The core principle of critical thinking is that people are bad thinkers. This includes you, me, and everyone else. Our brains did not evolve to tackle complex problems. Critical thinking does not come natural to us. In fact, we are highly susceptible to bias; for example, if we want to believe something, we excel at persuading ourselves. We lower the standards for evidence that supports our beliefs and raise them for evidence that contradicts them. A process called confirmation bias. It's how smart people can believe stupid things. It's how your favorite podcaster can convince themselves of a false claim.
Healthcare involves six main stakeholders: practitioners, industry, specialists, academia, the media, and you, the patient. I will examine the biases of each stakeholder, and their conflicts of interest, financial and non-financial. You will notice that they all share a common bias - a drive towards more aggressive care.
Practitioner bias
The Fee-for-service model is the most common way to reimburse healthcare practitioners. Whether it is a neurosurgeon or an acupuncturist. Instead of rewarding the practitioner for bringing the patient back to health, this model reimburses for each visit and each treatment, and as a result, it incentivizes more aggressive care. More visits lead to more diagnoses, more diagnoses lead to more treatments, and more treatments leads to more visits. A cascade of diagnostics and therapeutics. Even bad care, treatment failures and side effects, feed this cycle.
This incentive structure has been shown to affect the practices of surgeons. For instance, studies show that fee-for-service surgeons are more likely to perform surgery than salaried surgeons. Surgeons that own a surgical center are more likely to perform surgery than those who do not.
Healthcare is replete with examples of this aggressive care; however, the cascade always begins with diagnosis. The sicker you can be made look, the more it drives the other services. As Aldous Huxley famously said,
Medical science is making such remarkable progress that soon none of us will be well.
Overdiagnosis is being diagnosed with a disease that will never bother you during the course of your life. It's particularly prevalent in cancer screening, where some cancers are found at such an early stage, they would have never progressed. Examples include: prostate cancer, breast cancer, thyroid cancer, kidney cancer, and melanoma. Overdiagnosis is also common when we lower the threshold of diagnosis, like pre-hypertension or pre-diabetes.
Put off by this, many patients turn to practitioners of alternative medicine and pseudoscience, like Functional medicine or Naturopathy. Unfortunately, patients fail to appreciate that this is just another manifestation of the same aggressive healthcare system, but worse. These practitioners have the same biases and incentives, but without ANY accountably, scientific rigor, or protection from regulation. Patients are at risk of a fake diagnosis and treatments more likely to harm than work.
Industry bias
The industries manufacturing these tests and treatments, like laboratories, imaging centers, device manufacturers, supplement companies, and pharmaceutical companies, are also incentivized to promote more aggressive care. They want to move more product, and do so by enticing practitioners and patients with marketing and kick-backs. In a single year the pharmaceutical industry alone spent $60 billion marketing to doctors. This is not money wasted. Observational studies show that doctors are far more likely to prescribe a drug after exposure to marketing. The money your doctor directly receives from them can now be accessed through the sunshine act.
Specialist bias
Despite our veneration of specialists, they are particularly prone to bias. In addition to the financial conflicts that all practitioners have, they are philosophically and personally bound to their specialty and its ideas. They tend to see all disease from the perspective of their specialty, and treat all disease, with the tools of their specialty. As psychiatrist Abraham Maslow famously said,
"I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail."
Specialists also tend to dwell in isolated information filter bubbles, or "echo-chambers". The are surrounded by like-minded individuals in their practice, at their specialty meetings, and in specialty journals they read from. They are insulating from any negative information about their speciality.
A patient with back pain, for example, can see four different specialists and get four different opinions. The Spine Surgeon will see mechanical defects on MRI and fix it with surgery, the Chiropractor will find vertebral subluxations on X-ray and fix it with spinal adjustment, the Acupuncturist will detect blocked Chi and fix it by inserting needles, and the Physical Therapist will observe muscle imbalances and fix it by strengthening and stretching. Which one is right, and who should they ask?
Academia bias
Like the other stakeholders in healthcare, academia is also incentivized for more aggressive care. No one ever won a Nobel prize for showing a treatment does NOT work. To get published their paper needs to show positive results."This medicine works", "this exposure is toxic", or "this test is accurate". Getting published is the currency of an academic career. In an analysis of 2,000,000 medical studies, 96% had positive results. However, when we actually try to replicate some of these studies, less than 25% can be replicated. This is known as the “replication crisis" in science.
Media bias
Similar to academia, the media, whether it's a podcaster, instagram influencer, or a reputable newspaper, also needs to report on positive findings to get your attention. They get more clicks if they report a study that shows "the best time of to day to exercise is the morning", than "It doesn't matter what time of day you exercise." They are happy to take the false positive studies from academia and run with them.
Patient bias
You, the patient, are the end user for all the other stakeholders in healthcare. They are just the supply side responding to your demands. Ultimately, patients have the greatest bias for aggressive healthcare. You're not looking for mere fame and fortune, you're looking for something far greater: life, health, and an end to suffering. When one of the other stakeholders offers you some hope, it's not hard to imagine confirmation bias working to persuade you to accept their offer.
Designing a practice to address bias
It should be clear that bias in healthcare is unavoidable. Practitioners are rewarded financially for more aggressive care, industry is trying to move product, specialists favor their own specialty, academia is driven to publish positive studies, the media is driven to report positive studies, and patients just want to feel better at any cost. The one thing they all have in common is... more aggressive care.
These biases can be addressed first by reducing bias within my own practice:
Fee structure that aligns with patient goals - Concierge medicine does not employ the fee-for-service model. I generate income solely from my annual fee. Consequently, there are no financial incentives for more tests, more treatments, and more visits. Instead, my financial incentives are in line with your goals - keep you healthy and happy. If you are satisfied with my performance, you will renew with me the following year.
Deny other sources of income - My annual fee generates enough income so that I don't have to turn to other sources. This includes: no sale of supplements, no cosmetic procedures, no links to laboratories or imaging centers, no links to device or pharmaceutical companies, no paid speaking engagements, no links to medical start-ups or hospitals, and no stakes in books or clinics.
Remain a generalist - A generalist should never be tied to any idea that isn't easy for them to discard. If they specialize in Functional medicine, Longevity medicine, or Integrative medicine, for example, they lose their unbiased perspective. They are actually specialists in disguise promoting and tied to their pet idea.
Next, I help you identify and address bias in others:
Review of specialists - Since specialists are particularly prone to bias, I review their recommendations. A generalist is less biased and can offer you a unique perspective. We see you as a whole person and can incorporate your values and preferences into decisions, and with our comprehensive understanding of medicine we can also provide you with alternate options.
Teach you media literacy - The is motivated by clicks and novel positive findings. These findings are the least likely to be true. Learning how the media works is called media literacy, and is essential to help you identify bias. (for more details click here)
Teach you how to evaluate a claim - The best way to evaluate bias in others is to learn how to evaluate their claims. Although healthcare is highly technical, learning to evaluate claims for yourself can be simplified (for more details click here).
Finally, I help you identify bias in yourself:
Review of your own claims - You have actually evaluated hundreds of healthcare claims in your life, and acted on them. You determined that the antibiotic Zpac, for example, helps you every time you get a cold, or that a supplement your trainer recommended is good for your health. When you evaluated these claims what kind of evidence did you use? Anecdotal evidence, the opinion of an expert, clinical trials? Are these reliable kinds of evidence? Did you lower your standards of evidence because of your desire for the treatment to be effective? Learning to evaluate medical claims objectively, is an essential skill. (for more details click here).
Commentaires