Contrarian Medicine

           I have run into three writings on Contrarian medicine in the past days.  Perhaps three makes a movement.  In each case I appreciate the thoughts but am left with the question – who makes that decision? And the answer – for me, is that I want to make it, which undercuts the Contrarian philosophy.

            First, the ever-worthwhile Nassim Nicholas Taleb’s Antifragile is not as original as The Black Swan, but for those of us who enjoy rants it is worthwhile.  Taleb’s thesis is that complicated modern systems, probability based, interventionist and technologically supported are “fragile”, prone to collapse.  Fragile systems rest on assumptions which may either oversimplify or simply be wrong.  Antifragile systems grow stronger in stress, evolve and continue.  In medicine Taleb believes that our system is framed by big pharma to overdiagnose and overtreat statistical anomalies which are not diseases, and that the risks, effort and expense of overtreatment detract from necessary treatments of serious diseases for many people.  He is not opposed to interventions but finds our thresholds too low.  He is particularly harsh on concierge medicine for needing to find medical problems for a clientele paying a premium to get treatment.  Taleb’s thesis resonated with me as I have a constant battle with my concierge doctor, a great guy who believes that every phone call deserves a new pill.  I have him because I want him around if I get sick, but I earnestly believe that most things go away if ignored long enough, and I have a much higher threshold against intervention than does my physician.  However, when Taleb asserts that “serious” medical issues warrant intervention – who decides?  Our systemically wasteful health care system vests that in me, which suits me just fine.

            Second, University of North Carolina faculty Stefan Timmermans and Mara Buchbinder have written Saving Babies? a study of the introduction of newborn genetic screening in 2005 – 2006.  Under various state laws all newborns in the U.S. are now tested at birth for up to 54 different genetic conditions.  A veritable stampede of legislation brought on by heart-wrenching anecdotes – who could oppose testing?  Well, as the authors explain, testing has consequences.  First are the false positives, and the parents who are put on hold sometimes for months with false positive readings in some cases up to 80%.  Then, they note the problem that many of the genetic conditions tested for do not always lead to symptoms, so a family with the knowledge goes through a regimen of disease when older siblings with the same genetic traits are asymptomatic.  Then there are moving thresholds for defining “normal”.  Then, the authors note that many of the genetic conditions have no known treatment, so the foreknowledge may not lead to any particularly effective actions, or in some cases based on insurance or socioeconomic or cultural factors the treatment may not be practically available.  The authors find generally that for the politicians the concept of newborn testing is a cheap “yes”, but that the testing is driven by the researchers who say it should be done because it can be done rather than the clinicians who have to deal with the patients and the fallout.  Intellectually and fiscally the tests seem unsupportable.  On the other hand…if it were my child…

            Finally the March 2013 Consumer Reports, somewhere after a taste test of beef jerky finds that “Cancer screening is oversold”.  Giving the Susan G. Komen nonprofit an “Oscar for best use of misleading statistics” CR questions whether early detection actually leads to better outcomes, a concept similar to ideas floated in both Antifragile and Saving Babies and seemingly supported as to many women by recent studies.  I like the Contrarian concept, but I am more likely to take CR’s wisdom on beef jerky than medical choices.  I expect that until the tests are rationed or require payments everyone will want them.