I have sometimes been called a contrarian. This can be both a positive and negative label. The positive is that, sometimes, the contrarian view turns out to be correct. And, even when the future is unknown, the debate unsettled, a contrarian view serves to counter soft consensus thinking. In case you haven’t heard, consensus thinking is common in Medicine.
Contrarians are essential for scientific progress, which happens in significant part through forwarding hypothesis and then having them disconfirmed. Having just enough people with the right combination of intelligence and a temperamental inclination to court controversy is a major engine of progress.
Well said again Dr. Mandrola. One phrase I use with residents and fellows, as well as at department case rounds, is “just because we can, doesn’t mean we should”.
Reading your work has inspired me to become more of a medical conservative. And to resist, in your parlance, therapeutic fashion. As you note, however, that is often not the path of least resistance.
With all due respect, Dr M, the true Contrarians are the Functional Medicine docs ...drhyman.com › about-functional-medicine
'Functional medicine addresses the underlying causes of disease, using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership. It is an evolution in the practice of medicine that better addresses the healthcare needs of the 21st century.'
"Provides value" is a common benchmark for judging medical care. Currently, the United States health care "system". is judged to provide less value than other countries because the cost is higher and the outcome is poorer. One very common easily measured metric for judging outcome
is life expectancy. The USA comes up short in this measurement compared with many other nations.
Currently, many curative treatments for disease yield statistically real reductions in death due to the disease being treated but fail to lead to reductions in overall deaths of those treated for the disease. The same can be said about preventative measures aimed at some diseases.
When evaluating the "value" of medical interventions and recommendations ,this outcome statistic is frequently ignored and ignoring it is a fundamental reason that the AMerican health care system ranks behind other nations in the value of care provided.
John -- I enjoy your articles like this one, reflecting a healthy skepticism, healthy contrarianism. This trait should be standard in medical science. The burden of proof resides with those promoting the intervention, not with skeptics who have to provide counter-proof. Commercial interests have hijacked honest inquiry to the point where many researchers have evolved into nothing more than sales reps for the drug/device companies. Given the current state, I say "contrarians unite"!
The CAST study is one of my favorites to illustrate the folly of doing interventions based on an hypothesis, which "seems to make sense". Medical history is littered with countless similar, if less pointed, cases:
Back in the 1960-80's patients undergoing some pulmonary and cardiac operations would be "digitalized". Administered "prophylactic digitalis" as an anti-arrhythmic. After well designed trials were conducted, the practice disappeared.
Hi. Just stopping by to subscribe for future reading, but found your CAC article in AAFP very helpful!
https://www.aafp.org/pubs/afp/issues/2019/1215/p734.html
I dropped a comment and used this reference at “the skeptical cardiologist” substack and hope I did not misrepresent your positions.
Appreciate this deep dive and will book mark it for review the next time I’m asked to order a CAC by a patient.
Contrarians are essential for scientific progress, which happens in significant part through forwarding hypothesis and then having them disconfirmed. Having just enough people with the right combination of intelligence and a temperamental inclination to court controversy is a major engine of progress.
I love your thinking.
When my husband died last June, he was 68 and in Renal failure.
He had just retired 6 months earlier and had been a 6' 1'' robust and hardy guy.
He was 22 years post quintuple bypass, so they felt they needed to put two stents in his heart.
He coded 2 days later; they brought him back and intubated him after 3 tries.
Then they extubated him 3 day later.
All this while they were doing hemodialysis with removal of 2+ liters per day.
They were using a by-pap in the hospital.
He was never able to eat again and when they moved him to a skilled nursing facility after 22 days he died that night.
I questioned that he needed the stents.
It was sad because he had excellent doctors for years, and was already on the transplant list with Mayo Clinic and had a donor available.
His Mom and Dad at 88 and 89 are still alive, so it has been hard for his 6 sons and 27 grandchildren to understand.
I still love medicine, and the miracles that kept him alive for 22 more years than he would have had before bypasses!!!
Well said again Dr. Mandrola. One phrase I use with residents and fellows, as well as at department case rounds, is “just because we can, doesn’t mean we should”.
Reading your work has inspired me to become more of a medical conservative. And to resist, in your parlance, therapeutic fashion. As you note, however, that is often not the path of least resistance.
Please write about the studies to be discussed at ACC re: Na restriction in HF
I identify with your thoughts here. My skepticism has grown even more after hearing Peter Attia's discussion of the WHI: https://peterattiamd.com/caroltavris-avrumbluming/
I totally agree with your views John! Healthcare has turned into a major business these days!
With all due respect, Dr M, the true Contrarians are the Functional Medicine docs ...drhyman.com › about-functional-medicine
'Functional medicine addresses the underlying causes of disease, using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership. It is an evolution in the practice of medicine that better addresses the healthcare needs of the 21st century.'
John , love your writing. Truly a fan. Not sure the WHS is a great reference. I don’t think this study would hold up to your high standards.
Check out Estrogen Matters
Excellent article, thank you!
In a world of "zombie" groupthink and echo chamber "facts", we need your critical thinking. (Mic drop)
In a world of "zombie" groupthink and echo chamber "facts" we need your critical thinking. (Mic drop).
"Provides value" is a common benchmark for judging medical care. Currently, the United States health care "system". is judged to provide less value than other countries because the cost is higher and the outcome is poorer. One very common easily measured metric for judging outcome
is life expectancy. The USA comes up short in this measurement compared with many other nations.
Currently, many curative treatments for disease yield statistically real reductions in death due to the disease being treated but fail to lead to reductions in overall deaths of those treated for the disease. The same can be said about preventative measures aimed at some diseases.
When evaluating the "value" of medical interventions and recommendations ,this outcome statistic is frequently ignored and ignoring it is a fundamental reason that the AMerican health care system ranks behind other nations in the value of care provided.
Contrarian does not begin to describe your contributions. I prefer "gadfly" as the correct positive descriptor of what you provide.
John -- I enjoy your articles like this one, reflecting a healthy skepticism, healthy contrarianism. This trait should be standard in medical science. The burden of proof resides with those promoting the intervention, not with skeptics who have to provide counter-proof. Commercial interests have hijacked honest inquiry to the point where many researchers have evolved into nothing more than sales reps for the drug/device companies. Given the current state, I say "contrarians unite"!
The CAST study is one of my favorites to illustrate the folly of doing interventions based on an hypothesis, which "seems to make sense". Medical history is littered with countless similar, if less pointed, cases:
Back in the 1960-80's patients undergoing some pulmonary and cardiac operations would be "digitalized". Administered "prophylactic digitalis" as an anti-arrhythmic. After well designed trials were conducted, the practice disappeared.
Thank you!