Reading Barbara Ehrenreich’s “Bright-Sided” has been liberating in that is has given me permission to let my pessimistic nature out of the closet.
Well, it’s not exactly that I am pessimistic, but certainly I am not given over to brightness and cheer all the time. My poison is worry. Yes, I am a worrier, in case you had not noticed. So, imagine how satisfying it is for me to find new things to worry about. As if climate change were not enough, lately I started to worry about science.
No, my anxiety about how we do clinical science overall is not new; this blog is overrun with it. However, the new branch of that anxiety relates to something I have termed “fast science.” Like fast food it fills us up, but the calories are at best empty and at worst detrimental. What I mean is that science is a process more than it is a result, and this process cannot and should not be microwaved. Don’t believe me? Let me give you a couple of instances where slow science may be the answer to our woes.
1. Lies and damned lies
Remember this story in the Atlantic that rattled us with its incendiary message? Researcher John Ioannidis has been making headlines with his assertion that most, if not all, of what we know in medicine is in doubt, given how we do and publish research. And how we do and publish research has everything to do with the speed of “progress.” Academic careers are made with positive results, to sell news the media demand positive results, and to respond to this demand academic journals prefer only to publish positive results (this last phenomenon is referred to as “publication bias,” and is something Ben Goldacre rails against at length). A further manifestation of this fast science is that “no replicators need apply.” I am, of course, referring to an extension of the publications bias, whereby journals are not interested in publishing even a positive study that replicates a previous finding — this is simply not sexy. Thus, results have to be quick and positive to grab a share of our attention and sell academic prestige, journals and news.
2. Science output to drive business profits
In his book Supercapitalism, Robert Reich describes the growing demand by investors over the last several decades to squeeze ever-growing profits. It is clear that this chase after short-term profits has resulted in job loss in the US through outsourcing, the widening of the economic gap, and even the crash of the world economy following the collapse of the mortgage-backed securities house of cards. Much of the profit can be counted on to come through scientific innovations which may or may not improve our quality of life.
In medicine, where scientific progress is applied to our fragile being, being reasonably sure of our findings seems pretty important. Yet speed is once again the order of the day. I will grant you that speed is of importance in such diseases as advanced cancer, for example, where we may and should accept a level of uncertainty that we would ordinarily run away from in other circumstances. But doesn’t it make sense to be much more cautious before broadly accepting an intervention that happens before one gets sick, one that is meant to diagnose either early disease or a precursor to one? Should we not demand slower science before we allow anyone to medicalize such normal events in life as menopause and aging? Should this caution also not apply to screening for diseases that may or may not impact us in the long term, yet the chase could hurt us substantially in the immediate future?
But this is not the way to stimulate the economy or to make a profit. The half-life of a medical device, for example, is less than 1 year. After that a new “improved” version of the device is expected, whether it does or does not improve outcomes. For decades we were told to get screening mammography after the age of 40, only to find out now that the risks of this may well outweigh its benefits for many. The American Lung Association has just endorsed CT screening for lung cancer among current or former heavy smokers, yet the jury on its risk-benefit-uncertainty equation should still be in the thick of deliberations.
3. Science denialism
We hear a lot about how people are turning away from science. The state of Tennessee is about to descend back into the dark ages when superstitions instead of scientific theories dominated the classroom. A strong and largely anti-scientific lobby wants to bury any mention of human-driven climate change; fortunately, it looks like they are not succeeding. The anti-vaccination groups are getting more instead of less vocal following repeated debunking of any link between vaccination and autism. Science denialism is so rampant that there was even a need for a conference on how to address it. What gives?
While blaming everything on fast science alone may be reductionist, fast science in the setting of our growing societal innumeracy is a recipe for disaster, as we are seeing unfold. Our schools have failed spectacularly in their duty to educate kids about the process of science, while at the same time arming them with the “single-right-answer-to-every-question” attitude toward knowledge. This pernicious combination, along with the publication and reporting of sexy science at the expense of the more thorough analytic and introspective approach, seals the impression that the roller coaster of scientific knowledge represents not the very essence of how science should be done, but that science (and scientists) has failed.
Is slow science the answer to this fiasco? Only in part, I am afraid. Without altering fundamentally how we teach science at all levels, it would not be the cure, even if it were possible to execute. No, I am afraid that without teaching what science is, it is not even possible to get it to slow down.
Let me reiterate: the pace of scientific discovery is slow. This does not mean that we need to hide every step of it from view until we get the results that we deem worthy of sharing. On the contrary, I agree with those who think that sharing at the more interim steps can only improve what we do. Yet the innumeracy, fame and fortune are forces that put such free sharing in peril by misrepresenting it as the final answer to everything. And when the answer is changed, which is not only expected, but indeed desired in scientific pursuits, the public opinion punishes science.
Let me end with a quote I read on one of my favorite web sites, Brain Pickings, in a review of the book boldly entitled Ignorance: How It Drives Science:
Are we too enthralled with the answers these days? Are we afraid of questions, especially those that linger too long? We seem to have come to a phase in civilization marked by a voracious appetite for knowledge, in which the growth of information is exponential and, perhaps more important, its availability easier and faster than ever.
[…]There are a lot of facts to be known in order to be a professional anything — lawyer, doctor, engineer, accountant, teacher. But with science there is one important difference. The facts serve mainly to access the ignorance… Scientists don’t concentrate on what they know, which is considerable but minuscule, but rather on what they don’t know…. Science traffics in ignorance, cultivates it, and is driven by it. Mucking about in the unknown is an adventure; doing it for a living is something most scientists consider a privilege.
So, let’s celebrate uncertainty. Let’s take time to question, answer and question again. Slow down, take a deep breath, cook a slow meal and think.
Marya Zilberberg, MD, MPH, is a physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. She is the Founder and President of EviMed Research Group, LLC, a consultancy specializing in epidemiology, health services and outcomes research. She is also a professor of Epidemiology at the University of Massachusetts, Amherst. Dr. Zilberberg blogs at Healthcare, etc.
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I read both articles. Yours leaves out the whole Medicare Advantage program that provides gym memberships. Please.
The preventive care article might make sense although what constitutes preventive care? I have read recently that the Brits National Health Service is going to start refusing treatment to people who don’t make changes in their lifestyles to improve their health. To control costs. Probably you end up there eventually because from my observations people don’t change their habits.
Thanks for your reply.
At our age (You’ re 67 and I’m 68) I’m not sure we really want what you call “true insurance.” That would ratchet up our premiums even worse than what we now have. Why? Because we are entering those golden decades of expensive medical care. Check this out by Joe Flower.
Who is spending the money, using the health care resources? This follows a Pareto distribution: 20 percent of the people spend 80 percent of the money; 5 percent of the people spend half the money; 1 percent of the people spend 20 percent of the money.
He’s being polite, but he’s mostly talking about us old folks. Here’s the link…
https://thehealthcareblog.com/blog/2012/05/23/save-the-country-with-preventive-care/
Since I’m here, take a look at my list of NON-medical costs overloading the economic train wreck we call health care in America.
https://thehealthcareblog.com/blog/2012/04/01/what-if-the-supreme-court-2/comment-page-1/#comment-213509
I can’t disagree with what you’ve said but when I talk about a market solution (and I’m no right wing anti tax person) I mean a high deductible plan to cover catastrophe plus an MSA. I’m 67 and have Medicare and a carryover plan from my husband’s employer. I would love to ditch this arrangement and have true insurance. This might be cruel to some, but it would reduce costs for most of us. There are a few doctors who refuse to take insurance and charge about $50 for a visit – some lower and they can do this because they don’t require the additional staff and time to manage all the paperwork. The News Hour has had a couple of sets on a couple of doctors like this – but not lately.
Your point is well made but the alternative you imagine to be the solution is not.
…the only other option is rationing by the market.
That, my friend, is exactly what we already have and it is a train wreck. The revenue streams are from a variety of places, none of which qualifies as a real market-based model.
Market-based is when willing buyers and willing sellers agree on a market price. In the case of health care the sellers include a raft of non-medical sellers in addition to the actual medical people, and the buyers are populations which include beneficiaries of tax-advantaged group insurance plans (subsidized by employers, by the way, whose added medical expenses for workers compensation are in a separate ledger over and above any group medical arrangements), Medicare, Medicaid, and those who pay out of pocket.
The only arrangements that might be called “market-based” are those combining extremely high-deductible insurance plans with some form of HSA or MSA. All the rest don’t qualify as market solutions.
The revenue streams feeding the present system include payroll taxes for Medicare Part A, Social Security deductions for Medicare Part B, private premiums for Medicare Advantage (plus some kind of federal subsidy which I believe ACA is slowly pinching off) and Lord knows where the money comes from for Part D. In any case, it ain’t the consumer unless he is doing what my wife and I do — ignore the system and get generics from Walmart or Walgreen’s.
The list of NON-MEDICAL costs burdening the system is long and tedious. .And that list is what happens when your “market-based” remedy gets a shot at tax money and tax-advantaged insurance and company group arrangements. I have been plastering this list all over the place and you are welcome to take a look at it.
https://thehealthcareblog.com/blog/2012/04/01/what-if-the-supreme-court-2/comment-page-1/#comment-213509
I wish I didn’t come across as such a curmudgeon. Your mention of the disease lobbies and other fashionable causes is exactly right. The politics of the challenge is daunting to the point of hopeless. I’m reminded that we may have seen the elimination of smallpox in our lifetime, but with the current anti-vaccination crowd getting bigger and louder the odds of seeing similar global accomplishments are diminishing as we speak. (It all goes hand-in-glove with the anti-science, anti-government mentality snowballing this election year, but that’s a radioactive topic best left alone.)
As long as payroll taxes and Social Security deductions remain in place for the purpose of furnishing whatever passes for “health care” then it is incumbent on policy-makers to define the boundaries and limits of how those funds are to be disbursed. Yep, that’s rationing, no matter what you call it. And disagreeable terms like QALY (quality adjusted life years) and other boundaries will have to be put into place is necessary.
Ever since MedPac was em-paneled some years ago (1997) it was limited to recommendations only, and Congress routinely ignored their recommendations district by district, protecting a variety of insurance companies, device makers, drug companies and other special
interests. Now, thanks to ACA, that body (remember the famous “death panel”?) has been imbued with new authority. Congress is free to overcome their policy recommendations (if they have the balls to do so) but in the absence of Congressional reversals, that body finally has the authority to make its recommendations stick.
It was no accident that Dr. Berwick, who had to be put in charge by a recess appointment, was the target of so much political flack. He would have stepped on too many toes. I don’t know much about his successor, but it really doesn’t make a lot of difference until enough people wake up to the fact that if the non-medical overloading of the disaster we call “health care” in America is not cut back, we are on a glide path to crash and burn.
I would like to see exactly the kind of medical safety net you propose, yet it can’t happen without some form of rationing and in order to ration effectively, the various “disease lobbies” will have to be faced down. Including those for popular causes like autism and breast cancer. I don’t see how we do this politically, so if we can’t have rationing by this method, then the only other option is rationing by the market. Could be ugly, but there’s no way to control costs otherwise, and if we can’t control costs, we can’t provide the type of program you suggest.
“In the case of health care I would like to see a base-line safety net (not market-driven) to which any number of market-driven bells and whistles can be appended. I realize the notion of such a social contract smells of socialism and worse for market purists, but that’s the point where I must simply agree to disagree.”
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i am totally with you on that.
“I’m not comfortable discussing the morality of markets.
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I am. It gets insufficient attention, and usually ends up with people uselessly talking past each other, all selectively citing their pet economists, data, and philosophers — the equivalent of dueling Bible verses, and an equivalent waste of time.
Altar. My bad.
I’m not comfortable discussing the morality of markets. It’s too much like discussions of war, capital punishment or when life begins. Long ago I realized that legality and morality will never be congruent and there will always be differences of opinion.
In the case of health care I would like to see a base-line safety net (not market-driven) to which any number of market-driven bells and whistles can be appended. I realize the notion of such a social contract smells of socialism and worse for market purists, but that’s the point where I must simply agree to disagree. America is the richest place on earth and is unable to craft a health care for the greatest number at reasonable cost.
As for morality, I would rather leave that issue outside health-care discussions. Reproductive rights, assisted suicide and the anti-vaccination discussions are radioactive enough already.
I think of dollars and bullets as morally equivalent.
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That word wealth is loaded.
Some use it to describe income. For others it means net worth. For others it means a rich and fulfilling life, filled with happiness, regardless of disposable income. (During the Great Depression those with farms could eat well and have a roof over their heads when many more were too poor to buy food or pay for shelter. Which were wealthy?)
Likewise, “transfer of wealth” sounds too much like “redistribution.” Words like that lead to other words like entitlements and fair share. Next thing you know the argument turns political and from that point it’s all downhill.
Thanks for the spelling lesson.
“worshiping at the alter [sic] of market economics hoping for better health care is a Faustian bargain.”
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One has to ask; WHAT is the net moral justification of markets? (And, recognizing that not all “markets” are equally morally consequential.)
Simply caveat emptor, principally zero-sum (or negative-sum) transfers of wealth?
Good observations. And very perceptive to see the drive to business profitability (Point #2) as the disease it really is.
One of my pet peeves is that NIH does so much of the heavy lifting but tax-payers don’t get the benefit until they first make some serious contributions (in ADDITION to their already “invested” tax money) to the profitability of drug companies and other profit-making entities bidding for patents at wholesale prices.
One would think that in the interest of community service profitable companies could make a minimal supply of generics when the profits are sucked dry, especially when there is a critical and in some cases life-threatening shortage. But one would be wrong.
I just left a negative comment on the very same theme at another post regarding venture capital. The longer I watch the healthcare debate the more convinced I become that worshiping at the alter of market economics hoping for better health care is a Faustian bargain.
Check this comment.
https://thehealthcareblog.com/blog/2012/05/14/activist-seeds-the-latest-subtle-trend-in-seed-investing/comment-page-1/#comment-213677