The Case for Being a Medical Conservative

Drs Vinay Prasad, John Madrola, Adam Cifu, and Andrew Foy have written a fantastic article about what they call “Medical Conservatism.” Read it HERE

I never thought that those in the movement to prevent overdiagnosis/medicalization and overtreatment would be labeled as “conservative” in our thinking - but I identify directly with many aspect of this article.

I am proud to work with an organization (The Therapeutics Initiative) which does rigorous, unconflicted review of the medical evidence. Many (but not all ) of our conclusions are essentially that the drugs don’t work as well as we wish they did. And for coming to these conclusions, we have been called nihilists.

Like anyone, I want the medications to work, and work well. Yet, I understand that they often do not, and that we need to stop pretending that they might kinda sorta a little, when the evidence says that they (sadly) really don’t make a meaningful different for outcomes that matter to patients. This can be hard to reconcile in clinical practice where clinicians and patients alike get stuck on the hope of success in the face of illness and adversity.

The authors explain there terminology further:

Our choice of the term medical conservative does not imply a political philosophy, although William Buckley Jr.'s definition of conservatism aligns well with our approach to patient care:

“A conservative is someone who stands athwart history, yelling Stop, at a time when no one is inclined to do so, or to have much patience with those who so urge it.1

Here is what we believe:

Medical conservatives are not nihilists. We appreciate progress and laud scientific gains that have transformed once deadly diseases, such as AIDS and many forms of cancer, into manageable chronic conditions. And in public health, we recognize that reducing exposure to tobacco smoke and removal of trans-fats from the food supply have contributed to the secular decline in cardiac event rates.2 Indeed, medical science has made this era a great time to live.

The medical conservative, however, recognizes that many developments promoted as medical advances offer, at best, marginal benefits. We do not ignore value. . . . The medical conservative adopts new therapies when the benefit is clear and the evidence strong and unbiased. 

In the article, they show this graph, comparing the magnitude of benefit for a patient to the cost of the care, with some examples:

gr1_lrg.jpg

The area on the left is where we want to be. The “A” items make a really really big differnce for people’s well being. Not surprisingly, a lot of the modifiable social determinants of health live in “A” territory. The trouble is the “C” territory, the things that we do that make basically no impact for patients but that cost an extraordinary amount in terms of harms, burden, and financial measures for patients and society.

My colleague Juan Gérvas said it well when he wrote our ‘preventing overdiagnosis’ mailing list: “the end of the curve is not flat, but going down... [at that point, the] harms outweigh benefits.; on the end of the flat part of the curve, additional spending, whether it be on a new drug, device or diagnostic test, confers more harms than benefits to individual patients or society".