Critical Thinking and Patient Empowerment

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From an economics perspective, there are two main issues making patients vulnerable to bad healthcare. The first is that health, as a product, is in exceptionally high demand. It's not only essential for a good life, it's a product that everyone needs; whether you're ill and looking for a cure, or healthy and looking to live longer.

The second problem is that healthcare is a highly technical field. As a result, patients are unequipped to evaluate healthcare for themselves and reliant on experts for information. This is the information asymmetry problem, and leads to what medical economists call, supplier-induced demand. Patients are told what to demand by the industry selling it to them.

Together, high demand and supplier-induced demand have resulted in sordid history of medicine replete with bad healthcare. Far more bad healthcare than good healthcare. Whether it's bloodletting, lobotomies, stem cells, or actual snake oil.

Consequently, the best approach to healthcare isn't more healthcare, it’s about trying to empower patients to evaluate healthcare for themselves. This journey to patient empowerment has been a long one. It's important for you understand where we came from, and where we’re going. (See Diagram below). The journey starts with "Medical Paternalism" and ends with "Medical Paternalism".

The age of Medical Paternalism

Prior to the twentieth century, patients were completely excluded from healthcare decisions. Doctors saw patients as weak, debilitated, childlike victims, incapable of making good decisions for themselves. This "doctor knows best" mindset is known as medical paternalism. Below is an example from the writings of Hippocrates:

"Conceal most things from the patient while treating him. Give what encouragement is required cheerfully and calmly, diverting his attention from his own circumstances...revealing nothing of his future or present condition." Decorum, 400 BCE

Essentially, it was feared that the psychological impact of the diagnosis would affect patient outcome. This is articulated quite clearly in the 1847 American Medical Association code of ethics:

"The life of a sick person can be shortened not only by the acts, but also by the words or manner of a physician. It is, therefore, a sacred duty to avoid all things which have a tendency to discourage the patient and to depress his spirits."

For this reason, it became standard practice to withhold diseases with a bad prognosis. A practice that persisted well into the 20th century. In a 1953 survey, for example, 70% of physicians would withhold a diagnosis of cancer from their patients.

Society effectively granted doctors carte blanche, the freedom to sell and do as they pleased. A surgeon, for instance, made all the decisions without the patient. They neither needed the patient's consent, nor were they obligated to inform them of possible complications. There was no regulation. No malpractice. No accountability.

The reason doctors could get away with this was that the field of medicine lacked true scientific rigor. The evidence justifying a treatment was subjective; either a doctor's personal anecdote, or their pet theory of how the body works. There was no way to prove them wrong. In other words, you just had to "trust the expert". It was an Eminence-based medicine.

The age of Evidence-based Medicine

By the mid-20th century this all changed with the birth of a very different kind of evidence, the randomized controlled trial, or RCT. Here, a large group of patients is given a treatment, and a control group is not. Several experimenters then watch both groups until they witness real outcomes, like death or heart attacks.

Unlike anecdotes or pet theories, the RCT was truly objective. The control group eliminated being deceived by placebo effects, the real human outcomes eliminated being deceived by animal studies, and the many observers reduced being deceived by personal bias and foul play.

The RCT not only provided a reliable method to determine whether a medical claim was true, it also provided a means to evaluate the reliability of the other kinds of evidence (anecdote, animal study, experiment in cells, expert opinion, etc ). It soon became obvious they were quite unreliable, and established the foundational concept of Evidence-based medicine, the hierarchy of evidence. Some evidence is better than others (graphically displayed in the evidence "pyramid" below). Most of our ideas, the one's at the bottom of the pyramid, are wrong. Miracles in medicine are rare events.

The age of Accountability and Regulation

With the advent of objective evidence, it was no longer necessary to take an expert's word for it. In fact, experts would now be made accountable for their claims. And this manifested throughout healthcare, from research to practice. Some examples include:

• Sharing evidence - Researchers were expected to share their evidence and publish their findings in journals so that everyone had access. Today you can search databases like the National Library of Medicine (PubMed.gov) and find over 35 million papers. There are no secrets.

• Replication - Researchers were encouraged to replicate results. This exposed a big problem in science, the replication crisis. Less than 25% of basic research can be replicated.

• Peer review and consensus - Experts began to evaluate the ideas of other experts - their peers. Journals established a peer review process, and peers organized in medical societies (like the American College of Cardiology) to advocate on behalf of patients. The reason peer review works so well is because peers are not only the most qualified to understand the technical ideas of their specialty, they're in competition with each other. Only ideas with the most objective evidence will gain consensus.

• Legislation of medical practice - Objective evidence made it possible to establish objective standards of how doctors should practice medicine. State medical boards and malpractice attorneys emerged to enforce these standards. This protected patients from bad healthcare and from doctors without appropriate qualification.

• Health insurance - Health insurance emerged to pay for medical claims. Although their mandate is to save money and appears is self-serving, it also protects patients by weeding out the bad healthcare. They only pay for interventions backed by strong objective evidence.

• Regulation of drugs - Many dangerous drugs were being sold over-the-counter, such as infant formulas with opioids and cocaine. To protect the public, the Pure Food and Drug Act began regulating drugs in 1906, and eventually morphed into the FDA.

The age of Patient Autonomy and Informed Consent

Imposing regulation and holding doctors accountable for their actions forever changed the doctor/patient relationship. Excluding patients from crucial decisions would become "unethical". By the mid-20th century, patient autonomy - the right to make your own medical decisions - became one of the four pillars of medical ethics.

Patient autonomy also fell under the broader movement of individualism. During the enlightenment, society began to see the importance of individual rights, freedom, and self-determination. This flourished during the human rights movements of the 20th century, where high profile cases of abuse, such as the infamous Tuskegee and Nazi medical experiments, underscored the importance of patient rights.

Patient autonomy also started to win in the courts of law. Beginning in the field of surgery, in 1914, doctors a judgement required doctors get a patients consent prior to the procedure. However, mere "consent" wasn't enough. To truly be empowered, patient’s need informed consent. They need accurate information about the procedure, the pros and cons, so they can decide for themselves. A point brought out in a 1972 landmark case, where a patient consented to spine surgery but wasn't informed about the post-op complication, paralysis, they eventually developed. Today, when you have procedure, you are given an extensive list of possible complications you must acknowledge and sign. This is modern informed consent in action.

With patient autonomy at the forefront of medical ethics, and objective evidence to regulate the healthcare industry, it seemed like patients were finally empowered and protected from bad healthcare. The age of Medical Paternalism was finally over!

The age of Regulatory Arbitrage

Alas, this was not to be. In any market with exceptionally high demand, and where that demand is determined by the suppliers (supplier-induced demand), the market forces are so strong the suppliers will eventually find a way around regulation. This principle in economics is called regulatory arbitrage.

The suppliers of healthcare have found many ways around regulation, and are certainly no exception. Whether it's a neurosurgeon or an acupuncturist, a teaching hospital or a “wellness” clinic, a pharmaceutical company or a supplement seller. They're all just different manifestations of the same industry trying to sell you its product - health. Let's review some examples of regulatory arbitrage in healthcare:

1. Informed consent loopholes - Although surgeons are required to give informed consent by law, patient barely read the fine print, and surgeons can persuade patients with anecdotes and non-verbal cues. For example, 88% of patients undergoing cardiac stents for chronically blocked arteries, were under the impression that the procedure would prolong their lives, even though it only treats the symptoms.

2. No informed consent required - Outside of surgery, informed consent isn't legally required. When your doctor orders a cancer screening test, for instance, were you informed of the possibility of false positives results leading to further unnecessary tests and harmful procedures?

3. Alternative Medicine & Supplements - Through persistent lobbying, both of these industries have been able to deregulate themselves. Unbound to objective evidence, they can make outrageous claims with slim to no evidence. This includes: functional medicine, longevity medicine, and the trillion dollar "wellness" industry.

4. Criticism of regulatory institutions - When the ideas of individual scientists or practitioners don't make it through regulation (scientific peer review, government agencies, insurance, etc) their response is to attack that institution, and sometimes, even competing industries ("Big Supplement" attacking "Big Pharma").

5. Criticism of Evidence-based medicine - The last resort is to attack objective evidence itself. Claim that expert opinion, anecdote, and rat experiments, are actually the strongest kind of evidence. In other words, turn the evidence pyramid on its head.

   
   

The age of Misinformation

These last two strategies, criticism of regulatory institutions and criticism of objective evidence, are particularly subversive. They lead to conspiracy thinking and a mistrust in science and the institutions that apply science. We can see this in the polls. Public trust in science and doctors is at an all time low. In our current sociopolitical climate these are popular narratives, and through social media, they propagate exponentially in echo-chambers. 

However, without objective evidence and the regulatory institutions that apply it, patients are lost. A ship without a rudder. Any one claim with anedotal evidence and a rat study, anything they want. In fact, when you turn the evidence pyramid on it head, anything goes. This is why we hear such antithetical claims: "Never eat a piece of meat it will cause cancer", and "Only eat meat, it will prevent cancer". As Dr Oz (a well-known opponent of evidence-based medicine) said,

"It's my facts versus your facts." New Yorker, 2013

So who do patients trust and turn to?

Back to Medical Paternalism

Patients turn to the modern version of Medical Paternalism. They find an authority figure they can trust. A "health influencer" with the greatest number of followers, or a rogue scientist that disagrees with the consensus, or even a non-expert that simply aligns with their political beliefs. Instead of pressing them for objective evidence, they simply rely on their "authority". An eminence-based medicine. A single expert's opinion based on anecdotes, rat experiments, and a pet theory of how the body works. This is modern Medical Paternalism.

What's truly ironic is that almost every one of these health influencers consider themselves practicing the "healthcare of the future", a Medicine 3.0. In reality, it's the absolute opposite. It's not only regressive but taking patients back, literally, to the dark ages.

Critical Thinking and Patient Empowerment

This is why teaching patients Critical Thinking is crucial in modern medical practice, especially the primary care provider, the quarterback of the team.

The extra time afforded by the Concierge Medicine model allows me to design my practice towards this goal. The four following features are core components of my practice:

1. Emphasis on 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, with the goal of providing you with only good information. Clear, understandable, accurate, relevant, unbiased, and complete.

2. Evaluating medical claims - Although healthcare is highly complex it is possible to learn how to evaluate claims for yourself. The key is to take a systematic approach, and factor in our prior success rates. To read more, click here.

3. 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 decision-making. A process that 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.

4. Addressing bias - Bias is the major source of misinformation in healthcare, and addressing it is paramount. Within my practice, I have eliminated all sources on conflict of interest, financial and non-financial. Outside my practice, my aim is to help you evaluate bias in others, particularly specialists, experts, and the media. To read more, click here.

Only with good information are you empowered to make good medical decisions.