A new book critiques medicine

Anyone receiving or delivering healthcare is aware of these problems. These kind of critiques suffer from the same basic problem - they treat Medicine as a monolithic entity which is not intimately linked with society, culture, the economy and government. This conceit is necessary to write a book about it, and is a luxury available only to those who don't need to actually deliver or administer healthcare. It is also not the same thing as 'trying to make things better', despite what the author may claim. In truth the author is actually critiquing what they have decided falls under the umbrella of medicine, which they define at a particular point in time.

The problem is incentives, not sure why this guy wrote a whole book without realising this, but it is an easy mistake to make if you are thinking about the problem from your writing desk. People will minimise effort and cost, given a choice, and maximise profit subject to constraints. This behaviour exists even in highly trained health professionals already making many hundreds of thousands of dollars a year. Example - why do primary care doctors prescribe minimally effective drugs for depression? Is it because they can't understand a meta-analysis, can't remember all the patients the drugs didn't work for in their own practice, or because they are lazy or stupid? It is because a patient has come in looking for help and is sitting there in tears, and there is only 10 minutes to see them, and the history from the other doctor this person has been seeing for the last 5 years isn't available. And although everyone would be better off if the doctor spent an hour finding out in detail what is going on, carefully talking over the options, the side effects of various treatments and reaching a consensus management plan which starts with non-pharmacological therapies, and activates a government program which allows the patient to take extra time off work to attend therapy sessions with childcare facilities included. But it is easier for everyone to prescribe Prozac. This is the reality. Perverse incentives explain many of the problems in Medicine and healthcare systems. Nobody gets paid for delivering good care, nobody saves money by accepting good care. As shocking as it may be, delivering good care or exceptional care is a choice a health care team makes despite everything else. Similarly, accepting proven health care interventions is a choice a patient makes. Usually everything doesn't line up, and that is modern medicine.

The cited example of Gleevec also makes no sense to me. It revolutionised the treatment of 2 conditions which were almost completely untreatable beforehand (Chronic Myeloid Leukaemia and Gastrointestinal Stromal Tumour). The alternatives to taking Gleevec for these patients were A) Toxic minimally effective chemotherapy followed by death or B) Just death. All of this context is extremely important in discussing the side-effects which can be severe. This is what the patient and the doctor work out together. Some throwaway line about how toxic it is just makes no sense in isolation.

That’s kind of like complaining because programmers don’t know every language.

GP’s refer to specialists because medicine is such a huge body of work. Keeping up with even a small field takes a lot of time. Someone that tries to keep up with and more importantly remember everything is not going to succeed let alone have time to help you. Sometimes the next step is to take these results go up the chain and try again not hope the wrong specialist can still solve your issue.

It’s not a perfect system, especially if you actually have multiple independent unusual issues at the same time. But, that’s life with imperfect humans.

What this really makes me believe even more is that medicine as an institution is completely bankrupt. There are for sure selfless doctors who sacrifice for their patients. And medical care is fantastic for acute injuries and conditions.

But the system as a whole is very ineffectual for chronic diseases, and I would argue, outright harmed the public with its dietary recommendations.

Good solutions can often be left on the table, even by experts in $INDUSTRY, apart from whether they're experts or not; it's often a systemic thing. It's perfectly possible for an intelligent, rational person who is good at thinking about large and complex systems (who are overrepresented in the tech industry) to have an insight (that individuals in that industry might already have had) about things outside their own industry.

Relevant article: https://slatestarcodex.com/2017/11/30/book-review-inadequate...

It's really more like wishing a consultancy would employ a competent project manager. The thing about systems is that they're designed (even if only by refusing to design and calling it 'market driven'). Some work better than others.

I've certainly seen the difference in the small number of countries I've lived in - some do a much better job of coordinating services between generalists & specialists than others. But this has nothing to do with 'western' medical science per se, which is the primary modality of each of those varying systems.