Thread by @drjohnm

Twitter thread coming on what @adamcifu @VPrasadMDMPH @AndrewFoy82 and I think is the BEST approach to pt care. This is ...
The Case for Being a Medical Conservative.
amjmed.com/article/S0002-…
Thanks to the @amjmed for publishing this.

This started when @AndrewFoy82 wrote me a rough sketch of the medical conservative's approach after a journalist criticized those of us who are too skeptical of new therapies.

We begin by stating that the #medicalconservative is not a hater, non-believer or nihilist.

We then explain that using the term #medicalconservative does not imply conservative in a political sense. But .. William F Buckley Jr's definition of conservatisms aligns well with our approach to Medicine.

The principles of the #MedicalConservative are
1/ we appreciate the many gains made in recent years. We laud, for instance, the progress in the care of patients with AIDS and many forms of cancer. We also recognize gains in public health, such as reduction of public smoking.

2/ As we laud progress, we also focus on the VALUE of new interventions. The #medicalconservative leans heavily on the utility function pictured below Foy and I wrote about that here sciencedirect.com/science/articl…

3/ The #medicalconservative adopts new therapies --especially expensive or invasive ones--when the benefit is clear and demonstrated w/ evidence. @thebmj clinical evidence team has shown that only 11% of therapies have such clear evidence of benefit.

4/ The #MedicalConservative also knows that evidence can be tricky. Even when a p-value is significant or a relative risk reduction large, the absolute benefits may be small. We believe this information must be discussed w patients b/c people feel differently about tradeoffs.

5/ The desire for better decision quality drives the #medicalconservative to worry a lot about the commercialization of Medicine. Here we despise the widespread use of hype to oversell benefits and minimize risks of interventions.

6/ But please don't confuse our concern about commercialization with an opposition to private enterprise, capitalism, the accumulation of wealth, and more generally, against medical progress for the sake of it.

6b/ What we oppose is medical progress and its accumulation of wealth when it occurs UNDER THE PRETEXT of "science" without meaningful improvement in patient outcomes.

7/ Ah... And to determine true medical progress, the #medicalconservative embraces robust critical appraisal -- which is not personal, even though it often puts us at odds with content experts.

8/ At the core of the tension b/w content experts and those who appraise the evidence is that experts are often enthusiasts for their procedure or med, whereas the #medicalconservative is interested only in knowing whether there is genuine benefit for patients.

8a/ Remember here that TRUE progress and benefit easily withstands critical appraisal
Antibiotics for bacterial infections
CRT
PCI for STEMI
Repair of hip fractures

9/ You may be surprised that the #medicalconservative sees benefits from the confluences of interests of industry and clinicians. But...crucially these DUALITIES of interest must be ALWAYS be considered in determining the quality of the evidence.

9b/ For instance @eturnermd1 has shown the selective publishing of positive studies can skew the appearance of benefit. #EyesOpen always!
nejm.org/doi/full/10.10…

10/ In the end, #medicalconservative understands and embraces how little clinicians affect outcomes. This is ok. It's not nihilistic. It is, in fact, protection against our greatest foe -- hubris.

So there you have it. I hope you join us in being a #medicalconservative.
We think is is the best approach to patient care.