Evidence Based Medicine, Mindsets, and The Donald Trump Promise

Here is an excerpt from an editorial in the Lancet this week.  It is an unusual admission from corporate media that it is our mindsets that determine healthcare practice and influence behaviour. And it is a tacit invitation to ask why our mindsets can be so dominated by  Donald Trump’s Promise. Is this ‘mindset’ the same as consciousness? If so, and it varies, what of the unconscious?

Evidence-based medicine (EBM) has been a powerful influence on clinical practice. But one book should make even the most ardent EBM advocates pause. That book is How Doctors Think, by Jerome Groopman (Houghton Mifflin, 2007). Groopman, an oncologist, drew on the work of Daniel Kahneman and Amos Tversky (before both were made famous by Kahneman’s own bestseller, Thinking, Fast and Slow). Groopman used his clinical experience to show how easy it was, despite the very best evidence, to be misled by multiple personal biases—most notably the bias of “availability”. Clinicians will often make diagnoses or decisions based on the mental availability of particular pieces of knowledge, including what might be considered as “best evidence”. Groopman punctures easy assumptions that high-quality evidence alone can improve the quality of medical care. Unless doctors are aware of their own informational biases, the possibility of false reliance on “evidence” is not only conceivable, but likely. How Doctors Think should be required reading before any prospective physician is allowed to lay a hand on a patient. Last week, at the annual Rambam Summit in Haifa, Israel, Groopman, together with Pamela Hartzband, deepened the scepticism with which we should approach EBM. …

…  Doctors are educated to believe in their scientific appreciation of evidence. But we may not have educated ourselves to appreciate the mindsets that interpose themselves between evidence and our interpretations of that evidence. Based on extensive interviews with physician colleagues, Groopman and Hartzband identified three dimensions of the medical mindset that any doctor (and patient) should be self-consciously aware of as they make clinical decisions. The three mindsets each have two extremes—maximalist/minimalist, naturalist/technologist, believer/doubter. Ask yourself. Are you the kind of doctor who wants to go as far as you can with the latest technology and who believes in the power of that technology to make a difference to the patient? Or are you the type of doctor who thinks that less is more and who is inherently sceptical about claims for new discoveries? Groopman readily admitted to being a maximalist-believer, which probably influenced his decision in the 1970s to choose haematology as a career when bone-marrow transplantation became popular. Hartzband, by contrast, is a self-confessed minimalist-doubter. Their point was that most clinical decisions lie in a grey zone—there is no single right answer for everyone. The important step is less to adhere to some abstract notion of EBM, but rather to think hard about what kind of medical mindset you have. Whether you are a maximalist-believer or a minimalist-doubter will have a larger effect on your clinical decisions than the result of any single systematic review or randomised trial. We see these mindsets at play all the time in today’s scientific, evidence-informed medicine. There have been at least four US expert committees ruling on the safety and efficacy of screening mammography—with four different sets of recommendations. There have been three expert committees reviewing the evidence on screening for prostate cancer using PSA—with three different conclusions. So much for science. So much for evidence. What matters more are the mindsets of those “experts” reviewing the scientific evidence.

Here is The Donald Trump Promise, according to Groopman and Hartzband. Modern scientific medicine promises the right doctor prescribing the right treatment and the right procedure for the right outcome. It’s just impossible.

In very brief format: my argument is that

The formation of our mindsets is achieved through language. Language is made meaningful, and turned into speech, through master signifiers.  These organically bind the meaning of language to our bodies.  These master signifiers or objets-à, provide objects of desire for the fantasy of immortality and sustain the authority of capitalist regulators to continue to exploit the many for the few. 

So, to take this more slowly:  Hortons’ editorial is a timely  invitation to  reconsider the mechanisms by which ideology forms our values and prompts us to ask ‘How is our mindset determined?”

Three of the  extremes of the dimensions of the mindset conceptualized by Groopman are consistent with the three elements that make up the fundamental  structure of the ideology we call capitalism. These are, a) the faith in b) technological innovation to create c) surplus value.  And these are paraphrased by Groopman under the dimensions of:  belief, technology and maximalist.

However, instead of being spread out evenly along these dimensions the capitalist system tends to polarise these mindsets in one direction only. And, therefore, individuals’ values and mindsets aren’t each just spread along the axis evenly, but are instead also polarised. In capitalism the polarity is driven by its logic: the belief in technology to take life ‘to the max’.   This is a description of how the structure forms our mindset, where it is not only surplus profit that motivates but, as we know, also the drive to surplus-life.  It is this structure  that dominates the mindsets of the experts/industrialists/politicians controlling what is produced by science, and what is marketed, and consumed.

As we know, the clinical decision at patient level is increasingly dominated by, so-called Evidence Based guidelines which, as a rule, mostly command compliance and defensive medicine.    Therefore, individual clinicians or patients, when compared to the guideline producers, can only have limited impact on these decisions .  So, therefore, it makes sense to focus more attention on the marketisation of innovation, the production of guidelines and the intensification of e.g. prevention and screening programmes. At the same time we could be more sceptical at individual level, but in order to fend off and  resist demonisation and medico-legal sanctions this would require some solidarity and collective action.

A form of resistance, and its mission, might ask for more ‘sceptical healthcare’ characterised by:  a) less belief in expert appraisals (much more rigorous standards of proof of e.g. lack of harm as well as benefit, b) less reliance/emphasis on innovation (whilst not denying its potential), and c) less emphasis on maximalist goals for life (especially longevity) and more emphasis on life-lived (today) and, d) increased ambiguity about compliance with guidelines.  But in the end  how much difference can we make as individuals?

Important questions become then: How can we challenge the power of scientific practice and industry to continue enforcing the de-regulation of marketisation and the destruction of the public heathcare systems through privatisation?

Capitalism’s logic of fantasy requires:  a) the loss of belief in the impacts of misdiagnosis, b) the deregulation of industry so that it can provide an endless supply of technology that c) secures our belief in its promises of the one thing we are made to feel lacking, namely d) surplus life-security, and d) the society (here, markets, healthcare systems and science) that offers enough people the opportunity to consume their products to make profits.

The loss of belief is the key biopolitical mechanism at work. This is the repression into unconscious of the certainty of mortality. This is necessary to foster belief in immortality and a ‘maximalist’ mindset.  It is the loss of ‘received meaning’ (i.e. that is to say, the loss of impact on behaviour) of the sacrifice of the many for the few.   But how is this achieved?  How is a collective mindset nourished?

This, I think,  is achieved by stabilising belief and mindset through the use of language, especially by mainstream media, experts, industry, and governments.  In their speech meaning for language is achieved by attaching their rhetoric to certain key motifs: for healthcare these include for example: breakthrough/innovation is meaningful, survival/longevity/lives-saved from cancer are meaningful, premature death is meaningful, productivity is meaningful, sensitivity (of tests) is meaningful, prevention is meaningful, molecular/personal is meaningful etc.

Best wishes

Owen

Owen Dempsey MRCGP UK

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