46 Comments

Your invoking of Sowell’s great insight from “A Conflict of Visions” to the practice of medicine is perfect. My oldest brother was an internist (geriatrician) and one of the early adopters of EBM. Geriatricians see the inevitability of death more clearly than most and the good ones know the constraints of both medicine and the human condition.

I followed my brother’s advice to always look at the evidence and have rejected multiple medical and surgical recommendations as a result, particularly related to PSA testing and spine and shoulder surgeries.

From my access to insurance claims data during my business career, I knew the actual practice of EBM wasn’t particularly common. But it was during Covid that the stark differences between those who know the constrained vision is the only one with good evidence and those who don’t became so clear. Even more frighteningly clear is the reality that we are treated and governed by docs and pols who almost universally follow the evidence-free unconstrained view. We are mostly the worse for it. Your work and willingness to shine a light on the problem is much appreciated.

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But EBM can become its own belief system; you really have to look at everything very closely. Even our public institutions are now all public-private partnerships; all polluted by donation. I do agree with unconstrained view. Most of the advances in life span have been clean water, plumbing, antibiotics, vaccines, preventive care, and the like. Too much treatment that will not significantly help anyone but distracts from meaningful life.

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I agree EBM must be balanced against what we don’t know and sometimes risks are warranted to try something new. Unless I’ve misinterpreted it, the rest of your comment suggests you agree more with Sowell’s rationally constrained view, rather than its idealistically unconstrained twin.

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I would say that’s fair and has come

on over years and hard lessons in my own body. But we do need to go back to relieving suffering.

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Me too and good for you.

After a 9 hour surgery I developed a new definition of “necessary”.

Thanks to thoughtful commenters and author.

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I hope the reference to Thomas Sowell inspires others to read his works. Reading his magnum opus, "Knowledge and Decisions", as a young man had a profound effect on how I viewed practically everything. One of the great thinkers and expositors of the past several generations.

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Sowell's clear insights into human behavior are absolutely amazing & mostly accurate. "Conflict of Visions" should be required reading for high school students. Now I must order "Knowledge and Decisions"

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"Knowledge and Decisions" would top my list of must reads for people who want to understand the way the world works. It is the firm foundation for everything else he wrote. Second on my list might be "Economics in One Lesson" by Henry Hazlitt.

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Constrained thinking in my opinion aligns much closer to true scientific practice. Conclusions and interpretations must remain within the scope of results. Did the experiment actually show X without any spin on the question at hand. When there is money to be made, the “results” are whatever drives greater industry, not the true outcome which is to protect and aid patients.

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Well the next thing I do after this will be to look up that paper.

This is great stuff. Somewhat heartening that xarelto and eliquis spending exceeded corevalve….and that all those other devices (which have rarely equal ie Sapien ….but mostly less evidence ie all the rest) … attracted less spending. At least there is more data for those meds than for all of those devices.

It is truly baffling and maddening to see the low bar for approval of devices relative to meds, at least in the cardiology space. I’ve never understood the logic or justification for that disparity.

I don’t think a median of $50 would have outsized influence on anyone. However, I’d be curious about the top 1% of payments….how much that represents for cardiologists….who those recipients were….then matched to what those folks have publicly said. I imagine such a compilation would be interesting… and perhaps more than a little nauseating. And I wouldn’t be opposed to some naming and shaming besides.

I’d be even MORE curious about those top 1% lists matched to guideline writers, to see how much influence peddling $ exerts at the very top. I say this not because cardiology guideline writers hold any sway over me….I try my darnedest to practice to the evidence, and not to the guidelines (discouragingly recognizing more and more that those 2 things are not one and the same, as I had once thought earlier in my career)…but because every so often I venture to guidelines outside my strike zone (eg. PE) and quickly realize I have no idea about their evidence basis and need to take the guidelines at their word…then realizing most practitioners are in that same boat when it comes to perusing cardiology guidelines.

All that said, your summary statement hits the nail on the head. If spending this money didn’t work, pharma wouldn’t be doing it. That should give all of us pause the next time we each go to a conference, or a rep walks through the door.

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Sometimes the evidence and the guidelines are garbage. Then what? Patients still need care. Tricky.

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I agree.

I’d go further…not only are the guidelines and evidence garbage sometimes, but even when they’re not, they can only speak to the “average patient”, which yours in the moment often won’t be. And I agree, even in the absence of solid evidence, your patient still needs care, esp if it’s for symptoms for which they are actively seeking help.

So the “best evidence”, in that moment for that patient, may not be the top drawer replicated-by-multiple-large-RCT type of deal, but something much farther down the hierarchy of evidence quality. C’est La vie. You do the best with what you’ve got. What gets my goat is when guideline writers deem it fit to put that lower-rung stuff into guidelines; imo that type of stuff has no place in them.

One thing these pages (and those at Sensible Medicine substack) have reminded me of is the David Sackett principles of EBM. In an era where evidence has primacy (and so it should), we would do well to not forget the other pillars: of clinical judgment and comorbidities, as well as patient values and preferences. (As an aside, Canadian cardiology guidelines now often have a nod to “values and preferences”….but they are those of the guideline writers, not the patient).

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I'm always a fan of escrow for these sort of problems.

The patient pays into escrow and if they're alive in say 5 years the drug company get their medical fee. This would tend to suppress false claims for little cost. There would probably be a secondary market trading these payments. Which I have not thought of the implications

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Interesting idea. I doubt Pharma would go for it for obvious reasons. This would be a good way to address a lot of devices.

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As you wisely pointed out in your article, Sowell maintains that there are no perfect solutions but there are optimal solutions. Over and over, Sowell points out that optimal solutions require elimination of interference in the free market for goods and services. This almost always means eliminating government regulation and regulatory institutions. It is really not a great idea to have politicians and their appointees populating these groups and formulating policy. For example, how is that war on drugs going? Many people think the problem is "regulatory capture" by industry and that just having the right people in charge will take care of it. But a thorough examination of history tells us otherwise. During the late 19th and early 20th centuries various industries tried repeatably to establish monopolies but always failed. As soon as they tried to limit production and raise prices, new competitors would enter the market and undercut them. They then turned to the government to establish institutions and laws that would hamper their free market competitors. A thorough analysis of this process can be found in Murray Rothbard's book, The Progressive Era. So the optimal solution here is to eliminate the FDA, Interstate Commerce Commission, and practically all other government regulatory bodies at all levels of government. Would there still be problems? Of course, but it would be far superior to the mess that has evolved over the past 130 years.

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And eliminate paients as they are an interference

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Actually patients have already been eliminated in many places. Specifically those that have "single payer" systems. The single payer is, in every case, government. A viable economic system includes producers, consumers, and a number of intermediate institutions that facilitate exchange. When the government displaces the consumers we get the massive distortions in free exchange that we see today. Economics 1A.

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No, all our government agencies are public-private partnerships between monopolies and government. The market (not free) runs the government. We must have some government. If we taxed the super rich adequately and brought back anti-trust, we’d have nice things for everyone.

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I agree that government agencies are all public-private partnerships between monopolies and government. There is a term for that sort of arrangement used in both economics and political science: fascism. Most people think of fascism as some sort of right wing extremism but it is actually a type of socialism. Unlike pure socialism (communism) where the government owns the means of production, in fascist systems the means of production are mostly in private hands but the government controls everything through regulation. Thus the government runs the market---not the reverse. If we must have some government, it should be drastically reduced in size and power. Taxing the super rich never works because there are not enough of them and their wealth enables them to work the system to their advantage. Calls to tax the rich always end up raising taxes on the middle and working classes. Anti-trust can't be brought back because it never went away. It is alive and well and still used for the purpose for which it was intended---to allow some businesses to hamper some of their more successful competitors by involving them in expensive lawsuits.

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Thank you! Fascism is a dirty word. One day my father made me get the dictionary out and read the definition aloud in front of him, after I called someone a "fascist" (that was the insult my silly generation threw at anyone who irritated us). What a discovery to realize that what socialists really want is pretty much fascism. And we're there now in so many ways.

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It is incredible how few people know that the term Nazi was a shortened form of the German for National Socialism. I believe it was one of Hitler's aides who was asked to explain fascism and replied " I don't need to own the cow as long as I control all of the milk". I would award your Dad five stars on the father scale.

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I don’t what the year was when you first could click on a link at cdc to see their partners-fossil fuel companies, pharmaceutical companies, but it was not always so. Citizens United was a new low for unregulated dark money and corporate rights. Post WWII, we taxed the rich and our infrastructure showed it. We are in gilded age 2.0.

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You could always start a tiktok to reach us younger folk. But that might generate even more tension for you.

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At a cath conference after a complicated case was reviewed the cardiac surgeon summed up the situation . It was an example of " technology triumphing over reason" .

I have a friend (after 15 years I can call him that ) who services hot tubs. Mine leaked and he told me he needed a new cardiologist as his retired . He had a bypass 25 years ago and explained he had symptoms that were very concerning for progressive angina . He underwent a cath this week and a 95% RCA was stented. His LAfD mammary was perfect ...

I have sent many people for bypass and fought back against the let's do multiple stents knowing the surgeons would put in mammary and other arterial grafts.

As time has gone on that was a harder battle to win.

Then my friends cath films show up and it appears that "reason can triumph over technology" but it takes a bit of effort

He was discharged yesterday and said the new pump is in this week.

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Well, Dr. Mandrola, first, you are not old. I’m 87 and do not consider myself old. My wife, age 88, and I walk 5 miles a day minimum. My wife has to take a synthetic thyroid hormone; otherwise, neither of us take any medication. My total cholesterol is under 135. I work hard in our garden and go biking every day. We don’t have a cardiologist to thank for our good health. We looked at the research 40 years ago and decided to change our horrible Standard American Diet. We realized we already had CVD, and if we did not make some changes, we would follow our parents with strokes or heart attacks. We have been on low fat, low salt, whole food plant-based nutrition ever since.

So, how do you bring constrained thinking to younger doctors? And how do you limit industry influence? One way is to practice 21st-century medicine by emphasizing prevention. Yeah, sometimes you have to be a scold. I have read your review of a study purported to show that food had little effect on heart health. And you rightly got taken out behind the woodshed for a thrashing by your readers. But the evidence is overwhelming now that a whole food plant-based diet can prevent and even reverse CVD, hypertension, type 2 diabetes, and even some cancers. A few older doctors are taking this message to medical students and residents, including Dr. Michael Klaper, cardiologist Dr. Columbus Baptiste at Kaiser Permanente, and Dr. Neal Barnard of the Physicians Committee for Responsible Medicine.

If you can keep your patients healthy by helping them change their destructive lifestyles, then the pharma and device reps will have nothing to offer you. And you can do what I do when I visit a new doctor for a physical or a minor injury. My first question after introductions is, “How is your plant-based eating doing doc?” I ask this to find out if they are practicing 21st-century medicine. So the next time an industry rep shows up, ask them that and tell them if they want to bring food or wine and dine with you, it must be plant-based. That will scare most of them off immediately.

Your patients are going to need help adopting whole food plant-based nutrition. So you have to set an example. Plant-based nutrition allows you to go faster and longer on your bike rides. At every patient visit, you ask them how their plant-based eating is going. Fortunately, today, there are endless resources to which you can refer them. Facebook, YouTube, and other social media have plant-based, vegan, and vegetarian support groups that post recipes and ideas daily. Numerous services will deliver ready-to-eat plant-based meals. When money or fresh produce deserts are the problem, you can subscribe to boxes of perfect but slightly blemished boxes of produce for delivery to your door.

We will still need cardiologists. It’s often too late for prevention. And stuff happens. Cardiologists are supposed to be innovative. Lifestyle changes, especially plant-based nutrition, should be part of their toolkit.

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How about an old concept that still works: medical ethics. Yes, there is a right and wrong. Telling the truth is better for medicine than turning it into another cash cow influenced by industry and payers, as in insurance and the Federal government. Back in the dark ages when I taught Paramedics and practiced as same, there were so many opportunities for good: to do good, to speak the truth in love, to care about the outcome for our patients. I know, those were the old days when we were just “cowboys” trying stuff to see if it worked…no protocols, we were writing the protocols that I missed out on practicing in due to a series of severe back injuries (full disclosure, I have an Abbott Spinal Cord Stimulator implanted in my back which enables me to continue working in retirement in my true vocation as a Lutheran Pastor. I loved medicine, I am trying to love medicine now that I am just an educated patient. God bless you all and thank you for your service to all of us.

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Excellent reflection. Hope it is widely read. We need more constrained thinking in medicine.

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I also think despite problems there is no better career.

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The present generation is already corrupted and they are passing on their corrupt practices to the next generation. They call their beliefs “guidelines” but they fail to acknowledge these are really written by that dark money you’re writing about. I’ve met no more than a half dozen thoughtful students/residents in the past 10 years. Every thing is teach to the test. They vomit back what has been pushed on by their teachers. They’re better at guidelines than we were at anatomy. They do what they have been taught and even when you show the evidence doesn’t support these teachings they keep doing them and likely will until they retire.

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Kinda surprised that psych are high on the marketing list. I was in chronic non cancer pain and addiction and turned away every single opiate seller during the bloom of opioid liberation. And then turned away every bupe salesperson (usually young, attractive women). Once the organizations saw the money, true patient care went out the window.

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What advice would you (or others) have for a current medical student then?

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“The challenge is how to bring constrained thinking to younger doctors. One way is to limit industry influence.”

Yes absolutely this is one way. Might bring drug and device costs down a little too. Another way is for government regulators and journal reviewers to exercise constrained thinking too. Recent exposure has revealed unjustified enthusiasm for the new, acceptance of low-quality proofs of efficacy and benefit of the doubt to developers. We will all happily spend other people’s money on a hope and a prayer and pad our wallets in the bargain if no responsible party holds our feet to the fire, and none seem to be doing that right now.

God bless and happy Easter. Keep up the good fight.

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I am a fan of Ben Goldacre, suggest reading his book, Bad Pharma.

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