I often feel like we’re making health care reform way too complicated. We can become more antifragile in health AND cut health care costs tremendously by practicing what Nassim Taleb in Antifragile calls via negativa, or the negative road. Via negativa means that we gain more from subtracting than by adding. We avoid the side effects that compound when we keep adding to a situation, making it increasingly fragile.
In health care, this means we improve health by subtracting a potentially harmful thing through rational trial and error, like a food, habit, or toxin. As opposed to stacking one medication or medical intervention on top of another, without a true understanding of the side effects that also stack up on each other. All in the name of “evidence-based” medicine.
Think about it. It’s ridiculously less expensive to subtract than to add in health care. When someone says eating healthy food is expensive – is it more expensive than having a heart attack, ambulance services, an emergency room visit, cardiac ICU care, a heart catheterization, and a heart bypass? What about the non-monetary expenses of all the pain and suffering of the patient and his family?
If you could reduce your cholesterol level through subtracting certain foods and habits, versus taking a statin, which is the more antifragile option? Which option has more downside? And shouldn’t we in the health care system be promoting the more anitfragile option?
There are several reasons our health care system doesn’t function in this way.
The obvious (and most cynical) one is that there’s more money to be made in doing things than in not doing things.
We physicians make more money in scheduling more office visits and doing more procedures. Pharmaceutical companies make more money when you take statins than when you eat vegetables. Hospitals make more money when their beds are filled with patients utilizing their high-dollar service lines.
Perversely, even health insurance companies make more money with this setup. Now, you would think an industry built on actuarial assessments of health would lose money the more people utilized health care services. But this higher utilization just gives insurance companies the cover to mark up health care premiums, way more than they could if health care were practiced via negativa style. Contrast private payers with government payers like Medicare and Medicaid, who can’t mark up premiums like this but must increase taxes. Who’s much more likely to go bankrupt?
Of course, even private payers will start losing money if we health care practitioners suddenly started doing even more tests and procedures. But over time they can distribute the costs and preserve their profits by raising premiums.
Which simply illustrates an economic reality: health care isn’t free!
And when practiced via positiva style, health care overall becomes more expensive. Way more. In America these costs are passed primarily to employers, who through greater cost-sharing pass them to you. Or, through higher premiums, deductibles, and taxes, they’re passed straight to you.
Either way, let me repeat: health care is NOT free.
But certain interests in the health care system make out like bandits. And these interests – Big Physician, Big Pharma, Big Hospital, and Big Insurance – have lobbies that want to keep it that way.
Now, I would argue that the Big Physician lobby is easily the weakest of this group and has been crushed in the run-up to Obamacare. Nevertheless, we physicians are culpable in promoting via positiva over via negativa in health care. Why is this?
Taleb rightly points out that it’s much easier to sell acts of commission than acts of omission. Imagine I as a doctor saying to you, I’m going to fix X by doing Y. Versus I’m going to protect you from X by not doing Y. Which one would persuade you more easily?
The Hippocratic oath directs us to do no harm. A directive as quintessentially via negativa as there ever was.
But modern medicine in America disregards this maxim all the time. In part because our tort system penalizes acts of omission way more than acts of commission.
If you go to any ER in America today with abdominal pain, you will almost certainly get a CT scan of the abdomen. Ninety-nine of them may be negative. But the threat of being sued for not doing a CT scan that would have picked up the one in a hundred serious abnormality is too great. So it’s much easier to perform this act of commission.
And the acts of commission keep going. Some of the other 99 with no serious abnormality on the CT scan end up having something incidentally seen on the scan. Which leads to more office visits, more scans, and maybe more procedures. All for something that may have caused no meaningful harm. The specter of the lawsuit looms over each successive act of commission.
Let’s say you go via negativa and don’t order the original CT scan in the ER. The patient does fine. And you prevented the radiation from the scan from giving her cancer later in life. Would you ever get credit for this act of omission?
Many patients believe that their doctor who runs the most tests is the best doctor around, because acts of commission sell better. Even as their health care becomes increasingly fragile from all the tests.
And we often have big blind spots to the risks that may be compounding with all these acts of commission. If we don’t stop and seek to connect the dots, we can’t see what’s happening.
For example, let’s say you have reflux. Instead of encouraging you to subtract foods and habits that may be fueling your reflux, I give you a proton pump inhibitor (PPI) that powerfully blocks acid production in your stomach. Later you develop a deficiency of iron or vitamin B12. I then have you take supplements to correct this. Then later you develop a diarrheal infection from a bacteria called Clostridium difficile. I give you an antibiotic for this. Still later you develop osteoporosis. I give you a bisphosphonate drug to strengthen your bones. This causes more reflux, so I increase your PPI.
This seems absurd, right? But it happens every day in modern medicine! All the above side effects have been correlated with PPI use. But we don’t go back and connect an original action we committed, like starting a PPI, to later events that crop up in a patient’s health. And even if we did, we cite reviews from medical journals that state that there is no statistically significant evidence that PPIs actually cause any of these side effects.
The key principle that Taleb wants us to remember here, however, is that absence of evidence isn’t evidence of absence. We’re helplessly biased toward evidence of confirmation. If there’s no clear proof that PPIs cause vitamin deficiencies, we don’t believe this exists. Even if common sense would suggest that blocking stomach acid production indefinitely is unnatural.
Another example: Tobacco companies would in the past deliver the excuse that there was no clear evidence that smoking caused cancer. Again, in the face of common sense that would suggest that filling our lungs with smoke and chemical agents isn’t natural.
On the flip side, we foolishly disregard evidence of disconfirmation. As Taleb relates, you don’t need a large sample size to prove disconfirmation. N=1 is sufficient. Because disconfirmation of something is more valuable than confirmation of something that might be refuted later.
Taleb invokes Karl Popper in arguing that science should establish largely negative, not positive evidence. You learn early in life not to touch a hot stove. You didn’t need meta-analytic evidence-based medicine to get this. Your sample size was yourself.
Similarly, if in health care we focused on eliminating things, reducing risk, letting nature run its nonlinear course, and taking advantage of favorable outcomes, we’d have a much more rational and inexpensive system.
We could then allocate some of the massive, freed-up health care dollars to via positiva medical treatments that ARE necessary when nature’s course would lead to death. I agree with Taleb that we should be as aggressive as possible, say, in a case of necrotic bowel, which Mother Nature hasn’t solved. But in many other cases of illness, we should get out of Mother Nature’s way. She’s proven the antifragility of her treatments over a vastly longer period of time than we have.
But as Taleb recognizes, pharmaceutical companies are less in the business of going for home runs in extreme diseases than in nibbling around the edges of illnesses of diet and lifestyle. Instead of cures for rare metabolic disorders, infectious diseases, or cancers, we get drug after drug for erectile dysfunction, reflux, high cholesterol, and diabetes. How many of these do we really need? For conditions that can be cured without drugs?
Moreover, we push these drugs to ever-expanding ranges of what we consider disease. For example, instead of limiting anti-depressants to patients with major depression, we use them for people with melancholy. Even in the face of studies that show that aerobic exercise is as good as or even better at relieving depression than drugs, with less downside.
As Taleb clarifies, Big Pharma itself isn’t ignoble; what’s ignoble is its business practice of settling for singles in diseases of primarily diet and lifestyle. Conversely, when a company does hit a home run, it should be rewarded handsomely.
Malcolm Gladwell has also argued for this, in the debate over how much money Gilead Sciences should charge for its blockbuster drug Sovaldi. Sovaldi, and its successor Harvoni, have revolutionized treatment of hepatitis C, a virus that can cause cirrhosis and death from liver failure over time. Until recently, curing hepatitis C involved a drug combination that lasted up to a year and caused significant side effects. And in advanced cases, the cure rate was poor. Harvoni has reduced the treatment period to 12 weeks and raised the cure rate to over 90% — even in advanced cases of hepatitis C! And side effects are minimal. But currently the wholesale price for a 12-week course of Harvoni is close to $100,000.
Now, many governmental and policy groups are pressuring Gilead to drop the cost. But Gladwell rightly asks, why should it? Why shouldn’t Gilead reap the rewards of delivering a medicine that effectively cures a potentially devastating disease, in a circumscribed period of time? This IS what we should be incentivizing pharma to do – not come out with yet another copycat drug of marginal benefit over what we already have (and that is always cheaper).
But what, instead, does Big Pharma bombard us with? Commercial after commercial advertising a medicine that is purportedly the key to your quality of life. A life that has become increasingly medicalized. But one that would involve enjoying lunch in a sunny cafe, having a nice backyard barbecue with your neighbors, or tandem bicycling in the park with your significant other – if only you would “ask your doctor if [fill-in-the-blank-medicine] is right for you.” Now, such a commercial wouldn’t be complete without the legally requisite listing of downsides in as pleasant a voiceover as possible.
All this would be fodder for hilarious comedy (which it is, if you’ve ever watched Saturday Night Live), if it weren’t so dangerous to the lives of millions of people and to the health care system itself.
Another example of the danger of via positiva health care: bariatric surgery. This surgery involves some form of gastric bypass to restrict the intake and/or absorption of food. Not a month passes by that I don’t see some study in the medical literature proving its benefits in reversing obesity and its many complications.
But let’s apply the principles of fragility and ask ourselves, what are we doing here?
In 2013, The American Medical Association (AMA) officially recognized obesity as a disease. This isn’t just a question of semantics. Once the AMA calls obesity a disease, it gives obesity the imprimatur of being the end itself. A target for which drugs and surgery become increasingly justifiable treatment measures, by a profession that’s all too eager to promote acts of commission over omission. And then the target expands. Our profession finds more and more ways to medicalize obesity. Which we can readily sell to a society eager for a quick fix.
To be sure, bariatric surgery may be the fastest way to help a person lose weight and eliminate diabetes, hypertension, and sleep apnea.
But what of the downside? Bariatric surgery advocates point out that the complication rates of surgery have decreased. But most of these surgeries are irreversible. They involve some alteration of digestive anatomy from which there’s no going back. And the nutrient deficiencies that result from the alteration can be lifelong.
Does this sound like an antifragile strategy to you?
Wouldn’t a via negativa strategy of promoting constructive changes in diet, lifestyle, environment, relationships, and mindset be more antifragile?
The refrain I hear from advocates for surgery is either that this just isn’t realistic for a morbidly obese person, that it’s more nature than nurture, or worse, that this is insensitive – it guilts a person who’s tried everything to lose weight.
I think it’s unimaginative, self-serving, and just plain lazy for our profession to have this stance.
Let me be clear: Obesity isn’t a blame game on someone who just hasn’t tried hard enough or is weak and morally lacking. Obesity is a fragilizing consequence of modern civilization, for which we are both individually and collectively responsible. And instead of figuring out more creative, holistic ways of helping someone overcome obesity, we push another fragilizer of modernity, a gastric bypass? What a joke.
Finally, Health 2.0 promotes so-called accountable care organizations (ACOs). These ACOs rely on performance meaures that invariably pressure health care practitioners to prescribe more medicines to target, say, cholesterol or blood pressure.
But why are we satisfied with an increasingly fragile health care system filled with ACOs that pat themselves on the back when they save 5-10% on health care costs? This, through onerous campaigns that expose the system in hidden ways to big downside effects?
We know that a few people account for the lion’s share of health care costs. Why don’t we focus our interventions on them – and stop with the massive interventionism on everyone else? That may save 40-50% on health care costs.