The Future of Medicine

I recently read Virginia Postrel's wonderful and entertaining The Future and It's Enemies. For those who haven't had the chance to read it, the book examines the struggle between those who support dynamic institutions and those, namely reactionaries and technocrats, who support stasis - reactionaries for its own sake and technocrats to preserve their own influence. The thesis jumped up and perched itself upon the shoulders of Hayekian respect for local and tacit knowledge. It is a celebration of individualism and the human spirit.

Postrel strength as a writer is her entertaining style of stringing together examples from all walks and scopes of life, a la Malcolm Gladwell. How interesting, then, that she had almost nothing to say about medicine anywhere throughout the book. This is not a criticism mind you - I just couldn't help thinking the whole time I was reading it that she could have re-written the whole thing using examples only from medicine. Is there a realm not so riddled with technocratic thinking, centralized decision-making, and disrespect of individual knowledge and experimentation? Surely the list is short. I would like to discuss many of the hot topics in medicine - DTC advertising, electronic medical records, decisions regarding prescription drugs, health care finance - through this lens crafted by Postrel herself: dynamism vs. stasis.

So lets revisit the debate on over-the-counter medications. Here's how it works today. A prescription drug is submitted to the FDA for permission to sell without a note from your doctor. If this political body deems the evidence to point toward this being a good thing (however defined), then any willing buyer can walk into a drug store and buy it. If the committee deems it "too dangerous" to allow your average adult to have such liberty, then it will be required for a government-licensed agent to give written permission for a willing buyer to complete the previous transaction. On top of all this, some drugs are classified so that the licensed government agents will be monitored by another agency based on their prescription patterns.

I wrote at the time that this regime was based on a bunch of assumptions and that supporters of OTC restriction should bring these assumptions out from hiding. Chris Rangel tried to use this against me:

...[Y]our straw man argument reduces the prescription medication system to that of a restriction of access to health care that leads to harm. However, you never explain nor give specific reasons as to why you believe this is so. This is not something that you can assume because as Trent clearly states, you know what happens when you ass-u-me.

He was answering a commenter that was objecting to the FDA's rejection to mevacor's OTC application. Rangel's point seem to be that one can't assume either way whether such restriction is good or bad - study must be undertaken to examine the issue. Apparently there is a study that indicates that patients don't properly understand the uses and effects of statins.

That study notwithstanding, assumption of facts was not the type of assumption I was referring to. So let me explicitly outline what I was referring to: the current regime assumes that either patients can't be trusted to intelligently purchase medications and treat themselves, and/or that a group of experts can do better. It assumes there is an objective way to measure this and examines it in a way acceptable to everyone's standard of risk. It assumes there is one and only one standard of risk. It assumes that even the experts have to be looked after by super-experts, and I suppose that it assumes these super-experts are the end of the line needing no oversight. And most importantly, in today's world it assumes that the burden of proof is on the individual to prove that these assumptions are false.

It's easy to point to a study that says patients don't presently understand the risks and benefits of statins. After 60+ years in a regime where patients have no incentive to learn these things, and every incentive to submit to experts, what would you expect? Rational ignorance is alive and well. Of course, there is no way short of guessing what caused this turn of events - was it a tendency of the general public not to care about those things which effect their personal health, or was it because of the legal regime? I have a good guess; what's yours?

No, it's illegitimate to look at the present state in an ahistorical vacuum. Much better to think what would have happened in a parallel universe with every other variable holding constant except the legal regime for prescription drugs (however impossible that would be). Would patients be better off? I don't know, but I'd like to find out. What if patients became experts at treating dyslipidemias - it could free up physicians to spend their days treating things not so easily taken care of. All physicians complain about the little time they have to spend with their patients. Maybe if they didn't have to waste time with things patients could conceivably learn to treat themselves - they'd have more time to spend with their difficult diagnoses, their cancer patients, etc.

Or maybe they wouldn't. Maybe the patients just wouldn't trust themsleves to things better left to experts. I don't know what people would prefer given enough time under such a regime. But I do know what they are capable of. During my recent travels I found myself sitting next to two salesmen in an airport restaurant and I couldn't help overhearing their conversation. One was being treated for sleep apnea, and the second was experiencing some of the classic symptoms. The first proceeded to teach the second about the various treatment options for OSA, the pros and the cons. His presentation was flawless - the advice was probably better than I could give, and I'm about to graduate from medical school, and OSA is a common ailment. If a random patient can understand the pathophysiology and treatment options for a OSA, why could he not do the same for high cholesterol?

I can hear the easy objections: what about the risk of serious side-effects, the monitoring liver enzymes, the complication of other diseases? These are important questions, but beside the point. If prescription regulations had never been in place, how would chronic disease management be different today? Would clinical labs be walk-in self-service stations? Would there be classes on common disease management in high schools and colleges? How would medicine be different today if The One Best Way were not commanded from above? How would it be the same? And what characteristics would determine what falls in which category?

I don't know the answers to these questions, but I do know we have been denied the chance to answer them by people who are wedded to ideas that come only from central authority of expert bureaucracy backed by the force of law. The questions lie outside the box that many leaders of medicine today are stuck in. There is no greater enemy to innovation in service and management in medicine than this bias.

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