Critical thinking and Addressing Bias

The core principle of critical thinking is that critical thinking doesn't come natural to us. We are all bad thinkers. You, me, everyone. Our brains did not evolve to solve complex problems, they evolved to solve problems quickly.

As a result, we are prone to bias. For example, if we want to believe something, we excel at convincing ourselves. This is known as motivated reasoning. We lower the standards for evidence if something supports our beliefs, and raise the standards for something that contradict our beliefs. It's how smart people can believe stupid things. It's how your favorite podcaster can convince themselves of a false claim.

Healthcare involves seven main stakeholders: academia, the media, industry, practitioners, specialists, alternative medicine, and you, the patient. I will explore each one, their biases, their motivations (both financial and non-financial), and how they conflict with your healthcare needs. You will observe that they all tend to lean in the same direction - towards more aggressive care - and I will describe how I have engineered my practice to counteract these biases.

1. Academia bias

Academia generates most of the ideas that fuel healthcare, and therefore, is the first stakeholder we need to examine. Their incentive structure leads to a lot of false ideas. This is due to the fact that to get published and cited by others, you need positive results: "this medicine works", or "this exposure is toxic". No one ever won a Nobel prize for showing a treatment does NOT work. It's also relatively easy for a lone scientist to squeeze out (p-hack) a positive result. Case in point, in an analysis of 2,000,000 studies from academia, 96% were positive results.

However, when we actually try to replicate these studies, less than 25% can be replicated. This is known as the “replication crisis in science". What this bias means to you as a patient is that a treatment from academia is unlikely to work or the toxin does not cause the disease.

2. Media bias

The media - be it a podcaster, Instagram influencer, or a respected newspaper - has a similar incentive structure. They are also motivated to report positive findings: "this medicine works", or "this exposure is toxic". They get the most clicks from news that either has a message of hope, or a message of fear. In essence, they take the positive findings from academia, the ones unlikely to replicate, and run with them.

3. Industry bias

The ideas generated by academia and popularized by the media create a market opportunity that industry rushes in to transform into products for sale. These range from diagnostic products, like laboratory tests, imaging, and wearable technology, to therapeutic products, like pacemakers, supplements, and pharmaceuticals.

Industry is, of course, incentivized to move more of its product, and this leads to more aggressive care. More tests and more treatments. Industry's two biggest clients are patients and practitioners, and it reaches them through marketing and kickbacks - as much as the law will allow. For example, the pharmaceutical industry in the US can market direct-to-consumer. They can marketing and popularize the drug or the disease the drug treats. Some famous "disease awareness campaigns"include Low T, restless leg syndrome, and social phobia.

The pharmaceutical industry also spends about $60 billion a year on marketing to doctors. And it's not money wasted, studies demonstrate that it leads to more prescriptions. They also pay doctors kickbacks for speaking engagements and "research", and this data is now viewable to the public,

4. Practitioner bias

The fee-for-service model is the most common way to reimburse healthcare practitioners. This model reimburses for each visit and each treatment, and as a result, instead of incentivizing better health, it incentivizes more aggressive care. Studies show, for instance, that fee-for-service surgeons are more likely to perform surgery than salaried surgeons, and surgeons that own their surgical center are more likely to perform surgery than those who do not.

It's important to point out that the cascade or aggressive care always begins with diagnosis. The sicker you can be made look, the more it drives the other services. This often leads to a phenomenon called overdiagnosis - 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, such as prostate cancer, thyroid cancer, and kidney cancer, are found at such an early stage, they would have never progressed. Overdiagnosis also occurs when we lower the diagnosis threshold of disease that presents in a spectrum, like hypertension and diabetes. In a large population, even a minor shift in these thresholds to "pre-hypertension" or "pre-diabetes", can turn tens of millions of people into patients. As Aldous Huxley famously said,

Medical science is making such remarkable progress that soon none of us will be well.

5. Specialist bias

Despite our veneration of specialists, they are particularly prone to bias. Beyond the financial conflicts that all practitioners face, they are philosophically and personally bound to their specialty. They tend to see all disease from its lens, and treat all disease with its tools.  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."

A patient with back pain, for example, can consult four different specialists and receive four different opinions. The Spine Surgeon finds mechanical defects on MRI to be fixed with surgery, the Chiropractor finds vertebral subluxations to be fixed with spinal adjustment, the Acupuncturist finds blocked Chi to be fixed by inserting needles, and the Physical Therapist finds muscle imbalances to be fixed by strengthening and stretching.

Which one is right? Unfortunately, asking the specialists themselves is problematic. They are surrounded by like-minded individuals, whether in their practice, at their specialty meetings, or in the specialty journals they read. In these echo-chambers they are insulated from any negative information about their field. This renders them immune to refutation, and for all intents and purposes, trapped in their specialty.

6. Alternative Medicine bias

Many patients, put off with the bias and conflicts of interest in conventional medicine’s stakeholders, turn to Alternative Medicine and its many forms, like: Functional medicine, Naturopathy, Integrative medicine, and Longevity medicine. Unfortunately, what they fail to appreciate is that Alternative Medicine is prone to the same biases, the same conflicts of interest, and the same problems, diagnose more and treat more, however, due to it’s lack of regulation, these problems are actually amplified.

To begin with, the ideas that fuel Alternative Medicine also come from academia and its false positive findings. Anything that generates hope or fear, whether true or not, is then popularized by the media. However, instead of mainstream media, Alternative Medicine is typically popularized through Social media and podcasts, the perfect platform for the spread of misinformation. These popularized ideas create market opportunities which industry turns into products for sale, whether it's marked up organic food that does not contain the "toxin"that will kill you, a stem cell injection for longevity, a home vitamin infusion, a cold plunge, or a wellness spa. These are trillion dollar industries that market directly to patients and pay kickbacks to health influencers.

Alternative Medicine's practitioner are reimbursed using the fee-for-service model, incentivizing more aggressive care. And they act more like specialists, than generalists, living in information filter bubbles, immune to refutation. It's very hard to change their minds.

although relationships with diagnostic centers, supplement companies, and device manufacturers, are not.

All of this lead to more diagnoses and more treatments. There is one major difference, however. Alternative Medicine has less regulation, less accountability, and less need for scientific rigor, making patients more at risk for fake diagnoses and fake treatments.

7. Patient bias

As the patient, you are the end user for all the other healthcare stakeholders. They are merely the supply side responding to your demands. And you have the greatest bias for aggressive care. Your goals, after all, transcend fame and fortune. Your goals are life, health, and an end to suffering. Consequently, when one of these stakeholders offers you some hope, it's not hard to imagine motivated reasoning lowering your threshold for evidence.

Designing a practice to address bias

It should be clear that bias in healthcare is unavoidable. Academia is driven to publish positive findings and the media is driven to report them; industry transforms positive finding into products and practitioners are rewarded by recommending them; specialists are particularly confident in the products of their specialty and patients just want to feel better at any cost. The one thing they all have in common is... more aggressive care.

To address these biases, I first start by cleaning house, and 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 an 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: to 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 - Although I'm committed to maintaining a comprehensive knowledge base and a lifelong of learning, I have always remained a generalist.The strength of the generalist is that, unlike a specialist, they can easily let go of a belief if that's where the evidence leads them. If I began to practice Functional medicine or Longevity medicine, for example, I would be a specialist-in-disguise, promoting a pet idea hard let go.

Next, I help you identify and address bias in others:

• Review of specialists - Since specialists are particularly prone to bias, it's crucial their recommendations are reviewed by a generalist. Not only are we less biased, but we offer a different perspective. Because we see you as a whole person we can help you make better decisions by incorporating your values, preferences, and other life goals. And with our comprehensive knowledge base we can provide you with all the alternate options.

• Review of Alternative Medicine - Many patients seem to have a blindness to the biases and conflicts of interest of Alternative Medicine. They lower their thresholds for evidence. As a result, it is very helpful for you to identify and scrutinize the Alternative Medicine and pseudoscience claims you have adopted into your life.

• Teach you media literacy - Since the media is incentivized to show you positive findings that are unlikely to be true, learning how the media works, called media literacy, is a mandatory skill 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:

• You are not a good thinker - Gaing this humility is perhaps the difficult aspect of teaching critical thinking, although it's the most important.

• Review of your own claims - You have actually evaluated hundreds of healthcare claims in your life, and acted on them. You determined, for instance, that a Zpac helps you every time you have 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).