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Should Healthcare Improve Health
It’s almost a non-sequitur to ask whether or not a giant industry, with a well-defined goal, churning double-digits of GDP, actually works.
If pressured into an experiment we could easily design one that shows airplanes deliver people to destinations over 3000km away faster than trains (boarding time and travel to airport included). We could similarly prove they help people travel more, and more money spent on airplanes means more travel. Take a random group of 1000 people, give half 5000$ airline credits for two years, and we’ll certainly find that, on average they end up visiting more far-away places than the control.
On the other hand, this is not entirely unheard of.
A big and controversial example is the church. Where we’ve pretty conclusively proven that building huge cathedrals, converting “savage natives”, stomping out heresy and prayer have little results upon any form of well-being. But even here we must admit that, if the apparatus of science is unleashed upon religion, we will find interesting things such as people in religious communities drinking less, having longer-lasting marriages, and living longer with higher self-reported life satisfaction. We can argue about confounders and about the causal mechanism being replicable with things other than religion. But I think that, to most scientifically minded people, the lack of evidence is sufficient to not motivate them into becoming religious.
However, I keep being surprised by intelligent and scientifically minded people outright refusing to hear the evidence against medicine being useful. That’s not to say evidence against any particular therapy. There are many things that obviously work, such as emergency intervention for losing a limb in a car crash, where “almost certain death” is the clear outcome. There are many things that obviously work from a statistical perspective, such as vaccination against diseases such as covid, hep A & B, polio, HPV, yellow fever, rabies, and the like. There are also many things that seem to work, with good mechanistic evidence and promising studies, such as PRP for various forms of soft-tissue injury, or prophylactic therapy for HIV.
But this therapy-specific evidence is only more damming when viewed in the context of broader findings against medicine. Robin Hanson has written on this ad-nauseam, so I will let him do most of the talking.
1974 to 1982 the US government spent $50 million to randomly assign 7700 people in six US cities to three to five years each of either free or not free medicine, provided by the same set of doctors. … people randomly given free medicine in the late 1970s consumed 30-40% more medical services, paid one more “restricted activity day” per year to deal with the medical system, but were not noticeably healthier! (More, see also)
and
Oregon assigned a limited number of available Medicaid slots by lottery. … 8,704 (~30%) [very sick and poor US adults] were enrolled in Medicaid medical insurance. … at most see two years worth of data. … had substantially and significantly better self-reported health. … over two thirds of the health gains … appeared on the very first survey, done before lottery winners got additional medical treatment. (More)
No statistically significant effect on measures of blood pressure, cholesterol, or blood sugar. … did not reduce the predicted risk of a cardiovascular event within ten years and did not significantly change the probability that a person was a smoker or obese. … it reduced observed rates of depression by 30 percent. (More)
and
This study … is amongst the largest health insurance experiments ever conducted … in Karnataka, which spans south to central India. The sample included 10,879 households (comprising 52,292 members) in 435 villages. Sample households were above the poverty line … and lacked other [hospital] insurance. … randomized to one of 4 treatments: free RSBY [= govt hospital] insurance, the opportunity to buy RSBY insurance, the opportunity to buy plus an unconditional cash transfer equal to the RSBY premium, and no intervention. …intervention lasted from May 2015 to August 2018. …
Opportunity to purchase insurance led to 59.91% uptake and access to free insurance to 78.71% uptake. … Across a range of health measures, we estimate no significant impacts on health. … We conducted a baseline survey involving multiple members of each household 18 months before the intervention. We measured outcomes two times, at 18 months and at 3.5 years post intervention. … only 3 (0.46% of all estimated coefficients concerning health outcomes) were significant after multiple-testing adjustments. We cannot reject the hypothesis that the distribution of p-values from these estimates is consistent with no differences (P=0.31). (more)
But I think Hanson overlooks one of the best and funniest studies ever conducted, based on dutch health insurance data.
Data from 1913 conventional GPs were compared with data from 79 GPs with additional CAM training in acupuncture (25), homeopathy (28), and anthroposophic medicine (26). Results Patients whose GP has additional CAM training have 0–30% lower healthcare costs and mortality rates, depending on age groups and type of CAM. The lower costs result from fewer hospital stays and fewer prescription drugs
The funny bit here is that not only are all 3 types of alternative medicine trained GPs better, both when taken in aggregate and individually. But the best outcomes seem to come out of homeopathy, which is as perfect of a placebo arm as one can get.
This is not to say that all evidence points towards medicine having no effect whatsoever on health-related biomarkers, quality of life, or mortality. It’s just that most studies point towards this being the case, and the few that don’t, aren’t finding very significant effects.
This is surprising, given that we know a bunch of interventions clearly work, really well.
Regardless, I started with the problem of why well-educated people seem to ignore this evidence and chose to use, pay for, subsidize, pay others to, and lobby for subsidization of healthcare services.
Surely if there was evidence pointing towards more deaths, longer travel times, and increased costs of going by plane instead of train on most or all routes in Europe or the US, most of these people would start using trains almost exclusively. Why is the same argument not clicking here?
I think the issue is, at least in part, with a lack of understanding as to why this is happening. What parts of healthcare are broken. This in itself is a problem I can’t address because few studies are done trying to address this since the raison d'etre for these studies is being cognitively suppressed by most people in a position to run them.
Still, I hope that the evidence against medicine might be easier to swallow if people at least had some hypothesis for why it might not work, and which bits of it might work. So here are three such hypotheses, which in part make my own working model of healthcare.
i - Diagnosis Is Broken
It might be that this standard of rigor is not being applied during a normal diagnosis procedure. The evidence here is hard to assess since there’s no meta-analysis of the subject as a whole.
When most people run studies on interventions they are very careful to pick patients that actually have the condition being studied. There are exclusion criteria, both during the trial and during the analysis of the data. Doctors are instructed very carefully when to prescribe the new intervention.
But let me take the Dutch insurance trial as a potential example here. A comment I found here on the Dutch medical system is:
“go home, take some Tylenol and come back if you don’t feel better” is actually quite an effective strategy in this GP-as-gatekeeper model. Most of your patients feel better and don’t come back, as you couldn’t have done anything for them anyway. This keeps costs down and keeps the emergency room just for actual emergencies.
I think most people agree that, if someone comes into a GP complaining of head/back/stomach pain, just prescribing some acetaminophen as a placebo, instead of recommending investigations (which induce anxiety, cost money, and will find nothing) or prescribing opioids, is preferable.
... Except that most people forget acetaminophen is actually quite a dangerous drug.
Acetaminophen overdose is the leading cause for calls to Poison Control Centers (>100,000/year) and accounts for more than 56,000 emergency room visits, 2,600 hospitalizations, and an estimated 458 deaths due to acute liver failure each year.
Edit: someone on Reddit pointed out ~80-90% of those could be suicide attempts. If the above number of deaths *0.15 sounds not impressive enough replace the acetaminophen example with a 0.6% yearly risk of internal bleeding from low dose aspirin or other some such.
This is a first-order effect, ignoring the second-order effects of acetaminophen, which essentially stops inflammation processes inside the body that are critical for stopping pathogens and signaling cells responsible for healing tissue injuries.
So it might well be that a GP prescribing an actual placebo (e.g. a homeopathic pill) would have their patients fare much better. Or that someone never going to a doctor for backache and just “ignoring it” would fare much better. Even in the case where the GP recommends what is seen as a “completely safe treatment”.
Similarly, many such small interventions for issues that require non might be accumulating to cause long-term health issues in the long run. Be it overprescribing SSRIs for mild cases of depression, thus stopping people from trying to solve their actual issues, or fixing a minor & asymptomatic cavity “just in case”, thus damaging the structural integrity of teeth and inflicting infection vectors upon the patient for no reason.
I’ve personally had dentists recommend to me that I should totally shatter my mandible, do open surgery to transplant some bone from another part of my body, then wait a few months for it to heal back into a shape that might “improve my bite”.
I’ve also had really good doctors recommend surgeries for conditions that don’t improve with surgery, and where surgery is known to cause long-term health deterioration.
Not to mention I’ve had doctors recommend me “standard” procedures such as using vitamin A creams of acne, a product which, in the case of someone with high serum vitamin A like myself, would lead to liver toxicity without any evidence of improving health outcomes. Or use sunscreen, in spite of dozens of studies showing mostly no links, or even harmful links, between sunscreen use and various skin cancers.
Add to this common-sense “dumb” things such as doctors recommending powerful bleaching skin “treatments” and invasive investigations (contrast MRIs, arthroscopic investigations, endoscopy, colonoscopy, biopsies, radiology).
The problem with most “minor” treatments that get commonly recommended is that they are not dangerous enough to show serious side effects, and there are no incentives to run in-depth controlled studies to look for minor problems. There might be hundreds of other “minor” doctor recommendations that cause cumulative harm, which in of themselves are minor, but pile up onto someone that visits doctors dozens of times a year.
Now add onto that the fact that similar misunderstanding of evidence and misdiagnosis by doctors increases the chance of not being recommended actual life-improving treatments that have shown their worth in clinical trials where doctors were explicitly trained to use them.
Even if we have a suite of interventions that have mild effects when prescribed correctly, they also have side effects. If the prescription methodology of doctors is unable to select interventions correctly, we might have an effect that showcases minor improvements in clinical trials but leads to harm in “real” usage.
ii - Randomized Placebo-Controlled Trials Don’t Work
Controlled trials are a great tool to weed out ineffective medicine. Most doctors will use success in RCTs with large sample sizes plus FDA/EMA approval as reason enough to prescribe something. Even the most cautious doctors will probably give in once conclusively shown that something works by an impartial meta-analysis run by specialists on multiple studies.
If you agree with this methodology, great. I once again invite you to go to your local shaman and buy some homeopathic medicine (use scihub to open the study). It has better evidence than most drugs, in summary, it shows:
The combined odds ratio for the 89 studies entered into the main meta-analysis was 2.45 (95% CI 2.05, 2.93) in favour of homeopathy. The odds ratio for the 26 good-quality studies was 1.66 (1.33, 2.08), and that corrected for publication bias was 1.78 (1.03, 3.10). Four studies on the effects of a single remedy on seasonal allergies had a pooled odds ratio for ocular symptoms at 4 weeks of 2.03 (1.51, 2.74). Five studies on postoperative ileus had a pooled mean effect-size-difference of -0.22 standard deviations (95% CI -0.36, -0.09) for flatus, and -0.18 SDs (-0.33, -0.03) for stool (both p < 0.05).
Obviously, we’ll just go ahead and dismiss homeopathy based on the underlying mechanism and the fact that these trials show minor results and are run by motivated institutions which are prone to slightly altering numbers, not publishing any negative results, and doing as much statistical manipulation as possible without revealing the actual data unless required.
... But the exact same thing can be stated about many therapies, ranging from statins to aducanumab. Yet doctors seem perfectly happy to prescribe a lot of low-impact drugs.
Even worst, unlike placebo pills, low-impact drugs might actually have hidden side effects.
This gets even worst with interventions against malignancies such as cancer, which get a much easier pass when it comes to what’s considered efficacious. And “best practices” might encourage drugs with evidence for increased mortality.
That is not to say RCTs are a bad model. If effects are stunning enough, then an RCT should count as the definitive proof that a drug works. But if the results are minor we might be misled by research bias. This is a broader problem with modern science, which often ignores the importance of effect magnitude versus direction.
iii - Hospitals Are Dangerous
Going to the hospital is fairly common for conditions that are life-impairing but likely not fatal. Not to mention that people often get surgeries and engage in multi-day ICU stays for treatment.
Hospitals are primarily dangerous to anyone, even someone going for a simple consultation or to get an MRI, due to the presence of many sick people, some infectious, and due to the abundance of drug-resistant pathogens, which are mainly absent from other environments.
Once we get into receiving invasive treatment this gets worst. We have to keep in mind that most surgeries vs conservative trials are run at good hospitals, the kind that have doctors interested in running trials, and we might expect that doctors knowing they are participating in trials take extra care not to do things like... accidentally kill patients.
But accidental deaths are a huge concern when doing any sort of surgery, even elective ones. Stealing from Hanson again:
In 1999, the Institute of Medicine published the famous “To Err Is Human” report, … reporting that up to 98,000 people a year die because of mistakes in hospitals. The number was initially disputed, but is now widely accepted by doctors and hospital officials — and quoted ubiquitously in the media. In 2010, the Office of Inspector General for Health and Human Services said that bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year.
Now comes a study in the current issue of the Journal of Patient Safety that says the numbers may be much higher — between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death, the study says. That would make medical errors the third-leading cause of death in America, behind heart disease, which is the first, and cancer, which is second.
James based his estimates on the findings of four recent studies that identified preventable harm suffered by patients – known as “adverse events” in the medical vernacular – using use a screening method called the Global Trigger Tool, which guides reviewers through medical records, searching for signs of infection, injury or error. Medical records flagged during the initial screening are reviewed by a doctor, who determines the extent of the harm.
In the four studies, which examined records of more than 4,200 patients hospitalized between 2002 and 2008, researchers found serious adverse events in as many as 21 percent of cases reviewed and rates of lethal adverse events as high as 1.4 percent of cases.
By combining the findings and extrapolating across 34 million hospitalizations in 2007, James concluded that preventable errors contribute to the deaths of 210,000 hospital patients annually.
That is the baseline. The actual number more than doubles, James reasoned, because the trigger tool doesn’t catch errors in which treatment should have been provided but wasn’t, because it’s known that medical records are missing some evidence of harm, and because diagnostic errors aren’t captured. An estimate of 440,000 deaths from care in hospitals “is roughly one-sixth of all deaths that occur in the United States each year.” (more; source)
That seems rather horrible, but again, it doesn’t cover long-term damage from hospital stays such as non-fatal infections.
Finally, people opting out of medicine aren’t taking a vacation to visit a sunless brutalist building with sad people and agitation when they feel sick. They might instead call in sick and spend time playing board games with family, start eating better, go to the beach, or just sleep more.
iv - What I Do
I think the evidence against the efficacy of healthcare is pretty damming, and it scares me.
I don’t believe it boils down to just the above reasons and I don’t believe I have enough evidence to say they are true.
The one thing I refuse to do is close my eyes to the evidence of medicine not working. This is especially important since some parts of medicine obviously work, and the upside here is not just saving money, it’s significantly increasing my healthspan and lifespan by being very selective about the medicine I use.
My current protocol is something like this:
Don’t register problems as “medical” problems unless they are really bad or unless I have the mental time to investigate a solution. If my head hurts, my head hurts. If my head hurts every day for 2 weeks, that’s a medical issue. But I will try to avoid using medicine when I can rely on homeostasis.
Don’t heed any advice from doctors about elective treatment, look at the direct evidence myself. Doctors can be hypothesis generators and they can help conceptualize problems. They can turn “indistinct pain here” into “MRI shows inflammation in foobar muscle”, this is hugely useful for actually being able to look at the relevant evidence. Though one bit that shouldn’t be forgotten is that the diagnosis itself might be wrong, and looking at the error rates on the diagnosis you’re getting is an important thing to do before taking it as a data point. You have access to all the information a doctor has, you might be much worst at parsing through it, but you can afford to spend 100 times the amount of time a doctor would on your case.
Refuse all surgical interventions that aren’t life-saving outside of extraordinary circumstances. Obviously don’t refuse life-saving surgery after a car crash.
Avoid therapies that don’t have tremendously large magnitudes associated with their effect direction unless you are directly monitoring some biomarkers and have large volumes of evidence and mechanistic reasons showing no side effects.
Avoid consuming healthcare without significant time to reason about it. It takes time to go directly into the evidence instead of heeding doctor advice, so if you have dozens of ongoing conditions you won’t be able to handle all of them. The only solution is to try to prioritize, focus on the important ones, and forget the milder issues until you’ve solved the important ones... and hey, maybe they’ll heal on their own.
Once you’ve decided on a line of treatment try to double-check it by figuring out if at least one seemingly reasonable doctor agrees with it (potential confounder: if you dig far enough you’ll find a doctor that agrees with anything, homeopathy included… for further discussion on this see Rohit’s comment)
This is still not an ideal solution, there is vague semantics here for which I don’t have strict definitions.
If I’m mixing a multi-vegetable and algae powder with my morning yogurt... is that a medical intervention? A supplement? Just a way of consuming food?
If I go get a hot stones massage is that “medicine”? What about a sports massage at a qualified therapist?
Is doing some yoga for back pain a medical intervention? What about following a routine prescribed by a PT?
I don’t know.
The danger of not trusting medicine enough is starting to trust quackery too much. The way I solve this is by self-experimenting and finding broad-spectrum high-impact interventions I can always use.
But what will I do when I have a serious issue, no time or ability to interpret evidence (or no evidence to interpret), and my catch-all interventions fail? Do I just trust a surgeon? Do I go to a spiritual healer? Do I just ignore things like black liquid sipping out of multiple orifices?
I don’t know, my system has edge-cases which I’m sure will make it broken for people that aren’t lucky enough to be in their 20s. This is why my principal focus is still on trying anything and everything I can to monitor and delay aging.
The only thing I will say is that we have a long history where truth-seeking in the face of uncomfortable circumstances seems to work out. So we shouldn’t make ourselves immune to evidence just because the things it says will cause discomfort. We should figure out the extent to which we should trust it and integrate it into our lives, then hope for the best.
... or who knows, maybe we should just trust the evidence fully and abandon our life to join a California doomsday cult. I hear the epidemiological studies find it quite promising.
Published on: 2022-12-01
