A Broken Healthcare System, Some Lights in the Darkness, and Affirmation from George Lundberg

As Editor-at-Large for Medscape, Dr. Lundberg delivers to readers his informed perspective on up-to-the minute issues affecting healthcare and the practice of medicine. In addition to his work with Medscape, he serves as Editor-in-Chief at Cancer Commons, as President and Chair of the Board of Directors of The Lundberg Institute, and as a clinical professor of pathology at Northwestern University. Dr. Lundberg has more than 30 years' combined experience as Editor-in-Chief of JAMA (Journal of the American Medical Association), the 10 AMA specialty journals, AM News, Medscape, The Medscape Journal of Medicine, eMedicine from WebMD, and MedPage Today from Everyday Health.

A Great Medscape Article from Dr. Lundberg

Make Room for Mavericks Among Us

Do you know "truth"? I don't, but I sure do like to search for it. I see mainstream medicine as that developed and espoused by the "establishment." That is — forgive the alphabet soup — the AAMC, LCME, ACGME, ACCME, the medical education industry, NIH, CDC (and all state and county health departments), AHRQ, FDA, USPSTF, FSMB (and all state licensing boards), AHA, AAHC, UCA, MGMA, AMA (and all specialty and state medical societies), ANA, CMS, the health insurance industry, the HR benefits industry, PhRMA, NLM, the medical publishing industry, medical marketing and advertising, and assorted others. This is a rich, self-sustaining, propagating mega-behemoth, fully capable of producing-consuming-spending 18% of the US gross domestic product, approximately $4 trillion, or $12,000/person/year, and best characterized by Warren Buffett as an unbeatable economic tapeworm.

Mainstream medicine — peer-reviewed, guideline-based, bureaucracy-approved, insurance-controlled, medically crowdsourced, conventional wisdom medicine — is by and large a good thing, albeit expensive, and is the best route for most people and conditions, most of the time. Randomized, controlled, blinded (when possible) clinical trials with numbers large enough to assert statistical power must remain the gold standard.

But we must make room for maverick medicine as well. Many diseases and possible treatments do not present with sufficient numbers for large-scale trials, so we need alternative ways to evaluate them.

The value of patient autonomy is fiercely defended by many, and rightfully so. Take charge of your life; after all, it is your life. However, with respect to your health, this is best done with a trusted physician with whom you share decision-making.

The value of physician autonomy is likewise fiercely defended by many, and rightfully so. Medical education (undergrad, graduate, continuing) is worth much, as are degrees, licenses, certification, and staff privileging.

I see maverick medicine as essential as contrarian challenges to complacency or regimentation. Like serious investigative journalism, we should always be asking questions, challenging dogma, puncturing bloated myths, and seeking and reporting truth. My favorite medical maverick is not an American. He is GP Malcolm Kendrick of Scotland, who publishes a widely read blog — acerbic, witty, sarcastic, devilish, bombastic, invasive, irreverent, insulting, based on fundamental basic science principles like chemistry, mathematics, physiology, anatomy, plus a keen sense of history, clinical experience, and total intolerance of haughty BS. One recent column lambasted a major UK agency (NICE, the UK National Institute for Health and Care Excellence) that (I thought) holds worldwide respect.

But the best medical maverick may be the elegantly educated physician, also greatly experienced in real-world medicine, with the zeal of an investigative journalist, huge savvy on how to gather information, and laser-focused on critical thinking. This maverick has no government or industry ties to constrain or conflict, is truly independent, driven by truth-finding and telling, and practicing rapid information throughput dissemination. I am not describing artificial intelligence (although maybe someday). I refer to public media physician journalists such as Vin Gupta and Leana Wen, and angry critic Vinay Prasad.

Medscape columnist and Yale professor F. Perry Wilson; daily newsletter writer Dr Bill Bestermann; and my favorite COVID blogger, Dr Susan Levenstein and her Stethoscope on Rome are among the best at living out, critically analyzing, and broadly disseminating the rapidly moving fronts of medical information that beg for instant interpretation. Valued physicians like these can be both mainstream and maverick simultaneously.

There are a lot of physicians out there who don't know from nothing, for whom science seems an unknown never-never land. I lay that learning deficit on the US medical education system, which grants a "professional" degree, MD, rather than an "academic" degree, PhD. Rote memorizing of vast information is emphasized in many medical schools.

There may be a "science of medicine," but really medical science is more an amalgamation of many other solid sciences as applied to human health and disease. A person will not learn the critical thinking necessary for scientific understanding without dedicated and guided study.

Two of the generally most trustworthy guideposts for evidence-based medicine are US Food and Drug Administration (FDA) approval of a drug or device and approval for its specific uses. Once the Centers for Medicare & Medicaid Services (CMS) and other insurance payers also approve payment for a given product or service, it can usually be considered reliable.

Infallible, the FDA is not; witness the current Aduhelm debacle. So far, CMS has not announced a coverage decision for Aduhelm. Many physicians and medical organizations have announced that they have no plan to prescribe the agent, which may or may not have slight effects on a biomarker and none on brain function.

Mainstream medicine has gotten plenty of things very wrong historically, even in the 20th and 21st centuries. Sometimes non-MD mavericks are essential in noting where some of the failures may lie and in pointing to a different direction. I like to think that I have played on all sides of this serious circus over the decades.

Publications on topics such as these represent maverick opportunities:

·         Cancer as a metabolic (not gene-based) disease, by biology professor Thomas Seyfried

·         Registry-based virtual trials to screen for therapies, by podiatrist Al Musella

·         Topical hydrogen peroxide for premalignant lesions, by oncology journalist Ron Piana

·         Physicist Gary Taubes and the case against sugar

·         My own fingernail surgery for seborrheic keratoses

·         Dr Bill Bestermann on coronary artery calcium scores way back in 2007

·         Remarkable results in well-performed n-of-1 clinical trials

·         Entrepreneur Marty Tenenbaum, PhD, as a long-term metastatic melanoma survivor and an outlier in a "failed" early clinical trial of immunotherapy

Individual clinical observations must be considered anecdotes and the results not generalized until they can be validated in some way. I gag at hearing the word "ivermectin," the poster-child drug of the physician who had "a case" and erroneously projected it to be generalizable by extrapolation bias.

Make no mistake, there are legions of physician-kooks out there; just read some of the physician comments on Medscape to find an abundance, even a plethora, of physicians who would "not recognize good science if it punched them in the mouth" (to plagiarize Mike Tyson).

Beware of the true loonies, the politics-over-science bunch, the word-of-mouth rumors made ubiquitous by some active users of social media; the folks who recognize that an untruth, or better yet a half-truth, no matter how egregious and provably false, if repeated often enough in enough places by enough sources for a long enough period of time will come to be known as "true" by some, even by many. Members of the healing professions are not immune to the gaslighting phenomenon.

That's my opinion. I'm Dr George Lundberg, at large at Medscape.