Peeling Back the Layers of “Medical Conservativism”

I don’t know when describing yourself as a “medical conservative” became a thing. I only noticed it recently, persistently popping up among people offering contrarian Covid takes. But what exactly does it mean? Is it really something new? Should I agree or disagree with the philosophy behind it?

It turns out this current phenomenon was kicked off with a thought piece in August 2019, that opens with, “We have been called critics, haters, nonbelievers, or our least favorite—nihilists. We prefer the term ‘medical conservative.’ We believe this is the ideal approach to patient care”. It’s by John Mandrola, Adam Cifu, Vinay Prasad, and Andrew Foy.

The authors also use this phrase, which sums up the intent of the slogan, I think: “slow-adopting skeptical clinicians”. It’s new interventions with “marginal benefits” that they have in their sights. Otherwise, what they’re describing as medical conservatism is pretty much what all medicine claims to be. For example, “the conservative clinician deals with one patient at a time and is careful to communicate the absolute benefits/harms of the drug for that individual”.

What actually differentiates the medical conservative in this opinion piece is a particular posture towards evidence, and arguing that critical appraisal skills are more important than content expertise. The medical conservative, the authors argue, “adopts new therapies when the benefit is clear and the evidence strong and unbiased”, and they tap heavily on the hot buttons of interest-driven hype and anti-pharma sentiment.

Of course, evidence can never be truly “unbiased”, while critical appraisal can be very heavily biased indeed. To argue that we should all lean towards skepticism about new interventions and results of clinical research isn’t new, and it’s been quite common to argue, as here in 2018, that “we should start with a prior belief in the low effectiveness of medical interventions”. It’s generally put forward as a correction, a systematic adjustment for exaggeration within the medical-industrial complex/medical research enterprise. But here’s the thing. When your default position is disbelief and discounting, with your thumb always pressing on one side of the scale, you’re at risk of error. It adds a systematic distortion to perspective. It is, in fact, a bias.

The arguments for variations of medical nihilism/skepticism often focus on limitations in chronic disease treatment, in the world’s most privileged communities, to convince us. For example, while acknowledging that insulin saves so many people from dying very young, Richard Smith also points out “kept alive people with diabetes would develop complications” – as though anything short of eliminating all suffering is only a diluted marvel. It’s not. The limitations of medicine are part of any realistic picture of medicine, for sure. Personal experience won’t let me forget that. I’ve been enormously let down by medicine in my own life – the devastating nadir being the recent death of my son. But a focus on chronic disease treatment and failures is too narrow. Pull further out, and perspective shifts. Take a broader look at my circumstances in the last few years.

I can see – literally – because of health care: a pair of cataract surgeries and lenses. An amazing phenomenon globally. And I can walk freely because of a great experience of surgery and rehab after savagely shredding an ankle. Several hours in a dentist’s chair spared me a lot of suffering this year. A baby born at 31 weeks in my extended family is thriving joyously. The worryingly-high hypertension that re-emerged after the tormenting horror of hearing my son had died? Quickly brought under control with a couple of tablets a day that cause me no bother at all. And one of my current projects is related to the HPV vaccines, which will reduce the risks to my grandchildren and their friends from some hideous diseases – a great example of the global importance of vaccination. That’s all “medicine”, too, quite miraculous, and far too easy to take for granted. Yes, there are incredibly overblown depictions of the wonders of modern medicine that point only to them, but it’s easy to go too far in the opposite direction once you get up a head of steam. And that’s also a slanted perspective.

The authors of the 2019 medical conservative manifesto don’t offer any evidence to support their claims that a particular style of practice results in better patient outcomes, despite being so strongly in favor of evidence per se. That’s not unusual of course. Back in 2004, there was a BMJ theme issue on evidence-based medicine. In it, I wrote, “It is perhaps an article of faith, more than a matter of evidence, that the people being cared for by EBM enthusiasts are always better served”. I think that’s still true. The only evidence base offered for the authors’ perspective in the 2019 medical conservative manifesto is below, with an editorial cited as the source:

The BMJ clinical evidence team reviewed 3000 treatments used in the UK’s National Health Service and found that about one half were of unknown effectiveness and only 11% were clearly beneficial.

That statement is fundamentally wrong and clearly misleading. The source doesn’t claim that it was a review of treatments used in the NHS. In fact, it was a review of randomized trials, whether or not the treatments are in use, or were ever widely used at all. Indeed, the source data for the statements in the editorial comes with the emphatic proviso: “This does not indicate how often treatments are used in healthcare settings”. Even leaving that aside, there’s spin here in the data choice. For example, if you wanted to spin the same data another way, you could say, of all the treatments tested in randomized trials, 35% of treatments have been shown to be beneficial or likely to be, while only 8% were shown to be ineffective or harmful (or likely to be).

It is of course true that many interventions don’t work. That’s inevitable if there’s to be progress – lots of things have to be tried, if beneficial interventions are to emerge, existing options are to give way to better ones, and the way interventions are offered and to whom is refined. It’s important to stress-test clinical research of course, and to be very wary of hype. I advocate all that, too.

However, the answer isn’t to discount and diminish every inevitably imperfect study, or to imply there’s something heroic in reflexively responding, nope, not convinced, and setting your default position at advocating, don’t do it. What’s valuable is being better at sorting the wheat from the chaff, not telling us our working principle should be to assume it’s all chaff.

Given most new ideas will stumble and some will harm greatly, while perfect clinical research is impossible, it’s easy to get a reputation for knowing your onions if you rip into every study. What I often think of as the drive-by-shooting school of critical appraisal is low-hanging fruit. It’s far harder to manage your own biases, and to be able to judge fairly reliably when something works and is worthwhile before too-slow adoption extracts its own terrible costs.

Inventing new slogans and personal brands seems to be irresistible, too, but I doubt they often do much for patients either. I don’t think “medical conservative” is one that should catch on. The authors of the 2019 cheerleading for the term wrote, “Medical conservatives vigorously oppose hype in all its forms”. It’s a pity they didn’t apply vigor to their own.

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On a related note here at Absolutely Maybe, from 2018….

Scientific Advocacy and Biases of the Ideological and Industry Kinds

Disclosures: I’m not a medical doctor. My PhD is in medical sciences, and I specialize in critical appraisal of evidence. I wrote a post critiquing some writing by one of the medical conservative op-ed authors (Vinay Prasad) in December 2018, as well as criticizing his stance on Covid vaccines for children earlier this year. Other than interacting on Twitter with him and another of the authors, John Mandrola, I don’t think I have any other history with them. I consider Richard Smith a good friend and I must have quoted his views favorably on many occasions. (Though come to think of it, Smith did reject an opinion piece of mine I submitted when he was BMJ‘s editor many, many moons ago – which was probably very wise, and I’m glad that one never saw the light of day.)

The cartoons are my own (CC BY-NC-ND license). (More cartoons at Statistically Funny.)