine, see also, Piotr Skrabanek’s… The Death of Humane Medicine. Be warned; you can’t unsee this stuff.