My Facebook feed is riven in two. On the one hand, there are free-thinking, scientistic doctors, patients, and those who love them (or tolerate them enough not to hide their status updates). On the other, are Jews: and, for some reason having to do with personal curiosity and involvement with Yiddish speakers, many of them are Jews who are Chasidic, used to be, or are somewhere in between.
Both camps are in the throes of realignment. The former, because evidence-based medicine is screeching towards the end of a game of chicken, the other competitor being (unfortunately) the patient as a person, with power over her own decision making.
Let’s take the most recent example of this hair-raising collision: statins. Cholesterol medicines, in other words, and what to do about them. Yes, we should probably get rid of these artificial numerical targets, it seems like most people agree on that. But the new guidelines, according to which (grosso modo) everyone with an estimate 10-year heart disease risk of 7.5% “needs” to be on such a medication, are rightfully controversial. If you are the type to read JAMA articles, you will be entertained by John Ioannidis (he of the “half of all scientific findings are wrong”) on the one hand, who darkly prophesies “one of the worst disasters in medical history” due to vast overtreatment with statins. (Um. Flu? AIDS? The plague?), and, on the other hand, a professional, prudent take by some collaborators on the new guidelines themselves, who take what seems to be the best defense possible: The science is better; we are working towards incremental improvement of guidelines. In short: nothing’s perfect. This is a step forward from where we were.
If you read the articles back-to-back, it seems an awful lot like the internal breakup currently convulsing ultra-Orthodoxy. Belief and practice are at loggerheads, and tiny fish are getting squished between the logs. Are you a believer or not? Are you an incremental advancer or a revolutionary? Are you willing to listen to doctors by virtue of their social standing and hereditary place as healers, even if their advice might not be better than random chance?
Does medicine need a revolution to upend received wisdom – even the new received wisdom of our day, which is the dogma of evidence-based medicine – enthroning in its place the empowered singular patient? Sure, if you are the type to upend and revolt. But not even the most engaged of patients want to get rid of everything the medical establishment has to offer. Similarly, even those about to leave their hidebound religious communities sometimes find themselves at peace with a stable compromise. They don’t have to believe in everything.
If a revolution is possible, but we choose an incremental change, are we being sensible – or hypocritical?