For a more conservative medicine

@varelalaf

Last week I discussed the influence of machine learning on clinical practice, a dynamic loaded with chiaroscuro and, for this reason, I think it is worth echoing today the manifesto "The case for being a medical conservative" written by four doctors: John Mandrola (cardiologist), Adam Cifu (internist), Vinay Prasad (oncologist -haematologist) and Andrew Foy (cardiologist). The authors clarify that their manifesto has nothing to do with politics, but that, given the dazzle of technology and the pressure of consumerism; they are forced to embrace conservatism, a way of saying enough when nobody is willing to do it.

"Conservative doctors are not nihilists," they affirm. We value the scientific progress that has brought so many benefits to humanity, such as the fact of having transformed AIDS, and many forms of cancer, into more or less manageable chronic diseases, or having discovered the influence of tobacco and fatty foods on many cardiovascular diseases."

To better understand their position, the authors have chosen the classic graph of the economics of health that relates expenses to results.

If you pay a little attention to the graph, you will notice that many of the actions of modern medicine, such as screening for prostate cancer or the use of resonances for low back pain, is positioned on the flat part of the curve, that is, money lost, while cancer and chronic disease treatments would be in the mid-range. But the most interesting thing about the graph is that it illustrates that there are health investments, such as vaccinations, drinking water and public sanitation that have clearly demonstrated their high health and social performance.

Only 11% of treatments are actually effective

"Conservative medicine -continues the manifesto- recognizes new treatments only when the benefits are clear and the evidence provided is consistent and without suspicion of bias." But regrettably, this is rare. As an example, a review of three thousand treatments used in the National Health Service concludes that only 11% of them are valuable, while 50% of their real effectiveness is unknown.

Evidence versus experience

Clinicians are often enthusiastic about a mastering technique or treatment, of which they become adept and fervent advocates, and they often struggle to admit the work of evaluators in seeking the methodological robustness of studies that support the effectiveness of such actions. If it is the case that the benefit of clinical action is valid, such as antibiotics for bacterial infections, interventional angioplasties for acute myocardial infarctions or arthroplasties for femur fractures, then the mismatches disappear because evidence and experience will go hand in hand. Regrettably, as the NHS figures say, this overlap is rare, especially when it comes to evaluating the introduction of expensive therapies or disruptive technologies.

The conservative medicine movement believes in innovation, but calls for more rigour in clinical practice and more independence of professional judgement in the face of technological pride, and therefore calls, for the sake of a more humane medicine, to learn to live together with degrees of uncertainty.


Jordi Varela
Editor