History Matters Friday, January 27, 2023
1910 Again
Abraham Flexnor was not a physician, but he dramatically transformed the practice of medicine in the US. He was an educator who demanded that medical education conform strictly to the scientific method, and he published his findings in the Flexnor Report in 1910. Almost half of medical schools closed within a few years of that report, and the remaining ones changed completely. The new professionalization of American medicine was now restructured on a scientific foundation of reason.
What was the condition of American medicine prior to 1910 that necessitated such a cataclysmic change? Medical education and “doctors” used the field primarily as a financial enterprise without regard to valid scientific principles. “Proof” was provided by testimonials of patients (like today’s commercials) who had been miraculously cured by “doctors” claiming their personal experience and “secrets”. This approach in its worst form was epitomized by the “medicine show” selling “snake oil”. What were these questionable therapies used to dupe the American public for personal financial gain? Chiropractic therapy, massage therapy, natural herbal therapy, homeopathy, electromagnetic therapy, and probiotics, to name a few. After 1910, the scientific legitimacy of American medicine required the expunging of these unproven and even harmful therapies. This is well documented in the text Nature Cures: The History of Alternative Medicine in America.
The 1960’s saw a reincarnation of these alternative medicines back into mainstream culture. The scientific medical community countered in the late 1980’s and early 1990’s with “evidenced-based medicine”. The NIH, under pressure from some “pro-supplement” congressmen, concurrently established the office of alternative medicine to see if any of these popular supplements could be scientifically validated. Almost none of these have shown even a little benefit, including an extensive database of vitamin and mineral supplements. Well-respected scientific medical journals regularly report on their lack of value and potential dangers. Yet, chiropractic, massage, acupuncture, homeopathy, natural supplements, and probiotics have become a massive financial industry more popular than they were in the late 1800’s.
“Look at the past and you’ll lose an eye. Forget the past and you’ll go blind.”, Aleksandr Solzhenitsyn wrote in The Gulag Archipelago, recounting the Russian proverb. Today, many in the American medical profession are still placing profit before professionalism; and business strategy ahead of scientific integrity. It may not be entirely pernicious. It is said, “Do not attribute malice to that which can be adequately explained by incompetence” (Hanlon’s razor). Many “providers” have adopted vitamins, minerals, herbs, and now marijuana products along with the aforementioned “alternative therapies” into some aspects of their practices to satisfy the cultural and personal beliefs of patients and our culture. This was led by cults of medical personalities such as Dr. Oz, Andrew Weil, and other popular TV show personalities, many of which have no medical training who have become multi-million dollar gurus for a medical congregation that worships with a credit card thru a flat-screen.
Others are using their professional licenses and cultural status to become expensive beauticians, offering lasers, creams, and potions for ailments like “cellulite”, crow’s feet, varicose veins, love handles, sagging buttocks and small breasts. No serious person would consider these illness requiring a physician (except in the more extreme examples of disfigurement from trauma or cancer). But we have all drunk the capitalistic Kool-aid that says “If people are willing to pay for it, why not have a medical doctor practice upscale cosmetology?” We should be reminded that capitalism does not believe in a sacred oath to “first, do no harm.” Many physicians are practicing alternative medicine and boutique cosmetology on the side simply to increase their profits, seemingly without ethical conflicts.
Mainstream physicians have their own versions of making extra money by “making patients happy.” Physicians, now called “providers” are seeing patients (or having their mid-levels see patients) who are now called “health care consumers”—and they are given completely unnecessary, expensive, and often dangerous medicine for little other reason than the provider believes the patient wants it and it will make them happy (and may prevent them from being sued). While the medicine is safer and more scientifically valid compared to “alternative medicine”, the method of “sale over science”, is similar. Perhaps, some of this is from ignorance. There may be some undertrained “providers” who do not know that antibiotics are not recommended for a routine “sinus infection”. But some just lack courage to explain to a patient with bad low back pain that an MRI should not be done at this point, and can be harmful.
My generation of physicians have done great harm by acquiescing to patient preference over professional expertise: prescribing Zithromax for all things respiratory, Prilosec for all things gastrointestinal, Gabapentin for all things painful, anti-depressants for all things sad and frightening, and steroids and statins for just all things. These mostly valueless therapies are the proverbial tip of the iceberg that don't even take into account medical devices and unnecessary surgeries. It is not that these therapies are completely without scientific merit, but they essentially have no value, especially when applied to a much broader population than the drug/device was studied. When one compares the marginal magnitude of benefit against the price and potential magnitude of harm—it becomes valueless.
One more layer of this professional denigration dates back to the 1800’s. Patient-centered care is being re-defined and re-imbursed according to patient-defined experience. Patient satisfaction scores are updated versions of testimonials. Quality is not a scientific outcome but has become a metric of reimbursement based upon non-scientific grades. “Make me happy quickly.” is now what makes the money, regardless of the science. The consumer’s personal experience, not the fair allocation of proper science by a trained professional, determines the stamp of “top quality” on a website or billboard. The hands of philanthropy now wear the gloves of narcissistic consumerism.
A business-driven wagon has overtaken the American medical profession. Whether the medicine show is alternative medicine (now called “functional medicine”), medicalized cosmetology, an alliance or even just an acquiescence with what big Pharma promotes, or gaming CMS metrics for customer satisfaction; we are so strangely similar to that pre-1910 behavior. We need another Flexnor Report. Until then, the only power real physicians have is our professional duty to say “First, you must prove it.”And if it cannot be consistently and repeatedly proven, we must have the moral courage to say “This is not legitimate medicine.” We can only hope that physicians and patients will not lose the ability to see the difference between a professional ethos and a medicine show.
Written by Dr. Mark Mosley