Free Speech, The Flexner Report and Why Your Doctor Cannot Tell You The Truth

An anecdote:

When I had the large clinic, Tempus, one of my managers came up with the idea of doing radio advertising. OK, why not? He had a clever name for the campaign: “Undo Type Two.”

These were 15 second radio spots so not a great deal of medical information was conveyed beyond Tempus knew how to “undo type two.” Well, not only does the state have the power of life and death over its citizens it has an almost more unnerving power; the power to remove a professional’s license to practice his profession. Well, someone ‘turned me in’ to the medical board for daring to claim to be able to cure diabetes. For reasons more nefarious than I wish were the case we found out that an official at the regional offices of the American Diabetic Association was the source of the complaint.

Things worked out fine but I will admit that while I do not fear free climbing outrageously exposed lines on mountains and cliff faces I do fear the power of the medical board and its bureaucratic capacity to blunder through the lives of doctors trying to do their job. Now this was over 10 years ago and the idea of a physician advertising was a little uncomfortable for me then, still is in some ways, but there was nothing even remotely questionable about the claims Tempus made. Still, one disgruntled individual had the power to threaten my livelihood.  Hold that thought.

In 1910 Abraham Flexner published a report on the state of medical education in the United States. In his assessment American medical education was little more than a consortium of charlatans and criminals. He proposed that American medical education become more like the German one. All things good were invoked, ‘science,’ ‘professionalism,’ ‘uniformity,’ for example. Now, the early 20th century was aflame with medical theories from phrenology to chiropractic and osteopathic and from native American shamanism to séances as useful healing theories.

After the Flexner Report other therapeutic and theoretic modalities became not only disreputable but, in some places, criminal. Within a fairly short time American medical education became the envy of the world. I am not sure this was an entirely earned reputation; the English medical establishment had very high standards which derived from something more like a guild model than an academic one. Still, American medicine is something in which we can all take pride. Many public health scourges were defeated by the American model. It must be admitted that this academic model also suppressed some pioneering and important work; this for another time.

Medical schools became attached to universities, adopted ‘the scientific method,’ and became regulated by the power of the state as well as other professional organizations. I would have to say that overall these changes were a great improvement over the educational anarchy at the time of the Flexner report. Again, hold that thought.

A hundred years later, the public clamor for ‘alternatives’ to conventional medicine has become almost as economically powerful as conventional medicine itself. If one added together the amount of money spent on naturopaths, chiropractors, supplements, herbal medicine, etc, etc, you would find a very large result; somewhere well north of $100,000,000. From the medical profession’s perspective north of one hundred million dollars represents an awful lot of dissatisfied customers. One more time: hold that thought.

Two of my favorite ‘whipping boys’ are beta-blockers and statins. Beta-blockers have been used for decades and have caused numerous sorts of unnecessary misery: fat weight gain, sleeplessness, erectile dysfunction, depression, oh, and many, many unnecessary  deaths. This is no longer controversial; how you state these facts is controversial but the details are no longer in question.

Now statins, Lipitor and relatives, have never been shown to be of much statistical benefit. NNT, the number needed to treat, for someone who has not had a heart attack is approximately 1000 people per year to be of benefit to 1. Put another way if 100 people took statins for 5 years 98-99 would experience no benefit and over 20% would have developed one or all of the following: diabetes, cataracts, muscle injury, depression or memory loss. No one’s life would have been saved but 2%, not nothing, would have avoided a non-life threatening heart attack or stroke during that 5 year period. Eating peanuts has better numbers. Even 100 of those with prior heart attacks would need to take the drug for 5 years to be of any benefit to 4 people. Not nothing but not much; and all of the side effects above still apply. So much for the ‘scientific method.’

Let’s now bring those too-long held thoughts together. No doctor who desires comity with his professional peers or who does not wish some busybody at the American Heart Association, for example, turning him in and thus being at risk for losing his license will mention these numbers. When someone comes in the office with a cholesterol above 200 that doctor will write the prescription for whatever the current ‘standard of care’ expects.

Bear in mind the numbers that have underwritten the wide spread use of beta-blockers and statins were arrived at by ‘the scientific method’ or at least the simulacrum of it practiced in our institutions of great learning. Placebo has a much better record; placebo does not cause cataracts for example. By what standard and in whose eyes, forgive me the pun, did it become nearly criminal to not recommend statins? You can be the keynote speaker at the Scientific sessions of the American College of Cardiology and advocate adding Lipitor to the water supply but be shunned in your own community because you advocate exercise and better nutrition rather than statins.

In some interesting way, between the desire to do good, let us say the Flexner report is an example of this, and the inexorable machinery of bureaucracies, the simple, sacrosanct, right to freedom of speech has been lost.

There are over 800,000 physicians in the United States and about half that number, 400,000, are in primary care. I will tell you, I know from personal experience, that with or without justice, many of them, the primary care half especially, live in fear of saying the wrong thing, of even telling you what they actually believe. Some, a very fine young man and physician I’ve exchanged emails with in England for example, think something as simple as more ‘lifestyle’ education in medical schools will fix the oppressive pharmaceutical/medical model. He is not naïve, merely hopeful that this small crack in the dam will herald greater change later.

I wish this were true but I don’t believe it is.  I believe our very educational and physician formation process will need to be changed. The selection criteria for medical school will need to change. The educational goals of medical education will need to change. The bureaucratic and legal environment will need to change. So far as the pharmaceutical model exists it must be tied to disease that is not the product of an unhealthy culture and thus coupled only to diseases outside the purview of the well directed self; connected to multiple sclerosis, ovarian cancer, leukemia. Its tentacles must be untangled from medical education and most medical research. Only in this way will the medical professional take up the personal task of being healthy and be one of the real change agents of health in the broader community of his patients. As long as the teaching model, the personal model of the physician himself, and the broader culture expect some pharmaceutical magic cure for most of the behavioral diseases that burden our lives, our families and our economies then real change will not happen, cannot happen.

Smile, Have Fun, God Speed,

Dr. Mike