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".

No strong proof that flossing your teeth has medical benefit

This is the third in a series of "no evidence" posts I've made recently, with the first two being "No evidence that N95 respirators are better than surgical masks" and "No benefit to locked mental health wards."

Today's serves as another example of where something seemed like a good idea but... "sURpriSe!!!!" maybe it isn't. 

Certainly, the evidence is lacking to support the bullying that goes on in dental chairs around the world.
"Are you flossing?"
"Yes....."
"Are you sure?"
"Uhhh....." *guilty face*

Personally, as a reluctant flosser, and as a person who questioned the risk/benefit return of having wisdom teeth extracted, I feel a little bit vindicated here. I was always curious 1) if I asked the dentist to guess whether I was flossing or not, could they tell? and 2) Does flossing really do anything useful?

I can't lie to my dentist... how could they do their job if I did? So when asked "have you been flossing?" I usually tell them "no" or "yah but just for 2 months" if I had been doing so, in a phase of thinking I should probably try to stick with flossing. 

Last time I was feeling contemplative in between wafts of chemical smells and *wizzzzzzzes* of the drill in the neighbouring stall, I told my dentist and hygenist that if they could show me solid evidence of benefit of flossing, then I would do it. The hygienist listed a bunch of benefits and I went home to check it out. All the PubMedding in the world didn't find anything to back up her statements. Since they couldn't produce a strong reason for me to do it, so I decided to stop.

Flossing is not fun, it creates waste, and I can think of better things to do with 5 minutes a day. In fact, with those 5 minutes today, I can bring you this article in The Journal of Clinical Peridontology, which found:

The majority of available studies fail to demonstrate that flossing is generally effective in plaque removal. All investigated devices for inter-dental self-care seem to support the management of gingivitis, however, to a varying extent.

The paper did find that  inter-dental brushes (IDBs) are effective in removing plaque. These brushes I have tried and they look like little pipe-cleaners that you shove between your teeth. It feels about as good as it sounds!!! Ow.

I may wait for the randomized controlled trial (RCT) proving that those angry little bristles decrease caries (cavities) before attempting their use again, as "plaque removal" is but a surrogate marker for other things.

Further to the lack of advancement of evidence-based practice in dentistry, one periodontist. Dr Ghilzon, when interviewed by the CBC said:

I would say if you know how to floss I would continue just in case it does make a difference

When the CBC talked to Matthew J. Messina, a dentist and spokesman for the U.S. dental association, they pressed him. He acknowledged weak evidence, but he blamed research participants who didn't floss correctly.

It seems Dentistry is eons behing medicine in terms of evidence gathering let alone application. Whether employing patient-blaming, citing anecdotes, or declining to accept the value of evidence, Dentistry is set to follow Medicine in suffering the same "just in case" approach that dooms patients to overtesting and overtreating and promotes ignorance of the harms of intervention.  

See the original CBC article here.

Source: http://www.cbc.ca/beta/news/health/dental-...

COVER FEATURE: Dr Otte/Less is More Medicine in Canadian Family Physican

It is a pleasure to announce that the March edition of the Canadian Family Physician (CFP) almost entirely consists of articles that pertain to the 'right amount' of medicine; among them is a cover story about me (Jessica Otte) and Less is More Medicine.

Check out the cover article for yourself!

The CFP has recently shifted their covers to feature physicians who are practicing social accountability in medicine. It was an honour to be featured and, in so doing, bring attention to the need for real patient-centred care and consideration of the harms of too much medicine.

This month's journal is a seminal edition for the fight to find patients the right health care, thanks to the other related articles showcased:

Coccidiomycosis and other "Zebras" in Medicine; reconciling with Less is More

This is the first time I've had a peer-reviewed article published. Shortly after I wrote an email to the patient, the subject of this case report, to let him know, I was looking through my other emails and realized not only was it published, but that it had become the cover story for this of the British Columbia Medical Journal (BCMJ)!

Read the article here: A textbook case of coccidiomycosis (web version or a PDF version).

Ok, perhaps I shouldn't be so proud as it's not the Lancet or BMJ, but I think the BCMJ is pretty darn good and it was exciting for me to get to share this case in so doing, to make good on a promise to this patient to educate others about his diagnosis. It was also great to work with a friend, the very smart Dr Barlow!

I also liked the reflective exercise of thinking about how a "Less is More" kind of doctor could still diagnose exotic conditions.


The article is about an uncommon fungus (coccidiomycosis) that a patient I saw in on Vancouver Island had acquired. There's an expression in medicine:

"When you hear hoof-beats, think horses, not zebras."


One should never jump to the exotic diagnosis. However,  occasionally, people do have exotic diagnoses.

Even though I had to order some specialized tests to find out for sure what he had, this practice is still consistent with the "Less is More" philosophy. The idea is that in avoiding all the unnecessary stuff, we can use our time and resources wisely to order the RIGHT tests and treatments. It also helps immensely when patients are aware of their own health and can tell us their story clearly.

It all worked out because we had:

- A clear patient, advocating for himself, open-minded & contributing to my assessment and plan
- A doctor with time to hear the patient's story, medical knowledge appropriate for the situation
- Judicious ordering of tests (wrong test for most people, the RIGHT test for him)
- Confirmation of a suspicion gained from the history and reviewing the labs/xray that were already available

This was a highly satisfying case. I'm rarely clever, and rarely have a patient who is as good a historian as he. It's a wonderful illustration of a working acute care system, the benefits of being a patient who takes ownership for his health, and that some obscure knowledge is tucked away in my brain which will sometimes emerge when needed!