Doubt, Parachutes, Power, and Dr. Google

Paul: [00:00:00] Humans that aren't about to die have this annoying tendency to get better, and so whenever you bled someone, you could always say that's the thing that made them better.

Howard: [00:00:10] What's amazing is the evolution of this skepticism, the power of it.

 Paul: [00:00:18] We're back again, to talk a little bit about changing ideas, about how we think about medicine. Hey Howard.

Howard: [00:00:24] Hi, Paul.

Paul: [00:00:27] So there's this idea of Dr. Google and how people's ideas about what they should pay attention to, and whenever they're told something by medicine, by medical science, by doctors that they should pay attention to.

But over the last hundred years, the whole idea of what we should believe and think about and trust in terms of medicine has really changed. And one of my favorite examples is back in the early days of medicine, that one of the best ways to stay healthy was to stay the hell away from doctors, obviously.

And because the outcomes weren't particularly good to the point that -- and I know we've chatted about this before -- but there's this great book called The Butchering Art, about the early days of anesthesia and Joseph Lister and what have you -- and that one of the main prerequisites for being a good orthopedic surgeon was being "built like bull": very big It's because you could hold somebody down and get their leg off in 30 seconds.

Howard: [00:01:18] You had to be able to cut fast.

Paul: [00:01:20] That's an extreme example, but it's, it really has changed. And for good reason, I mean, I mean, you can provide better examples than I can, but the, the ideas of what constitutes effective therapies back then are pretty remarkably different.

Howard: [00:01:36] Things have changed a lot.  we used to just bleed people. We bleed people, we bled people and cut off

Paul: [00:01:41] Yeah. Fast

Howard: [00:01:42] Wasn't much else to do -- extremely fast with whiskey.

Paul: [00:01:47] Like Gilligan's Island or something .Who knew if it was life was life was like this and the, and  the key is let's not tell, not necessarily what the case with limbs, but with quack therapies like bleeding people, humans that aren't about to die have this annoying tendency to get better.  And so you're never quite sure whenever you say bled someone, I can always say that's the thing that made them better, but I have no idea. And if I'm really irresponsible, I might say, I may not say that I have no idea. I might say that this bleeding thing was actually the thing that made you better. And   that's one of the reasons why some of these early quack therapies hung on as long as they did, right?

Howard: [00:02:22] To this very day, right? Why braces work? You had shoulder pain for three months, but all of a sudden you started taking,  ancient quid Lee tree root and it felt better. And of course it's the root, So it's, it's not only  Dr. Google, but it's really, who's looked at as an authority. You just need a, a loud Facebook page today, and you're gonna get an audience for your supposed treatment.

Paul: [00:02:54] So this has changed a lot over the last hundred years, and you could argue that in some ways we became a little too reverential about the proclamations of your favorite doctor dude, and usually a dude in a white coat, but there were some good reasons.

One of them was the arrival of some real....there's a euphemism that you often hear in the medical trial community about parachutes, but these are like therapies that you just can't argue. They work and they work so well, and there's, there's such an, a level of effectiveness that they're like parachutes.

We don't need to do any, we don't need to test them as you might think, because look, people are surviving. And in a sense, even though this is maybe not an example of something that never went through trials, but I've often argued that one of the reasons why medicine went from being thought of as dangerous dudes in white coats, who could hold you down and cut off your leg to, Oh, this is worth it, this is worth seeing, these people was the arrival of  antibiotics in particular penicillin with the rise of the germ theory of disease and all of a sudden doctors had something to do and something to do that really, really worked.

Howard: [00:04:00] Yeah, that was revolutionary. And if you think back, there are a few of those really amazing moments, in my own world, sir, John Charnley, who figured out that we could actually replace a hip, and that it would work. and to his credit. Yeah, no contemporary prosthesis or cementing technique, surpasses his results. Some of us up until very recently have seen his patients walk in the office. 29, 30 years later.

Paul: [00:04:34] Which is remarkable.

Howard: [00:04:35] really is

Paul: [00:04:36] no, that's just astonishing that you would see that. But that also goes to the core of the issue though, right? That we went through a period of really rapid change in a few core disciplines, like specifically our treatment of communicable diseases, specifically some therapies in terms of prosthetics and what have you.

And then there's this perception that there's a lot of new therapies and things that have come along over the last 20, 30, 40 years, but they're not that much better than, than what was before your example in the hip replacements is a great one. But you can also go to the oncology community where increasingly it seems as if very expensive new therapies, might have someone hang on for another six months longer, a year longer, and these are not parachutes anymore. These are things that undoubtedly people want and will pay for, and that allow them to have a better quality of life or whatever else. But it's not a life changing therapy like penicillin or an activity changing therapy, like, like a, like a hip replacement. And so I've often wondered if one of the reasons why we're changing again in terms of people's willingness to pay as close of attention to medicine as they once did is because of, in part that's changing. There's, there's this sense that we're not seeing as many parachutes as we once did. So, maybe medicine isn't as important to these people as it once was in, in that narrow sense.

And then the other argument that, people feel like they've got a lot more information out there and as they collect more information, They find medicine more equivocal than they thought it was. Oh, they think red wine is good for you. And then they think red one is bad for you and these kinds of things. So there's these two competing forces that are causing people to pull back and say, wait a minute. They don't actually know what they're talking about. Look how they're changing their mind about all these things. And there's nothing that's quite as blockbuster and important anymore as these other things. So what the heck, it can't hurt me to try something else.

Howard: [00:06:34] So it's true.  there, there are these radical discoveries that really change the landscape. And then we make incremental improvements on them. and we do so to maintain patents; we do so to maintain profits; we do so, as surgeons to look for procedures,.There are orthopedic companies that design products for procedures, where the procedures didn't take place previously. However, it turns out they probably not necessary to begin with. And the same thing happens in the drug world. Yet people become skeptics oftentimes for the wrong reasons. So statins, right. there are some who believe statins should be in the drinking water, and now there's a growing population of people who doubt their efficacy.  There's papers that show that no, you don't get limb pain. But I can't convince anyone of that anymore. And the diet people. Right. And so what if your LDL is 500 and your cholesterol is 750? I guarantee you, you won't die of heart disease. don't quote me. That's not my view.

Paul: [00:07:44] Yeah, certainly not

Howard: [00:07:45] what you can read online.

Paul: [00:07:47] Yeah.

Howard: [00:07:48] So it's, we're contending with so many different things because we've had only,  modest, incremental improvements in so many areas of medicine of late. and we've pushed some therapies too hard, too far, too fast. We've made the cost, especially in the United States, exorbitant. We've made it,  an easy way to go bankrupt. and as you mentioned with, with chemotherapy agents, there's so many that are on the market now where you extend the benefit for three to five months, yet it cost a hundred thousand dollars a

Paul: [00:08:22] Yeah, which is just staggering.

Howard: [00:08:25] So it’s, it's become quite challenging sometimes,  as I joke with patients in, in the office, again, I'll, this is a social media issue. But before a knee replacement patients only know people who did terribly after their knee replacement. However, when they're in the office, four weeks out and they still have some pain, they only know people who did great after knee replacement and they have no more pain.

Paul: [00:08:58] Right. Classic behavioral theory. Right. Then they've got a commitment now to finding a particular solution.

There's a great book by Naomi Oreskes  from, I don't know, 2010 or so called Merchants of Doubt, which is highly worth reading, but it's essentially about the successful campaign the tobacco industry ran for decades to convince people that there was more doubt than there was in the medical consensus with respect to the health effects of carcinogens in tobacco and tobacco cigarettes.

And the book is a really nice look-- not nice, it's actually awful-- but it's a, it's a well done look at this very effective industry in creating doubt, because doubt is good for business. And I sometimes wonder if one of the reasons why doubt is good for business in, in, in medicine, in lots of other ways.

Like for example, in the nutrition industry, if I can't unequivocally demonstrate that you're completely quack. therapy, you sell through a webpage or Facebook or whatever else is bad for you. Well, then I guess it must be good for you and I can, sew that doubt and that's good for my bottom line.

Howard: [00:10:01] It's true.

Paul: [00:10:02] And so this there's an, there's an industry endowed creation in some ways, social media is just an accelerant for this write up. And people find each other and reinforce each other's views of these things. And because they discover each other online and build these communities, the doubt industry gets a, a tailwind that it wouldn't otherwise get.

And, and I think that, that in some ways it takes us up to today, right? Because the, the, this is happening again today where we're seeing probably some of the highest levels of, charitably, skepticism, and uncharitably, the rejection of the medical consensus and medical opinion that I've, I certainly ever seen.

I mean, all of a sudden, I, I joke, but we've got, everyone's turned into  Scooby doo epidemiologists all and with their own notions of efficacy of particular treatments and, and, and, and ideas in the context of the current coronavirus and I'm assuming you see exactly the same thing, but I guess I'll ground it and say, ah, well, how do you deal with that?

I've used it. You know what the consensus is. And yet you have people show up in your office. Who've got very well I'm sure entrenched and deeply held ideas about what's effective than what's not. I mean, that's just a crazy position to find yourself in.

Howard: [00:11:19] What's amazing is the evolution of this skepticism / denialist. the, the power of it and what, or depth and breadth of it .When it first, when this first started,and we were working through March and April, especially in New York. it was brutal. Yet we come home and the skies are sunny and it's getting nice out and everyone's walking around and they're looking at me, they're like, this isn't real.

Right. I'm like, Let's let's go 15 minutes and I'll show you how real it is, but those are isolated cases., and usually with a little bit of education, maybe I couldn't flip them completely, but at least they understood, they stayed home. They isolated, et cetera. But now fast forward to August. I have colleagues who don't believe that this is real:  99 .3% of people live. Why should I care?  They walk into my office without a mask on I'm like, you can step back.

Paul: [00:12:29] Oye.

Howard: [00:12:31] Ah, it's so it's really,  the, the, the breadth of this denialist movement and skepticism movement is, has really broadened out,

Paul: [00:12:45] To bridge back to the Dr. Google conversation, is this an  artifact of people feeling like I can take more control over my life and I've Googled a bunch of stuff, and I've discovered that, as you say, the case fatality rate is relatively low across a broad population ,and let's not get into cohorts and what have you, but nevertheless, that's the, that's the supposition people walk with. And so they get armed with that data, and in they come and they feel like they're fully loaded and ready to reject what they hear. Is that what it is, that that's where they're collecting this stuff?

Howard: [00:13:18] I don't, I don't think it's data driven. I think it goes back to what we talk about all the time, how we're normalizing these incredible situations, how humans are capable of normalizing terrible things if it arrives  slowly over time, and it's a new normal.

Paul: [00:13:40] Yeah, I joke all the time that we closed California on a quarter the number of daily cases that we opened it on. What the heck, this is crazy. But that's a classic example of that had become perfectly normal. It was terrifying. And then it went on for months and then it became normal.

And that became something that rather than being nervous about or afraid of you just say, Oh, well, I don't know anyone that's dead. So or died of this, and so on I go, which is, which is to your point, right? It's a remarkable statement, about charitably human resiliency and uncharitably, our ability to stand on a precipice and say, This is fine.

Howard: [00:14:17] So I think that makes it very challenging for science to correct those beliefs. Cause this is now your new normal, 190,000 people dead, the equivalent of five airplanes falling from the sky every day. But so that's their filter when they're interpreting new data or what they read or here. Not to mention the fact that depending on the network or source of your data or input, you're going to hear completely different theories

Paul: [00:14:51] Yeah. So is there anything that you've found that works. There's an awful lot of interesting research on the topic of how to have there's even a book called how to have difficult conversations. And it's in particular about the idea of how to  talk to people who hold diametrically opposed opinions. And not only that, who've become more entrenched the more they feel like those opposed positions are being, argued against. That that just puts them even deeper into their private fort.  In the research, they argue that presenting data rarely works because they always have other data that they think, or they, or they think your data is somehow flawed because they were told it was flawed or something else.

Howard: [00:15:33] You're absolutely correct. Don't tend to use data. I tend to use stories, much like in how I describe everything on my website, et cetera. And that, or people who need treatments, who need something that is going to require their believing that they need to wear a mask and have a COVID test to enter the grounds at the hospital. They will all of a sudden, be quite compliant with our desire for them to wear a mask. But I'll be honest, I don't know if I've convinced anyone. I really don't. and I certainly see more skeptics now than I ever have. It seems to, becoming, it's almost an epidemic, right, of skepticism.

Paul: [00:16:21] It is. I had retina surgery a few years ago and did a bunch of research and so on, but I didn't walk in and I,  I like to think I have a pretty good handle on things that people are about to carve me up about. But I didn't go in and say,  this vitrectomy, I want to do it with 14 gauge rather than 16 gauge.

I don't, I didn't go in and try to start trying to explain to people or why I thought of a,  a vitrectomy procedure was a bad idea and they should have done a scleral buckle instead. I mean, I'm, I have to imagine I'm in the majority here. I just don't have, I know enough to know that I have no idea what I'm talking about on that stuff and have no business expressing a strong opinion.

And so is this unique to COVID and to this particular topic, or do you have people who walk in with equally strong opinions about say, I don't know, metal on metal hip implants or something else where they have just an unmovable, unshakable opinions about other things.

Howard: [00:17:18] I absolutely have had people come in with an ACL tear, they want me to do the surgery and they say, I want a double stranded hamstring graft. I wanted, what. Yeah.  They get very specific or,  the literature shows that you don't need a brace after an ACL reconstruction. And I hate them because I'm trying to convince them

Paul: [00:17:44] Yeah, you want them

Howard: [00:17:45] They, the brace will tell them that they're fragile, but the brace will give the average practice, another $500 boost. But I thought it's impossible to convince them that they don't need a brace because their friends had a brace and everyone has a brace.

So anyway, it is becoming a little more challenging in that respect. I haven't seen much blow back on procedures, other than some knee replacements where the advertising, about robots, and how, and how wonderful it's going to be, has come to

Paul: [00:18:21] But that's not a rejection. That's not a rejection of the procedure. It's just a, Hey, I have a shinier way of doing it though, right?

Howard: [00:18:27] It's a rejection of the physician who doesn't use it or tries to explain that the literature shows it's not necessary in the vast majority of cases and that it does have a place, but it's not necessary in them. And they will go seek out and find someone, who

Paul: [00:18:44] Yeah. I just think that, and maybe stories are the path.  If you read the research on this topic of having difficult conversations with people, that stories are one way that it demonstrates that I'm not going to try and overwhelm you with data; I'm not going to throw 10 studies at you. I'm not going to try and force you to present whatever it is that you've got that's your, your prior on this. And then I'm going to try and refute it and make you look bad. I'm just going to tell you about people I know who were in your situation and here's what happened. Can be one of the more effective ways of dealing with this  resistance and very much echoing what you were saying.

Howard: [00:19:19] That's absolutely my approach. and that's my approach in COVID. And that's my approach to people who have gotten to the point of analysis paralysis. If they're trying to decide if they want to have a joint replacement, et cetera,

Paul: [00:19:35] So let's go back to where we started on this. Now that people are fairly aggressively and outside of the realm of coronavirus,  using Dr. Google for their own diagnoses, has it in general been helpful to you in your practice? I show up, I've got a knee injury. I tell you, I think it's, an ACL tear. I think it's a this.;I think it's a that. And I'm doing self-diagnosis. Is it good, bad, neutral, mostly just a bunch of worried well, showing up? I mean, in general, has it, has it helped liberate give another set of eyes looking at problems for you or ...? I don't even know because I'm not certain anymore. I used to be very optimistic about this stuff and I'm much more on the fence than I was before.

Howard: [00:20:15] So,  it depends on, on what phase of our care journey we're in. So if it's your first visit to me and you just injured yourself, you might not be right. Right. Everyone who twisted name has a swollen knee thinks they tore their ACL.

Paul: [00:20:31] right.

Howard: [00:20:31] Um, and anyone who hears that snap knows they tore their Achilles, but other than that, they're often wrong.

so it doesn't necessarily help at the first encounter. And as most good physicians will tell you, it's the history that matters. So I'm listening to you. I want to hear your words, what happened, what it feels like, where it hurts when it hurts, et cetera. And that will really help me arrive at the diagnosis.

Now, if we're contemplating a reconstruction or a repair or a complex procedure, I'm going to give you a number of key words. We're going to have a long discussion, but now your eyes are a little glazed over and you're starting to get a little worried and nervous and,  from our experience and literature that you're not going to remember anything. So it's very useful, now, if I send you home, come back in a week or two, we have another discussion. Now you've had time to read about something specific.

Paul: [00:21:29] Hm. That's interesting. So I'll tell you, and this is probably just speaks to my star Trek Spock-ian instincts, I used to go in and talk to somebody. I'd done some stupid thing and, and, and, I would go in and the first thing they do is start telling me they want me to get the case history and I was, I would get really pissy about  it.

And the reason is because I don't want to tell you a story. Here's what hurts. Here's here's what happened in three bullets. Let's move on from this. I actually reached a point for a while where I decided it was patronizing, where it was some  crazy, Let's just do this because doctors always do this and it makes you feel like a small child telling stories.

And I got out of that mode, but it was interesting. And I've talked to a few friends of mine about it also fellow bad athletes. And it was interesting how common that was. It was like none of no, no, no, no. I'm not going through the whole Storytime thing. This is what happened. Here's three bullets ... I'll just send you a PowerPoint slide later. Let's get on with this.

Howard: [00:22:27] So,  it's interesting.  we had this shutdown, we went, to online, virtual consultations. Many orthopedists were of the mindset,this couldn't possibly work, right? This has to be an in-person visit. But as I said, the history is often what gives it away. So when I look back now on people who I saw virtually during the pandemic, made the diagnosis or presumed diagnosis now have carried through with that. So now I have validation, that,  at least 85 to 90% of the time that's initial suspicion was accurate, proven on, radiographs or MRIs and subsequent surgical intervention or not. So it's very interesting because up until this point in my career, I didn't have a good way to validate that.

Paul: [00:23:21] So that's really interesting. That's  a, a medical version of the classic Turing test from artificial intelligence, right. This idea that if I have some, some supposedly intelligent system and I put it in a separate room and I can have a conversation with it and ask it questions and not know whether it's a, an AI algorithm or a human than in some sense that passes for being intelligent. And this, this is a similar experiment where if you abstract away, I don't get to grab your knee and manipulate it. I don't, I, I don't get to do all the usual tactile things, not because they're bad ideas, but because I can now take it down to its absolute base component, which is tell me what happened and how it happened.

Howard: [00:24:01] Right. How it happened, what happened, what you felt when it hurts, what you do to make it feel better. Are you awake at night? You're not awake at night, et cetera. That all is incredibly powerful in terms of making a diagnosis.

Paul: [00:24:18] Years ago I had one of my many crashes on my bike and, it was, I had hurt the patella tendon. And I, weeks later, it was still red. And I thought that's crazy. Why would the skin be red there? Yeah, I was in talking to my guy about something else, and, he said, What’s going on here, right? I mean, you're, you've convinced yourself that there's a problem here. And so what you're doing is you're rubbing it all the time. There's nothing wrong. Just, you're just checking all the time, see if there's something wrong, which is making the skin inflamed. And so you now you've convinced yourself there's something wrong. I'm like, Oh, that makes a ton of sense. And, but that thing would never show up. I mean, for a little while, he was like, ah, that's interesting. I wonder why would be red there? And he's like, Dude, leave it alone.

Howard: [00:25:02] That's super funny. Every now and then you do get those people who come in and say, it hurts you when I touch, and they don't want you can't tell, tell them, just stop touching it.

Paul: [00:25:13] Stop touching that all the time and you'll be fine. So, yeah, I, I've been there, touched that.  is the thing. Cause so as I look looking forward and maybe I think coronavirus is such a unique Dr. Google and a lot of other things going on, including politics here, obviously. example, but are you in the camp that this further democratization of information and data is making medicine easier?

Or is it that, and this is closer to where I come down now, is that people are becoming more aware of the uncertainty, the equivocality of an awful lot of medicine, that findings change on a constant basis. And I, I actually got to the a point where I tell people you'd be better off to pay less attention to medical research because it's a slow consensus building process that can take years. And you may have to wait until there's 20 years from now, and there's a meta-analysis of all the stuff's been done with over, over the prior 20 years before it's worth saying, I think it's kinda like this, right.

Howard: [00:26:10] Right.  there, there are so many things we don't have, the perfect answer to, I think the democratization of information, has been, overall I'll say net positive. We still have, some demographics who just want to hear what the doctor has to say. Right.  and they're gonna, and then they're gonna listen to you and do what you ask them to, and then you have a group who will be empowered by the information, then use it to their advantage. And then you're going to have a group, oftentimes younger, who are they going to fight you with it.  You're going to give them, how you've incorporated the data into your practice and your techniques or theories. And they're going to come back at you, sometimes, with an attitude that they may know just as much as you about this topic.

Paul: [00:27:05] Yeah.

Howard: [00:27:06] So I'm, I'm, I'm cautiously optimistic. but I'm skeptical.

Paul: [00:27:14] Yeah. Yeah. I wish I didn't have to say it, but that's closer where I've ended up on all of this. And I want to believe that there's an episode here where people are getting their training wheels in terms of learning how to think about a fast changing domain, coronavirus, and at the same time learning how to think about research and other topics in medicine that are, that were opinions change. But I, I don't know if humans are very well equipped to deal with either.

Howard: [00:27:39] Well, I think,  I've had this discussion recently a lot. Ah, we don't know how to interpret data. and probabilities, right? We don't understand statistics and yet our kids get no education. We got virtually

Paul: [00:27:54] Oh yeah. Right.

Howard: [00:27:54] on that. I think that has to change because otherwise you don't know how to vet a source. You don't know how to read a paper, interpret it. you don't know what an observational study is. Meta-analysis. Or randomized control trial. And what the difference is nor do you care right now. You just read it from Jack on Facebook, who said it in all caps, so it has to be true.

Paul: [00:28:17] Everything in all caps is true. So. That's what I'm told anyways. Well, great. Well, thanks, Howard. This has been super.

Howard: [00:28:23] It was a lot of fun, Paul. Thanks.