Dr. Nuance versus the Crusaders of the Lost Art

The two writers who got inside my head were polar opposites. Christopher Hitchens was an atheist, who mocked religion incessantly, and spared few sacred cows – he went after both Mother Teresa and Bill Clinton, though for patently opposite reasons. G.K. Chesterton, the sardonic, plump Englishman, went after heretics. Hitchens destroyed orthodoxy. Chesterton mocked radicals. Hitchens once quipped that “what can be asserted without evidence can be dismissed without evidence.” Chesterton quipped that the rebel, the infinite skeptic, was in fact a decerebrate orthodox. If both were on Twitter they’d be trolling each other, non-stop. Though fighting on opposite sides, they had a commonality – they punished sloppy thinking, one with prose and the other with wit.

I’ve long wondered who would be healthcare’s Hitchens and Chesterton. Physician writers have generally been disappointments, because they veer, almost uncontrollably, towards tedious self-flagellation, ever keen to internalize medicine’s original sin – an imperfect science, a stubborn art. Unlike prophets of yore who risked harm in expressing their views, medicine’s prophets moralize from the comfort of their six-figure salaries. “We do too much”, they say, even as they’re grass fed by the excess they so disdain – count me in this army of hypocrites.

For many years healthcare watchers have been fed a steady stream of Disneyland economics, trite platitudes, which have simplified the complexities of healthcare – cheesecake factories and checklists, value not volume, “we must do things for patients, not to patients” (needless to say that often to do things for patients you must do things to patients), amongst others. Whatever purpose platitudes are supposed to serve, they bring all critical thinking to a jerky end. I recall several talks during the passage of the Affordable Care Act in which the speaker would romp to a standing ovation for stating blithely – “let’s pay doctors for doing the right thing”, with me still muttering “how?”

In the midst of getting carpet bombed by bromides I was forwarded a piece by Dr. Lisa Rosenbaum. I almost didn’t read the piece – I rarely read perspectives, other than mine. Before reading perspectives, I check their provenance. A young cardiologist writing in the NEJM – I was convinced this was another writer enthralled with Rawls distributive justice – another tedious medical moralizer. I was wrong.

In the piece Rosenbaum explored the complexities of defining quality and value, and difficulty in paying for performance. This was long before it became fashionable to question the value of measuring value. I could believe what was written, but I couldn’t believe that it was written, even less so that it was published. To mix a metaphor, it seemed that I wasn’t alone in the Potemkin village who saw that the emperor had no clothes.

Rosenbaum is neither Chesterton nor Hitchens, but in a space crowded with piety her writings are a breath of fresh air, and induce an uncommon, though not an unsurprising, amount of ire, such as her trilogy on physician-industry relationship. To make the case that money corrupts is easy and requires little courage, particularly in the age when disclosing financial conflict of interest is like brushing your teeth. To make the contrarian case that financial ties with industry lead to net benefits is dicey. But it is precisely because it is dicey that it extracts more linguistic muscle, more thought, more logic, and more courage. Rosenbaum delivered, and if her detractors prevailed, it was only by a whisker, and not for the lack of her prose.

Both Hitchens and Chesterton might have patted Rosenbaum for taking the unpopular side. Hitchens might have been happy that a sacred cow, such as our obsession with financial ties, went unspared, and Chesterton that the unfree radicals were gently mocked. I, for one, was just pleased watching the riot unfold on social media.

It is Rosenbaum’s most recent piece which has drawn the most ire, in which she asks whether the less-is-more movement has, in its missionary zeal, oversimplified overuse in its crusade against too much medicine. I should, at this conjecture, disclose that I’m a less-is-more apostle – I’d like to think that I’m more of a John the Baptist – I want others to run with it. Diagnostic and therapeutic, particularly diagnostic, incontinence offends me. I believe the role of medicine is to heal the sick, not hound the well.

One cause of angst was the use of “crusade” in the title of her piece. Bush Jr. realized that “crusade” isn’t a word which should be used lightly. “Crusade” relegates the less-is-more movement from science to religion, and is admittedly an unfortunate choice. But apt. Very apt. I invite you to watch this movie on the state of American healthcare, called “Escape Fire” – the analogy here is with a fireman who burnt a fire to stop a forest fire. The movie is sensational but tedious. I hoped Dirty Harry would walk in any moment and save me from soporification. I’m sorry – but if you believe healthcare reform is an “escape fire,” then you shouldn’t be offended by “crusade.”

Elsewhere, medical errors have been compared to a jumbo jet crashing every day, even to urban genocide. I struggle to understand how someone can remain inert by these hyperbolic, and frankly absurd, analogies yet be offended by Rosenbaum’s allusion to the holy war. What am I missing?

Rosenbaum’s strength is her weakness – her prose, which is so lucid that you know exactly what she’s saying, unlike that of many medical writers who use such barbaric prose that their thoughts remain stuck in their ampulla, means that the reader, drawn to arguing with the author, forgets that their intemperance is a testament to her skill. The job of a writer isn’t to tell you how to think but what to think about. Rosenbaum has achieved this marvelously.

A perspective isn’t a meta-analysis, it isn’t a quantitative truth, rather it is supposed to encourage the reader to examine the conventional wisdom, no matter how settled the truth appears. Thus, the charge that Rosenbaum’s piece should have been better peer reviewed misses the point – peer review is merely micro-group think. A good essayist shouldn’t just survive peer review but actively dodge it, if she wishes to challenge group think. A good essayist must take a stand, and Rosenbaum did, admirably.

For an essayist it is the post publication review which is important, and no better compliment to Rosenbaum could have been paid than by veteran journalist and a cardiology maven, who knows more about cardiology than cardiologists, Larry Husten, who tore into some of her arguments. Husten is a fine writer, too, and has an eye for controversy. It seems Rosenbaum got inside Husten’s head in the same way Hitchens once got inside my head – an applause to Rosenbaum for getting inside Husten’s head, and to Husten for graciously allowing her to get inside his head – it takes two to a dialectic. This is the way it should be.

I take one exception to Husten’s critique – in which he says Rosenbaum is an apologist for the status quo, a medical conservative. It is easy demonizing a healthcare system which has gained international disrepute – though oddly, doctors still queue outside the American embassies in New Delhi and Beirut. U.S. healthcare is so imminently disagreeable that pointing its flaws isn’t rocket science. What’s more challenging is understanding how we got here, what drives waste, and what will be forfeited if we curbed waste.

These inconvenient questions are repeatedly dodged by our thought leaders, but Rosenbaum refuses to ignore them – whether this is her strategy for conserving the status quo or changing it is beside the point – trade-offs exist. If Rosenbaum is supporting the status quo she is certainly not taking the path of least resistance. My guess is that Rosenbaum was exposed to Shakespeare very early on and literally read every single word in every single play, and has an uncommon, and rather unshakeable, appreciation of human complexity. Regardless, the point is that Rosenbaum didn’t invent trade-offs in healthcare – they exist despite her, not because of her.

Trade-offs mean you must choose. For some the choice between overuse and underuse is a false one. It is false if one considers underuse as a resource and access issue, and overuse as an abundance issue. It is unclear whether overuse creates an opportunity cost leading to underuse – the logical answer is that it does, and it certainly will in budget-constrained systems, though the effect in the U.S. is less clear, because overuse finances some of healthcare, it finances many services, including the less profitable ones.

Anyway, this is not the point I’m belaboring. Rather, I’m talking about trade-offs between more use (overuse) and less use in areas of abundance. How much is the trade-off? It depends. In some situations, such as incidentally detected thyroid nodule, the harms of overdiagnosis/ overtreatment overwhelm the miniscule gains so much so that trade-offs aren’t even worth exploring. In others, such as the new definition of hypertension and statins for primary prevention, there is a real trade-off between extending longevity in many, and conscripting many, many, more to the ranks of disease. I believe we’re overstretching – YMMV, and that’s fine, but we can at least agree on the trade-off.

Another example is imaging. In the diagnostic pursuit of potentially fatal conditions, particularly in low pre-test probability situations, such as pulmonary embolism, ischemic bowel, aortic dissection and acute coronary syndrome, there is a trade-off between false negatives – missed cases – and both the frequency of imaging, and the number of false positives. This trade-off is a fact of life, the basis of signal theory. Doctors overtest because of a culture of safety, a culture accentuated by reports from the Institute of Medicine that diagnostic errors are a plague, and defensive medicine, and societal expectations and not least because, as Rosenbaum candidly admits, “possibility is not the same as probability, but when you’re bearing the weight of another person’s life, the distinction often feels meaningless.”

Which is to say that physician decision making has become like Pascal’s wager – Pascal said that he’d rather believe in God than not, because if there was even the slightest possibility God existed, it was better to err towards believing in God, and thus enjoying heaven, than not believing in God. To borrow the language of option traders – there’s little downside to believing in God. For physicians, the possibility of a catastrophic miss looms large in their decision making. This is most evident in emergency medicine where physicians must decide whether their patient has a life-threatening condition based on imperfect information. Once you think Pascal’s wager – possibility and plausibility always trump probability, and the art of medicine, which is essentially probabilistic, is killed.

The emergency room, depending on your perspective, is either the swamp of waste or the epitome of appropriateness. Appropriateness is difficult to define, ex ante. Waste is a typical Tragedy of Commons – many physicians believes it is the other physician at fault. Emergency physicians blame cardiologists for clogging the outflow pipeline in to the hospital by doing too many stents for stable angina, cardiologists blame emergency physicians for over reacting to chest pain and weakly positive troponins, and radiologists – well we blame everyone but ourselves and our incontinent hedging.

To reduce waste, you must define appropriateness and what is appropriate depends on what you wish to achieve. Let me give you an example. In my days, when life was easier, we would literally ram a nasogastric tube down a patient’s throat, passed the squamocolumnar junction, until it reached the stomach – we were mostly, 98/100, times successful, but occasionally the tube would end up in the patient’s lung. This is now considered a “never event.” To prevent this “never event”, radiographs are taken as the tube is gingerly passed through the esophagus – multiple radiographs are taken until tube reaches the stomach. Is this waste? Depends if you think it is appropriate – regardless, the point is that you need lots of imaging to prevent a “never event”, to practice medicine like Pascal’s wager. Call this waste, call it whatever the hell you want – but there’s a trade-off.

I’ve heard a safety officer say – “we have too much waste and too many missed cases” – without conceding they’re part of the same problem. It’s like wanting a bath without getting wet. You can’t. The obvious retort is that it’s not about overuse or underuse, but an ephemeral “right care” – but that’s a cop out which pretends that trade-offs don’t exist, which isn’t true because as Rosenbaum diplomatically puts it, “it’s not clear that we have the evidence-based knowledge to reduce waste safely.”

I’d have gone a step further and said – let’s reduce waste, let’s make diagnosis more specific, less sensitive, let’s make clinical medicine an art again, and be forthright that it’ll come at the expense of missing a few catastrophic cases. Who is on board? Anyone?

It is quite likely that Rosenbaum and I aren’t equally perturbed by waste, I’m probably more perturbed than her. But we don’t need to agree precisely on how much waste is too much. All we need to agree on are the trade-offs. Because if we can agree on what the trade-offs are, we can at least agree on the terms and conditions of the fighting waste. I’ve seen very little in the less-is-more literature which explicitly acknowledges trade-offs, which concedes that the fight against overuse will come at a cost, but that cost is worth it. If we don’t acknowledge the trade-off we’re back to square one.

The ire against Rosenbaum is unusual. I’ve seldom seen anything like it. It’s as if people read her work and ask, “why aren’t you with us?” It reminds me of Bush Jr’s “you’re either with us or the terrorists.” Rosenbaum has been called “dumb” and “naïve.” Was Atul Gawande “dumb” for comparing healthcare to cheesecake factories, for selling checklists as our panacea? Were the creators of meaningful use “naïve”? Was the crew who brought you “in healthcare jumbo jets crash daily” dumb? If not, why such vitriol against one of the most courageous healthcare writers of our time, who has singularly brought back nuance in healthcare discussions?

Rosenbaum has not replied to a single Tweet belittling her. Brave lads – try this next time – try coming on Twitter several times a day, seeing your timeline flooded with sarcastic and condescending retorts from important people, and half-wits, and then bite your tongue and not retort. I don’t know how many lads will have the strength to restrain themselves – I certainly won’t.

I’m all for a colorful savanna. One of my favorite Tweeps is, in fact, a leading critic of Rosenbaum – Vinay Prasad, another courageous physician, with gruff, who can take on a movement, my natural ally in less-is-more. I’ve often wondered who is braver, Rosenbaum or Prasad. Then I realized that the question is moot. Because the healthcare savanna needs them both.

Meanwhile, can we please bring back the lost art of medicine?

Thank you.


About the Author:

Saurabh Jha is a radiologist and contributing editor to Healthcare Blog. He can be reached @RogueRad


Categories: Uncategorized

7 replies »

  1. You want to bring back lost art into medicine? Is this because there are too many causes for abdominal pain and we cannot, for example, afford to look for delta amino laevulinic acid in the urine of all patients?

    So we have to put on a serous face and think artfully.

    But… but… but… we could screen for acute intermittent porphyria in many patients if ALA were much cheaper.

    No one decries a complete history. This is a mental remembrance from the patient. Most lab tests tell a physical remembrance of the patient [what has the bone marrow been doing?]. We oddly criticize trying to obtain too much physical history–lab testing and imaging–from the patient because we have been brain-washed into thinking it will lead to expensive and risky investigations of false positive leads. [ it costs too much is the real reason]

    But, if labs were cheap and hospitals did not treat them as profit centers and clinicians were wise enough not to follow every feeble lead–just as they do not chase down every weak clue in the history–our workups would have more bits of total information and thusly would arrive at more accurate diagnoses and interventions sooner. This is our cannonical primary obligation.

    It’s good to have plenty of lab tests if they can be made cheap and safe and physicians trained to look at all resuts with grains of salt. Artists don’t skimp on paint or brushes.

  2. I am an n=1…..but in my experience this is exactly right. I miss my old school primary care docs who listened closely to my symptoms and concerns/worries…..now replaced with docs glued to their directions from the computer screen.

  3. When I was in training about 30 some years ago, we had old-time family docs that stressed the art of history taking and examination. I have always believed that at some point, practitioners of the medical arts (nurses included) develop a 6th sense of “something not quite right” that hits the back of the brain to alert to a potentially bad problem. This is no different from a talented musician who instinctively knows how to make a chord progression, or a wood worker who feels how to shape the wood. The issue is that in today’s reliance on modern technology and the distraction of computers, coding and box-checking, the fine art of appropriately ordering tests or procedures has been lost, notwithstanding the looming threat of malpractice if something is missed. Until we get back to the basics of medicine and the physician patient relationship, harping on “value” and avoiding overtesting is an exercise in futility.

  4. The Hawethorne Effect and TRUST as therapeutic strategies. Now, there is a combination of phenomena worth a wide-ranging, stream of thought. Just turned 1100 on my chronometer, dispelling any likely burst of curiosity. Too bad, the Hawethorne Effect surfaces in such odd circumstances.

  5. Most apt phrase of the day: “peer review is merely micro-group think.” My perspective is that the biggest issue isn’t overuse vs. underuse – it is right diagnostics and right treatment, vs. wrong diagnostics and wrong treatment. There are doctors practicing the lost art of medicine, quite successfully to the gratitude of patients with “lifelong,” “unexplained,” and “hopeless” diseases who are miraculously recovering from them. How? By focusing on triggers, from the mundane and overlooked (think fungi, metals, mold, dental infections), to the inconvenient. They are now a bit beyond the frontiers, which have shrunk to computer-assisted algorithms, checklists and Rx based on average results for average people, often massaged and nudged by well-paid industry-sponsored academic researchers.

    A word on the inconvenient: FDA device regulations are about 40 years out of date. There is no recognition of genetic variability, no “Precision Device” framework, no recognition of long tails. The entire system is upside down: patients need to prove harm to get a warning or ban or recall, vs. the need for manufacturers to prove long-term safety for significant numbers over several years. FDA requires no pre-screening for biocompatibility before devices are installed, and patients are not given the courtesy of an information sheet or written informed consent when it comes to dental. FDA still insists nickel, mercury and plastic mesh are quite safe in the body – counter to the growing number of researchers finding and countries acting otherwise, to the benefit of their populations’ better health, and longer lives, at lower cost.

    So less is more if it is the bad stuff. More is more if it is the good stuff. Medicine is best when it is a blending, melding and merging of art, experience, intuition and engineering – work the problem until you figure out the causes and the treatments, and make sure you have all the data – and elephants – in the room to diagnose and treat.

  6. So how do the consequences of a missed catastrophic case in the U.S. compare to the consequences in other developed countries from Canada to Western Europe to Japan and Australia? By consequences, I’m thinking about lawsuits and payouts as well as the impact on the perceived reputations of the doctor(s) and the hospital.

    If I’m an ER doc facing a patient I don’t know, never met, and have little or no information about his or her prior medical history, I’m going to order lots of tests too given the litigiousness of our society.

    With respect to end of life care, by contrast, especially when the patient is elderly and frail, I think we have lots of room for improvement in determining when to stop treatment and communicating the futility of continuing further treatment to family members who can’t or won’t let go. Can’t doctors just say I’m sorry but there is nothing more we can do if that’s the case?.

  7. I had no idea she was so controversial. When I have read her stuff I have found it kind of interesting as it always fun to read someone who deliberately tries to take a “different” POV on issues. However, I think if you have read health care policy for a long time, and then tried to implement stuff at your own hospital or network, I don’t find it especially controversial. Broadly, and I don’t read everything she writes, I think she makes it clear that there are trade-offs on almost everything. I thought we all knew that by now, but apparently not.