Patient Empowerment

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Summary

A core dilemma in healthcare is that everybody wants to be healthy, yet we're easily fooled by false claims and treatments that don't work. Even dangerous treatments spread and become popular. This leaves patients vulnerable. Consequently, better health is not about more healthcare, it's about understanding the enterprise of healthcare. How treatments are developed, how they compete, and how they spread.

About

A Bird's-eye View of Healthcare

The best way for patients to learn about healthcare is to take a bird's-eye view: define healthcare, the scope of healthcare, and the market that's formed around it.

What is Healthcare?

Healthcare encompasses any good or service that claims to improve your health. From testing (blood tests or activity trackers), to procedures (surgery or acupuncture), to lifestyle products (organic food or gym equipment), to practitioners (health influencers or certified professionals). Healthcare overlaps with everything in our lives; literally, how we eat, sleep, and breathe.

The Healthcare Market

We live in a market economy. Wherever there is demand, a competitive market will arise to supply that demand. With its scope, the healthcare market is massive. It is valued in the tens of trillions.

About

The Driving Force of Healthcare

Like any market, the Healthcare Market and its players respond to market forces. Understanding these forces is key to understanding the current state of healthcare.

Buyer Demand

We (the buyers) all want good health. Good health is on top of our list of things we desire the most, and bad health and death are on top of our list of things we fear the most. In surveys, billionaires would offer half their fortune for ten extra years of life. It's hard to find another commodity with this much demand.

Buyer Action Bias

In addition to demanding good health, buyers have a bias for action. We prefer doing something over doing nothing. Doing something gives us a sense of control, even when it's not the best choice. When we feel ill it's hard to do nothing, even though the majority of complaints resolve on their own. When we have a cold, for example, we reach for an antibiotic, probably causing more harm than good.

Seller Action Bias

The sellers, made up of industry and practitioners, are also driven by action: doing something over doing nothing. Doing nothing is hard to monetize. "Let's wait and see if you get better" or "Other than the basics, we have nothing to make you live longer" is hard to monetize. The practitioner de-facto financial model is 'Fee-for-service'. A model that rewards action: more appointments, more tests, more diagnoses, and more treatments. Regardless if they are a neurosurgeon or an acupuncturist.

About

The Disease & Treat Model

With both buyers and sellers searching for actionable items, the goal of the seller is to convince the buyer that they have a disease and that they have a treatment for that disease. This is the Disease & Treat Model of healthcare. To sell a solution, you must have a problem. Let's explore this model, beginning with research - those who discover the diseases and treatments.

Researcher Bias

The researchers in healthcare are motivated in two ways: 'publish or perish', and 'disease or treatment'. In other words, they need to generate a lot of research, and whatever they're studying needs to show that it either causes disease or treats disease. No one ever won a Nobel Prize for showing that something does nothing.

A Plethora of Low Quality Research

This creates a plethora of low quality research. Over one million scientific papers are published every year in the field of healthcare. Most of these studies are cheap to produce, like test-tube and rat experiments, and 95% of it shows: this is a disease, or this will treat the disease. With low quality research, the seller has a cheap and easy way to generate evidence to support any diagnosis or any treatment they want.

Disease: Converting People Into Patients

With low quality research, the market can easily generate or amplify disease.

This happens in several ways:

• Lowering Diagnostic Thresholds: pre-hypertension, pre-diabetes, mildly elevated mercury levels, mild ADHD

• Turning a Risk Factor or Biomarker Into a Disease: Insulin resistance, weak grip strength, less than 8 hours of sleep.

• Expanding Test Usage: full-body MRI, wearable biosensors (Oura ring, CGMs),

• Turning Exposures into Disease: mold, mercury, pesticides, GMO's, sunscreens

• Poorly Understood or Unvalidated Disease: leaky gut, chronic Lyme, chi imbalance.

• 'Medicalization' of Social Issues: social phobia, male pattern baldness.

• Turning treatments into disease: vaccines and autism, statins and dementia

With 'wellness', healthy is not good enough, you could be bigger, stronger, smarter. With 'longevity', aging is the disease and we all become patients at birth. Aldous Huxley famously remarked on this in the 1950’s, "Medical science has made such tremendous progress that soon none of us well be healthy."

There is also a synergism here. Diagnosis not only feeds the treatment market, it creates a market of it's own. A market of diagnostic products.

Converting Things Into Treatments

With low quality research, it's easy to convert almost anything into treatment. It's why we see 90,000 supplements on the US market. Other examples include:

• Basic nutrition (eat less food and less processed food) converted into a trillion dollar market of premium products: organic food, non-GMO food, functional foods, and (ironically) processing the food into supplements.

• Recreational and performance-enhancing drugs (THC, psychedelics, ketamine, testosterone, human growth hormone) converted into treatments.

• Recreational and relaxation activities (sauna, cold water immersion, meditation) converted into treatments.

A Very High Product Failure Rate

When we try to replicate this low quality research, less than 80% can be replicated. This is known as the replication crisis. It is a direct result of researchers trying to make their studies look positive. But it gets worse; even if the the low quality research is replicated, less than 1% work when subjected to the high quality research, large human clinical trials, called randomized placebo-controlled trials, or RCTs.

When we really test our ideas most do not work. Every penicillin lies on a mountain of bloodletting and leeches.

About

Why You Are Vulnerable

With the buyers, the sellers, the researchers, and the practitioners all driven by action - doing something over doing nothing - you (the buyers) are vulnerable. Let's explore how this manifests:

The Information Asymmetry Problem

Healthcare is exceptionally hard to evaluate. It's much easier to figure out if your TV's working than your longevity supplement. Healthcare requires special knowledge, and the seller knows far more than the buyer. This is the information asymmetry problem. The buyer can either attempt to learn healthcare for themselves, very problematic in a world full of misinformation, or they can rely on the seller to tell them what to buy. This is like asking your butcher how many steaks you need. The seller determines demand. Either way, the buyer is vulnerable.

Using Low Quality Research

With over one million health-related scientific papers published every year, the research component of healthcare is massive. Most of this, however, is low quality research, such as test-tube and rat experiments, and 95% of it shows that the claim is true: this is a disease, or this thing will treat the disease. With low quality research, the seller has a cheap and easy way to generate evidence to support any diagnosis or any treatment they want.

Converting People Into Patients

The basic economic model of healthcare is that the seller must convince the buyer that they have a disease. With low quality research, the market can easily generate or amplify disease.

This happens in several ways:

• Lowering Diagnostic Thresholds: pre-hypertension, pre-diabetes, mildly elevated mercury levels.

• Turning a Risk Factor or Biomarker Into a Disease: Insulin resistance, weak grip strength, less than 8 hours of sleep.

• Expanding Test Usage: full-body MRI, wearable biosensors (Oura ring, CGMs),

• Turning Exposures into Disease: mold, mercury, pesticides, GMO's, sunscreens

• Poorly Understood or Unvalidated Disease: leaky gut, chronic Lyme, chi imbalance.

• 'Medicalization' of Social Issues: social phobia, male pattern baldness.

There is also a synergism here. Diagnosis not only feeds the treatment market, it creates a market of it's own. A market of diagnostic products.

With the popularization of 'longevity' and aging as a disease, we all become patients at birth. Aldous Huxley famously remarked on this in the 1950’s, "Medical science has made such tremendous progress that soon none of us well be healthy."

Converting Things Into Treatments

With low quality research, it's easy to convert almost anything into treatment. It's why we see 90,000 supplements on the US market. Other examples include:

• Basic nutrition (eat less food and less processed food) converted into a trillion dollar market of premium products: organic food, non-GMO food, functional foods, and (ironically) processing the food into supplements.

• Recreational and performance-enhancing drugs (THC, psychedelics, ketamine, testosterone, human growth hormone) converted into treatments.

• Recreational and relaxation activities (sauna, cold water immersion, meditation) converted into treatments.

A Very High Product Failure Rate

When we try to replicate this low quality research, less than 80% can be replicated. This is known as the replication crisis. It is a direct result of researchers trying to make their studies look positive. But it gets worse; even if the the low quality research is replicated, less than 1% work when subjected to the high quality research, large human clinical trials, called randomized placebo-controlled trials, or RCTs.

When we really test our ideas most do not work. Every penicillin lies on a mountain of bloodletting and leeches.

About

Regulation and Avoiding Regulation

From a seller's perspective, the strategy is clear:

• Induce demand by creating disease.

• Monetize diagnosis.

• Monetize treatment.

• Use low quality research for evidence (inexpensive and shows product works)

• Avoid high quality research (expensive and shows product does not work or unsafe)

Regulation For Your Protection

Knowing this strategy and our history of harm, the healthcare market is not a 'free' market. From the beginning of the twentieth century, the products and the practitioner began to be regulated for your safety. Regulatory agencies such as the professional associations, the FDA, and state medical board require that:

• Researchers claims are reviewed by their peers, fellow experts.

• Diagnostic tests are validated for accuracy.

• Treatments are subjected to high quality research (RCT's)

• Practitioners prescribe only evidence-based treatments and follow an ethical standard of practice.

Regulatory Arbitrage, Disclaimers, & Deregulation

Markets respond to regulation by either finding ways around regulation ('regulatory arbitrage)' or by lobbying for deregulation. Below are some examples:

• With a disclaimer, diagnostic labs can sell unvalidated and inaccurate tests.

• With a disclaimer, the supplement industry (deregulated in 1994) can sell any of its 90,000 products without high quality research.

• With a disclaimer, health influencers, and even persons with no training, can bypass expert review, and monetize misinformation in books and social media. A practice that synergies well with the upsell of the other unregulated tests and supplements.

• Alternative medicine practitioners have legal and regulatory immunity to prescribe treatments with low quality evidence. (Conventional doctors are currently fighting for similar immunity).

• Stem-cell doctors go off-shore to sell their products (Stem-cell tourism).

Leveraging Institutional Mistrust & False Dichotomies

A growing sociopolitical shift towards mistrust in science and institutions has been weaponized as a marketing tool. Regulatory agencies like the FDA or professional medical societies are framed as "gatekeepers" or "corrupt actors" who are suppressing the truth. This mistrust leaves patients vulnerable to influencers and clinics that claim to have "secret" knowledge.

Creating a False Dichotomy

The wellness, alternative medicine, and longevity industries have successfully rebranded themselves as a 'healthier and safer' alternative to 'Big Pharma and surgery'. Patients who are naturally skeptical of conventional medicine often lower their defenses for their products. Yet, these are simply different branches of the same aggressive profit-driven system they mistrust, with the same biases and conflicts interest. From the buyers perspective, from the frying pan into the fire. The only difference is strategy: avoid regulation and proof of safety and efficacy, embrace patient's appeal to nature fallacy, lean into the public mistrust of conventional medicine by pretending they offer an alternative.

About

Why the Wealthy and Healthy Are Vulnerable

Because the healthcare market is trying to sell products that mostly don't work this makes the wealthy and the healthy particularly vulnerable.

The Payers

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The Wealthy

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The Healthy

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About

The Spread of Healthcare

Direct-To-Consumer Marketing

For the seller of healthcare, the best marketing is you, the buyer. Your stories - or anecdotes - of getting better spread treatments fro

Anecdotes

For the seller of healthcare, the best marketing is you, the buyer. Your stories - or anecdotes - of getting better spread treatments from person to person. This is not new. It's been going on for millenia. From bloodletting to peptides.

For patients, anecdotes are incredibly powerful. For medical science, anecdotes are incredibly misleading. Of all the issues in healthcare that make patients vulnerable, this is probably the number one factor.

Treatments Seem to Work in Friends

We are bathed in stories of someone who tried something and felt better. Occasionally these anecdotes are impressive and even lead to a medical discovery. However, the vast majority of anecdotes are unimpressive. When properly interrogated, the results are muddied by: poor documentation, multiple treatments, and hard-to-measure outcomes, like pain. More often than not, the real reason for improvement is placebo effects, natural recovery, and effort justification. After spending $30,000 and enduring the pain and the travel to an off-shore stem-cell clinic, we are far more likely to look for and spread a positive result than the embarrassment of a negative one.

Media and Misinformation

The bias to report false positive papers and false positive anecdotes creates an asymmetric amplification of ineffective treatments. This is further accelerated by social media, which spreads fake news faster and further than true news. Even dangerous treatments can become immensely popular. For the vulnerable patient this 'social proof' is highly compelling. In behavioral economics and network theory this is called an 'informational cascade'. It's the cause of 'herd' behavior, and the spread of irrational ideas. The history of medicine is replete with thousands of examples, including: Z-pac for cold virus, blood-letting, and monkey testicle transplants.

Ultimately, what this means is that the trendy treatment that's all over social media, that your friends are doing, and that works in a test tube, probably does not work. It's circled the planet three times before anyone has even contemplated testing it with an accurate test. This leaves patients very vulnerable.

About

Engineering a Practice to Empower Patients

My practice was specifically engineered to empower patients. Using the above issues as blueprint.These special features of my practince include:

Allotting Time for Education

It's been estimated that just 20% of a doctor's visit is dedicated to patient education. In my practice, this is turned around. I prioritize most of our time together to be spent on education. The goal is to provide you with understandable and accurate information and level the information playing field. You will have the same information as the expert. Accurate information is the cornerstone of patient empowerment.

Learning to Evaluate Medical Claims For Yourself

Medical Science has been the single greatest step towards patient empowerment. Going from eminence based medicine to evidence based medicine. I would argue that the most important invention in the field of healthcare was The Randomized controlled trial. Not because it is a definitive test of a treatment, but it is the foundation of knowledge and calibrates the other kinds of evidence.

The importance of sharing evidence - submitting your ideas to your peers, consensus, replication. Science vs pseudoscience - Prove yourself wrong. To read more, click here.

Shared Decision-Making

Some decisions in healthcare are black and white. These are the minority. For everything else patients need to get more involved in the decision-making process. Incorporates your values, preferences, and circumstances. It is an open and collaborative process where you're encouraged to question everything. We work as a team and I treat my patients as equals. To read more, click here.

Remain a Generalist

Specialists are incredbility improtnat for the practice of medicine. However, with all the their biases, it is crucial to have an expert on your team that is a generalist. Someone expert in evaluating medical claims, that does not have their skin in any one particular medical claim. If your primary care doctor is doing 'functional, 'longevity', or 'integrative' medicine, they are no longer generalists. They are specialists. The concierge model gives me the time to help my patients evaluate claims but my most important commitment is to always remain a true generalist.

Addressing Bias

Bias is the major source of misinformation in healthcare, and addressing it is paramount. Within my practice, I have eliminated all sources of conflict of interest, financial and non-financial. No selling supplements. Outside my practice, my aim is to help you evaluate bias in others, particularly specialists, experts, and the media. To read more, click here.

Teaching Media Literacy

The 'social proof' from social media and friends can be quite compelling. A basic understanding of how the media works, what's called 'media literacy', is crucial to be able to understand how bad ideas spread. A vital tool for modern living.