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Ehrenreich makes an excellent point that screenings are not the be all and end all of medicine, and that there is an easy way to over-rely on them. This was particularly interesting to me because as an epidemiologist I learned a lot about the limits of screening tests and the mathematical machinations behind them and their recommendations. The line you call out about averages is really interesting, and totally true! Global averages mean nothing when the rare event happens to you.

That being said...these first few chapters have felt more like an attack on health care as a whole instead of a critical examination of certain components. There have been a few instances where Ehrenreich describes a practice done back in the earlier days of medicine (or, even, last century) and uses that as evidence why doctors are terrible, without acknowledging a change in practice. Feels a little unfair.

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For me, the line from Ch.1 was, “A cynic might conclude that preventive medicine exists to transform people into raw material for a profit-hungry medical-industrial complex.” Like a whack up side the head is what that felt like. Even if you trend a bit cynical, that, I mean ...

But then in ch 2 she peels it back, saying the reverence expected of OBGYNs and child birth in the 50s was, in hindsight, atrocious. Which encourages the thought process of ‘always be questioning’ which is, you know, super science-ey.

Which she makes a pretty coherent argument for medicine taking praise from said science-itude ... but also being arrogant and looking down on those questioning types of attitudes. No matter where you sit, you can’t have it both ways.

This is great, and the cynicism, I hope, barrels forward into insurance and these large medical groups.

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Ehrenreich comes across to me, a retired pediatrician as a very bright, very educated person who overthinks. Her discussion is heavily footnoted, but only 3 out of 50 footnotes are to academic articles. Most are to articles in newspapers and magazines. She's building a case based on cherry-picking. Modern medicine deserves critique and it is far from perfect. It is, and needs to be conservative. The process we physicians follow is structured. This was done 100 years ago to eliminate practices that allowed physicians, often with substandard training, to advocate approaches that had no scientific basis. It seems she is advocating that medicine be practiced in a way that a physician can follow a muse without subjecting it to structure and verification. That way leads to more suffering, injury and death.

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While Ehrenreich has been pretty unflinching in her condemnation of certain medical practices so far, I don't expect to her to tip fully into denialism. She has mostly been going after practices that lack a true evidential backing and has been taking a relatively clear eyed approach to the cost-benefit analysis of some treatments that are not often subjected to it. She has not made much mention of practices that actually ARE evidence backed (e.g. antibiotics for bacterial infections and vaccines for viral infections); however I imagine she will not have much ill to say of them.

The discussion of some treatments being no better than a placebo and the comparison to other 'rituals' reminds me of an article I read some time ago. I'd have to go find it again to be sure I'm getting my details exactly right and to credit a source, but the gist of it was that a treatment that had a particularly nasty side effect was being combined with an odd and unique scent being in the air and giving the patient an oddly colored and flavored drink along with the actual treatment. After a few iterations, the treatment itself was stopped but the patient continued to have regular exposure to the drink and scent combination to elicit a placebo response that gave most of the beneficial parts of the original treatment without the danger of the side effects.

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There was a relevant article in the post last month: https://www.washingtonpost.com/health/how-one-medical-checkup-can-snowball-into-a-cascade-of-tests-causing-more-harm-than-good/2020/01/03/0c8024fc-20eb-11ea-bed5-880264cc91a9_story.html

There was another, which I can't find, that talked about how testing in the ER is actually making "doctoring" worse - where an ER doctor can clearly diagnose what is wrong with the patient, but must wait hours to treat, until all tests come back.

I'm only on chapter one so far, and I'm intrigued. She almost did it, but I hope we don't walk into a "being disabled is worse than being dead" trap. I feel like it's coming.

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I was reading Ch. 3 while waiting for my annual physical and wasn't sure whether that was karma or a scary omen. I ended up waiting an hour for my appointment and then listened to my doctor recite a long list of questions that I had just answered on a pad while waiting for the whole thing to start. So more data to add to her conclusions.

But the thing that got me was a few pages later when she comes down hard on the teaching of organic chemistry. Chemistry is about DNA and bonding, organic chemistry is about carbon and the fact that it has a valence of four and can produce so many intricate, complex molecules, like proteins and fats and sugars and immune-suppressors, etc. It is going to take me a while to forgive her for that.

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I'm also curious to see if she crosses the line from (healthy, I think) skepticism into denialism - though I don't think she's really approached that line yet. A lot of this is resonating with me and I'm wondering if it's due to my own history with doctors. Being young (and therefore invincible) I've never really felt the need to see a doctor and I've only just started going within the past 2 years. And as I discovered very recently, my doctor is actually a DO (vs. an MD) and I get the sense she'd be nodding along to a lot of what's been presented so far.

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Found the 1st three chapters exciting because I never knew if or how far the author was gonna go off the rails. I don't think she came across that great in these chapters. That said her comments "Once I realized I was old enough to die, I decided that I was old enough not to incur any more suffering, annoyance or boredom in the pursuit of a longer life" and "Being old enough to die is an achievement, not a defeat and the freedom it brings is worth celebrating" are both worth giving lots of thought to moving forward when it comes to health and wellness in our daily lives. As for Groopman, he sounds like those out of touch old school baseball types who rail against analytics being used in their sport.

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Ehrenreich's critique of medicine as often being eminence-based rather than evidence-based is pretty fair, I think: physicians expect to (and often do!) command such respect and humility, that it can be very difficult to question or criticize one. Many doctors offer disproven treatments because it's what they've always done, and patients simply accept the doctor's authority because, well, they're doctors, they're supposed to know best...

With that said, I think it's important to remember that the evidence is also often not great. The human body is in many respects poorly understood, and healthcare professionals of all stripes are often fumbling in the dark trying to make sense of a patient's symptoms. Mammograms are difficult to read and often inconclusive, blood pressure and heart rate measurements aren't very good indicators of longevity and long-term quality of life, and many other commonly-used indicators and tests aren't as conclusive as we might be led to think.

Overall I think more physicians should be willing to recommend the approach Ehrenreich espouses at the beginning: "Eat well... Exercise... because it feels good, [and] seek help for an urgent problem, but [not] looking for problems that remain undetectable." Peace of mind and simple living have a lot to recommend them!

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