Doctor, are you FDA-approved?

Posted on August 16, 2008. Filed under: Everything you wanted to know about doctors, medical ethics |

For the most part, the “practice” of medicine does not work like a science. I wrote that comment recently on the Overcoming Bias blog. Prior to 1910, when the Flexner Report was released, there were no general guidelines for teaching American doctors. As a result of Flexner’s recommendations, over half of the American medical schools had been closed by 1935, leaving a total of 66. Since then, with the growth in population, the number has climbed to 129, with each of these following the same rigorous standards. There are no “bad” American medical schools (unless they all are bad). All American doctors are trained in a evidence-based curriculum. All “board-certified” doctors must give at least the minimum number of  correct answers on the Board examination, and demonstrate the ability to avoid being fired for the duration of their specialty training, such that the Professor is somewhat obligated to give a recommendation, since the candidate was allowed to complete the program. 

So why isn’t the practice of medicine a “science”?

Once a doctor has received a license to practice in a particular state (determined by the opinions of unrelated state boards), for legal purposes, he is an “expert on the skin and its contents”. That is, everything human. The only things (beyond personal good judgment) that prevent non-surgeons from performing surgery, for example, are the needs to obtain hospital/procedure privileges (peer-governed), and the threat of economic loss through civil litigation (malpractice suits).

When a prescription drug is approved by the FDA, the manufacturer must specify uses for the drug, which also must receive approval, based on efficacy and safety studies. **NOTE: all FDA-approved pharmaceuticals have a proprietary name and a non-proprietary name; “generics” are proprietary drugs whose exclusive patent has expired, allowing other companies to manufacture the drug without doing further studies. Thus, all “Zoloft” is “sertraline”, but not all sertraline is Zoloft, because Zoloft’s patent has expired.** Even though the drug companies cannot promote an approved drug for a non-approved use, the practicing doctor legally can use an approved drug for anything he chooses. So, although Zoloft was approved only for treatment of depression and obsessive/compulsive disorder, I used it to prevent premature ejaculation. According to Pfizer, although I never treated anyone for depression nor OCD, I was the volume leader in Zoloft prescriptions in my region. There was a good reason why it worked for premature ejaculation, but there was little true “science” in its use.

Doctors are free to use their judgment in the evaluation and treatment of patients. While some of this may be evidence-based, much of it is anecdotal, and hence, not science. Ask 10 mathematicians to give a list of all the prime numbers between 0 and 100, and all the informed answers will be the same. Ask 10 doctors how to treat erectile dysfunction, and it is quite likely that there will be 10 different protocols. In one of the first lectures I attended in medical school, the Dean stated that anecdotes were more dangerous than lies, because they contained the same lack of evidence, yet were more convincing. While continuing medical education is required by all states for continued licensure, none has any requirements about the quality or topicality of the CME. I could sit at my computer on the Internet today and qualify for all the CME hours I will need for the next 2 years, yet never learn anything that is relevant to my practice nor even necessarily true. Fortunately, most ill humans either recover, remain chronically ill, or die, with or without doctor-intervention. I said most, not all.

The ability for the system to attract doctors with high intelligence and science potential is diminishing. During the Viet Nam conflict, when the military draft was in effect, medical students were deferred. There were about 20 applicants for each slot in medical school, consequently the schools had a large pool of high-IQ students from which to choose. In 2007, 42% of applicants in the USA actually matriculated, as noted here. At some schools, more were accepted than rejected. I believe there are several easily detected reasons for this trend:

  • Diminished earnings. Currently, on average, a college student who goes on to become a medical/surgical specialist will not catch up in earnings with his college classmate who became a CPA and went directly to work until the doctor is about age 45. Tough recruiting problem if you’re looking for really smart people. While demonstrating surgery in a European country in the top eight of world economies, over a 2 year period I remarked to my native escort that most of the surgeons seemed intellectually average. He said, “Of course they’re not smart. It’s a socialized medical system, and they all work for the government. They average $28,000 annually. What kind of a doctor can you get for that?”
  • The contingency payment system for civil litigation: no cost to the litigant, no penalty to the attorney for being wrong. It’s a lottery ticket.
  • Diminished prestige, a typical discussion of which can be found here.
  • Trends toward transhumanism/AGI could (will?) make doctors superfluous. This would be an important factor for me in choice of profession, as well as preferring to have put my efforts into that field. However, most doctors, as well as most other people, are unaware of the technological Singularity.

That said, when I’m terribly ill, I want it to be in the USA.

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