Concierge Medicine and critical thinking
Updated: Jul 19, 2020
A comprehensive approach to your medical problems is essential. Being aware of all your potential diagnosis and treatment options leads to better medical decision making. (To read more about a comprehensive approach click here.)
Too many cures
However, while investigating almost any health topic, you will quickly notice a dilemma: there are too many options. Think about supplements; there are 87,000 supplements currently on the US market. Each one claiming to be, not only a treatment, but a “magic bullet” - a cure with no side effects - backed by strong testimonials and "scientific evidence". In fact, after a thorough investigation of any given health topic, you will discover so many cures, you may find it difficult to choose one.
Why are there so many cures?
Incentivized for cures
The reason their are so many cures is that all the players involved in healthcare are incentivized for cures. From scientists to patients. Everybody wants cures, so we have lots of cures.
Scientists and academics are incentivized to create cures. The discovery of a cure carries with it fame, fortune, and academic advancement. Scientists are expert at finding patterns in random noise and pay more attention to positives findings than negative findings. Unfortunately, there is no incentive to do what is really important in science, replicating experiments and testing to see if cures really work. No one ever won a Nobel prize replicating an experiment.
Industry is incentivized to manufacture and promote cures. Cures are very profitable and the current system of drug and device approval makes it easy for products to be approved. Industry is responsible for testing their own products. This is like letting the fox watch the henhouse. Results are easily spun to make products look better and safer than they actually are. Industry can also influence the other players in healthcare: academics, medical societies, and doctors are funded, and patients are bombarded with marketing.
Doctors are incentivized to offer cures to their patients. From an altruistic perspective they want to end pain and suffering. From a financial perspective they are rewarded by selling more product and doing more procedures. (To learn more about incentives in medicine, click here.)
Finally, patients are incentivized to welcome cures. Pain, suffering, and the fear of death are very strong incentives indeed. It’s understandable that this clouds judgement; even patients who normally exercise excellent judgement and moderation in other aspects of life. Wishful thinking makes them gloss over details and lower their standards for evidence.
Everybody wants cures, so we have lots of cures.
Because there are so many cures for every health problem, we need a tool to help us differentiate the ones that work from the ones that do not. This is where critical thinking comes in...
What is critical thinking?
We have many tools, instruments, devices, and machines in medicine that help us diagnose and treat problems. Yet, by far, the most important tool we use is our brains. It is the tool that evaluates all the other tools.
Critical thinking is a way of diagnosing and treating errors with our thinking. A thinking repair kit. Critical thinking is a way of understanding how out brain thinks, and assessing the brain and the ideas it generates. The ultimate goal of critical thinking is to correct our errors in thinking to make our ideas more accurate. In short, critical thinking is a repair kit for ideas.
Our Thinking is Flawed
The most important prerequisite of critical thinking is to acknowledge that our thinking is flawed. Like any tool, our brains have limitations. They are not as accurate as we think. We are social creatures with complex emotions. Our brains were designed to think quickly for survival - not to solve complex problems. We are prone to cognitive errors such as logical fallacies and cognitive biases. Thinking critically is an unnatural act. As neuroscientist Morgan Levy stated,
“Millions of years of evolution did not result in humans that think like a computer. It is precisely because we think in an intelligently illogical way that our predecessors were able to survive."
Once we realize our thinking is flawed, we can go on to fix these problems. He continues,
"Scientists expend an enormous amount of time and energy going to school in order to learn how to undo the effects of evolution so that they can investigate natural phenomena in a logical way.”
A standardized approach to evaluating a medical claim
Critical thinking helps us identify flaws in ideas. This is accomplished by creating an objective framework. We must construct a standardized approach that anticipates our flawed thinking to sort out which supplements are likely to work, and which are not. This standardized approach involves the following ten steps:
Getting back to our dilemma - 87,000 magic bullets.
Step 1 - Take nobodies word for it (nullius in verba)
This is the motto of the UK's Royal Society of Science, dating back to 1660. It is a response to the common logical fallacy of appealing to authority - believing a medical claim because it is endorsed by an authority figure, without examining the evidence yourself. It acknowledges the fact that the brains of other people are as flawed as our own. Always ask for evidence.
Step 2 - Be Unbiased
All claims need to be evaluated impartially. You should give no preference to one claim over another based on your personal beliefs. Be objective and start with a clean slate.
Step 3 -Tackle one claim at a time
Some treatments claim to treat many conditions - from cancer to wrinkles. These are called "panaceas". The number of claims can be overwhelming. Tackle one at a time.
Step 4 - Stick to claims that are measurable and provable
Clarify the claims. A supplement may claim to 'boosts your energy'. Energy is a subjective feeling and hard to measure. A supplement may claim to "reverse aging". This is difficult to prove directly. There are no clinical trials lasting a human lifetime. Instead, try to stick to claims that are measurable and provable. For example, a supplement that claims to lower blood pressure; blood pressure can be easily measured, and the experiment to prove whether it works is simple and conceivable.
Step 5 - Assess plausibility
Is the claim congruent with our current understanding of physiology, and the natural laws of the universe? For example, the claim, "supplements have no side effects", is not congruent with our understanding of physiology. The human body is a complex system with countless biochemical pathways. A chemical, natural or not, creates a cascade of effects, some good, and some bad. Substances from nature, like potassium, botulinum toxin, or arsenic, can be very harmful. Prescription pharmaceuticals derived from nature, like penicillin, aspirin, and statins, all have side effects.
Implausibility does not prove a claim is false; however, implausible claims should require stronger evidence. As Carl Sagan said,
"Extraordinary claims require extraordinary evidence."
Step 6 - Review all the evidence
One of the most prevalent cognitive errors in science is confirmation bias, or cherry-picking. An expect selects the evidence thst confirms his hypothesis and ignores or downplays the evidence that disconfrirms his hypothesis. This is why you can watch a vegan documentary and be convinced by the presented evidence to never eat a peice of meat of again, and then watch a low-carb, keto, or Paleo documentary and be persudaed of the opposire conclusion. Track down all of the evidence relating to the claim. Whether the evidence confirms the claim, or disconfirms the claim.
Step 7 - Rank the evidence
The evidence needs to be ranked by its ability to test a hypothesis. There is a hierarchy of evidence. Some evidence is only hypothesis-generating - it helps us formulate new ideas. It is preliminary research that might lead to something, but needs to be repeated and confirmed with other experiments. This includes: anecdotal evidence, laboratory evidence, observational evidence, authority, and ancient wisdom. Other evidence is hypothesis-testing, like randomized controlled trials. These studies confirm hypotheses by testing ideas on real patients, looking for real outcomes, and comparing them with control groups. These studies take years to complete, require large numbers of scientists and subjects, and are very expensive. Because of this, there are many hypotheses in medicine and few that are properly tested. Most of the evidence in support supplement claims, for example, are hypothesis-generating.
There is a decline effect in medicine. As potential cures are subjected to better and better studies, the effects seen in earlier studies disappear. Most claims that look good in preliminary studies turn out not to be true. For example, it's estimated that less that one percent of drugs that look good in basic science experiments work in large clinical trials. The likelihood of a supplement to cure Alzheimers Disease is relatively low after considering that Pharmaceutical companies have spend $600 billions dollars on Alzheimers Disease in the last 20 years to no avail.
Step 8 - Look for sources of bias in the evidence
Evidence can be biased because is it produced by biased individuals. These individuals may be motivated by academic advancement, or a financial conflict of interest. For example, some studies are funded directly by the supplement industry. Most bias directs research to produce positive results; showing that treatments work when they do not. Be more suspicious of positive results than negative results.
Step 9 - Benefits to harms ratio
Step 10 - Alternative options
Step 11 - Self regulation
Recognize the limitations of your own brain. Be willing to change your beliefs as new evidence emerges.
Supplements represent an incredible opportunity for drug discovery. However, supplements are currently supervised and promoted by an unregulated for-profit industry. Separating truth from hype requires a critical thinking approach. We want them to be effective. A nice simple solution. In realty, the human body is complex, and problems in medicine are complex. Simple solutions are almost always wrong. As H. L. Mencken wrote,
"For every complex problem there is an answer that is clear, simple, and wrong."
Moreover, it is quite clear that none of these sources agree on a single solution. Each one seems to have a powerful and simple solution of their own. For a full critical thinking evaluation of supplements, please see my lecture on 'How to evaluate supplements'.
Lessons learned from critical thinking in medicine
Data is skewed, results are spun, studies are cherry picked, and conclusions are glossed over. All of these forces work together to cloud the truth, producing an abundance of cures, with very few that actually work.
In comparison, the pharmaceutical industry spends trillions of dollars on drug discovery. Most drugs fail, and the ones that do work, only work partly, and certainly have side effects. There is an obvious incongruity between the claims of the mostly unregulated supplement industry, and the reality of the regulated pharmaceutical industry.
We should not take the claims of the supplement industry at face value. If something sounds too good to be true it probably is. This opens the door to critical thinking in medicine...
Critical thinking and Integrative Medicine
Integrative Medicine doctors are smart, caring, innovative, and think outside the box. A core component of their philosophy is try to employ a comprehensive approach - provide each patient with all their options. However, the subsequent critical thinking and ranking of the evidence is conspicuously absent. This is because Integrative Medicine is defined by its acceptance of all forms of evidence. Anecdotal evidence, laboratory evidence, observational evidence, authority, and ancient wisdom are all acceptable forms of evidence. In fact, so many of its treatments are based on implausible ideas and weak forms of evidence that any attempt at a hierarchy of evidence would result in an implosion of the field. Instead, claims are taken at face value without comparison with competing claims. There is no criticism or peer review. Everything works and everything works equally. A comprehensive approach without critical thinking is unhelpful and leads to chaos.
So many of the treatments are based on implausible ideas and weak forms of evidence that any attempt at a hierarchy of evidence would result in an implosion of the field.
Critical thinking and Concierge Medicine
The Concierge Medicine model is the optimal model to practice critical thinking in medicine. My practices is small. I have ample time to perform critical evaluations of medical claims, and a ample time to teach patients about critical thinking in medicine.
However, not all concierge doctors apply critical thinking to their practice. It can conflict with the demand to please patients. A critical approach often leaves the patient with very few options for their medical problems. That's not good for business. Patients want a diagnosis for their medical problems and treatments that work. Furthermore, critical thinking skills take time and experience to develop. Humans may be born with a general capacity for critical thinking; however, critical thinking in specific fields needs to nurtured. Medical school don't teach doctors how to think, it teaches them what to think. Most of critical thinking skills are achieved only after many years into practice. A doctor, for instance, that has seen thousands of fads and treatments come and go in her lifetime, may be better equipped to evaluate a new fad than a doctor straight out of training.
In my practice, critical thinking is one of the core elements. I have developed my skills over 25 years of practice, evaluating thousands of medical claims. I teach my patients to question everything - even claims that I make. My goal is to come as close to the truth as possible, offering my patients the most likely diagnoses, and the most likely treatments to work, based on objective evaluations.
I teach my patients to question everything - even the claims that I make.