That is, at least for some, a provocative title for a medical post.
Avoid, no matter how tempting, broadening my remarks to a general theory of politics.
As young medical students, even if we sat in the back and sometime read the newspaper, we still showed fealty to the lecturers; to our mentors. It was obvious that they knew more than we did about physiology, anatomy, endocrinology; biochemistry not so much as that was a ‘hard science’ of clear rules and little room for interpretation.
As students slide into the clinical years the teaching becomes more like studying wisdom literature; the wise council of seasoned practitioners imparting their occult art, whether internal medicine or thoracic surgery. Though on the latter point I must mention that as I did my modest duties across the operating table from the justly famous Dr. Shumway, during ‘open heart surgery,’ he once told me: “Mike, I could teach a monkey to do this.” Well, that is the craft and practice of the art of medicine. Still he knew a lot and I and many, many others listened and learned from such as he. He was a great teacher by the way.
Along the way, broad pronouncements were made by various governmental bodies: low fat diet, mammograms for women over 50, wear your seatbelt, wear a helmet, beware of strangers, take the oral form of the polio vaccine, drink two glasses of wine a day… you get the idea. More expert advice from more experts about things that either were nonsensically reasonable (did I really need an expert to tell me that?) to outright malignant malpractice (eat a low fat diet; part of a death cult by now) to things with unforeseen and in fact unforeseeable consequences like teaching the fear of strangers so thoroughly- missing children on milk cartons which had more to do with domestic disputes than real risk to the innocent bystander- that it resulted in almost no one walking to school and thus not getting needed exercise. Kids on milk cartons meant no exercise for most children; no one intended that but it was a very rational response to irresponsible good intentions of brilliant experts. Beta blockers for heart attacks because the heart needed to work less; no, in fact it needed to learn to work in a new and better way and was ‘blocked’ from doing so and thus people died in cardiogenic shock from taking something they did not need and was of help to no one and great harm to many. This last is a 40+ year practice. Did it really need to take that long to figure out this was a bad idea or is it still around (it is still being done!) because committees and Academies are self serving, all but sessile bodies comprised of ‘experts?’
OK, back to liberal vs conservative. In order not to get stuck to the linguistic tar baby of evolving language by ‘liberal’ I simply mean the impulse of the expert to tell the non-expert how to live and think. By ‘conservative’ I mean the even simpler thing that almost all good comes from the mind, intentions and actions of the individual. Einstein couldn’t get a job in a German university: Lister, Pasteur, H. Pylori by Warren and Marshall… the list is long and not only from the past that institutions, committees, groups are terrible at creating, at helping, at even and especially giving good advice; such creative responses are the nearly exclusive purview of the individual. By the time there is a consensus the consensus is wrong. The consensus has missed the next and deeper understanding.
How, you reasonably ask, does this apply to the practice of medicine and your health? Let me give examples where institutions make sense and where they create havoc. Along the way I hope to provide some guidance in how to choose whether to submit to the institution or the individual for guidance.
With enough minute-to-minute biological information, body temperature, urine output and heart rate for example on a room full of people, say an intensive care setting, an informed observer, no doctor needed just a good algorithm, you can see an infection early enough to prevent it becoming a life threatening sepsis. Sepsis, full body infection, is the number one most expensive in hospital condition in the United States and even when not fatal can lead to kidney failure, loss of fingers and toes and other unpleasant consequences. Here is a case where lots of data on lots of people, minutely tracked, with clear end points of safe, minimally invasive responses can lead to lives saved. So score one, a big one, for the ‘experts.’
Here is a counter example: Drink two glasses of wine a day; it is good for your heart. This is so universally taught and believed that I have never, that was a never, had a patient post coronary bypass graft, or heart stent, that was not told this bit of wisdom. I’ve heard it as an almost magic incantation from physicians and patients alike for 40 years. Well, we now know that alcohol increases a woman’s risk of breast cancer and that there is apparently no safe level of alcohol ingestion that does not increase a woman’s risk of breast cancer. Has the medical profession been teaching something we now know increases a woman’s risk of breast cancer? Well, maybe. What we do know, what any modern family knows, is that alcohol is bad for a large proportion of… alcoholics. Where I live and work the romance of wine, cognac and even cigars is so prevalent that it out weighs any counsel against their use; after all ‘it is good for my heart.’
As the decades come and go the percentage of my patients directly harmed by alcohol varies from a low of 20% to a probable high of almost 40%. The waxing and waning is, I think, just the working out of the vagaries of time, but the harm is real and lasting. The harm varies from the purely metabolic, low threshold fatty liver disease for example, to the social and relationship harm of impaired social functioning. If someone looks forward to alcohol as a way to ‘relax’ be clear that this is the hallmark of addictive behavior; I find this a lot in my practice: families are harmed, communities are harmed.
Well, I am over my self imposed 1,000 word limit so I will try to wrap this up: the list is long and the consequences dire of all the harm expert advice has caused. I have little doubt, but for obvious reasons less data, about the harm of always following one’s own ‘advice.’
The only safe harbor, the only sure path, is to ‘measure it.’ Measure your bone mineral density, your VO2 max, your triglycerides, you testosterone, your inflammation, your genetic and modifiable risk makers, your happiness, how closely you hold your friends, how deeply you cherish your family, whether you are refreshed from your nights sleep. Measure these things, improve these things. Don’t listen to experts for they are almost always wrong. Listen to your body; use technology to do so, don’t become dependent on that technology, another addiction, but be available to every metric of guidance at your disposal and seek out more. The wonderful thing about the body is it always makes sense; often at a level beyond our understanding of the intervening variables but at bottom it will and we need only follow very ancient advice from the Delphic Oracle, “know thyself,” or my favorite version from someone who died refusing to be called an expert, Socrates: “an unexamined life is not worth living.”
Smile, Have Fun, God Speed,