The woeful shredding of medical integrity

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A middle-aged lady once approached me for severe disabling fatigue and brain fog that incapacitated her over the years, and the run-of-the-mill tests and multiple specialist visits left her high and dry. Using Functional Medicine approaches of a thorough history, physical examination, broader evaluation & some targeted tests, it appeared that this woman could be suffering from functional hypothyroidism. In this condition, her blood tests appear within normal ranges, but she struggled with multiple symptoms of hypothyroidism (an underactive thyroid gland). After discussion and complete informed consent for trying an unconventional approach, we decided to address root causes through lifestyle interventions & a trial of thyroid medications and supplements. She did remarkably well in the treatment program and never looked back. To recap her own words – ‘It has been life-changing’. 

On one occasion, when I was away, she ran out of medication. She had to see her local doctor urgently, who was alarmed by her use of the medication despite test results being within normal ranges. Her insistence that the medication helped immensely fell on deaf ears. The doctor refused the prescription, insisting that it was not in the guidelines and, therefore, whatever she said would not change his approach. It’s sad but true – today’s medical practitioners have become ‘cataractually’ blinded by what I would term MGD (Medical Guidelines Disorder), and it’s reaching epidemic proportions with negative implications across every aspect of healthcare.

Dr William Osler, a Canadian physician and one of the founding members of the Johns Hopkins Hospital in the USA, perhaps could foresee the trajectory of medicine when he said: “The practice of medicine is an art, not a trade; A calling, not a business; A calling in which your heart will be exercised equally with your head.” We sure have moved a long way away from using our heads, and without a shadow of a doubt, our hands are not on our hearts. 

Guidelines and algorithms plague modern medicine, and they are beginning to stink. 21st-century AI-modelled medicine is a potpourri of guidelines and drop-down flowcharts used to diagnose and treat human diseases. Somehow, as intellectual as we have become, we have begun to believe that we can treat our bodies just as we engage our dishwashers, where we get a particular outcome by pressing a few buttons per the manufacturer’s instructions and ensuring the once-yearly maintenance checks. Sadly, not quite so. 

The knowledge acquired of the infinitely complex systems of biochemical interactions and their physiological responses has evolved through centuries of age-old medical wisdom. Today, we still need to learn more and have more answers to why disease occurs. 

Integrating automation into modern-day healthcare sounds exciting and may prove invaluable in many ways, but it could pose significant challenges in some core aspects of medicine. Everything has pros and cons, but it will be a steep learning curve with some challenging times ahead. It would be fascinating to see how the merger pans out, considering that in clinical medicine, practising physicians know all too well that patients do not share the same physiology and biochemistry in addition to many anatomical variations. With our brimming medical knowledge, treating the human body systematically without considering the outliers would be reckless. Also, clinical medicine is miles apart from research or analytics, where we can control parts of the environment to a large extent. We all respond differently to treatments that may work for some, not others, owing to our individual variabilities. The broader medical community agrees that cookbook medicine could never be the right modus operandi for disease management and the road to recovery and wellness.

Recently, I received an email with an attached flowchart titled “The expert group’s pathway for the identification and management of patients with NAFLD/NASH” (For the reader, NAFLD and NASH stand for Non-Alcoholic Fatty Liver Disease and Non-Alcoholic Steato-Hepatosis, respectively, both reflecting fatty liver disease of varying degrees.)

Mostly, everyone appreciates having a flowchart at work for its predictive abilities. It helps solve problems, streamline and narrow down lengthy thought processes, cut downtime, quickly employ strategies, and easily reach a particular outcome. In healthcare, it helps the treating physician understand and predict outcomes based on the situation presented before them and take appropriate measures. Sounds fair.

However, the anticipated benefits of having an algorithm are overridden by three negative consequences, which we will explore. To begin with, patients get herded into groups based on the flowchart, assuming it’s all black or white. What if it’s not, and it has shades of grey? Has this factor been considered? Each person has a different set of contributors to illness, beginning with genetics and epigenetic drivers. We cannot assume that people and diseases behave similarly. Sadly, this approach has already brought medicine to the cliff’s edge.

As a second point for discussion, what is at stake is the loss of critical evaluation, independent thinking, and analysis of the given situation. Inadvertently, an “expert class” is selected and delegated this responsibility (as above), thereby freeing the treating physician from the nail-biting, nerve-racking, brain-engaging hassle of evaluating each patient individually and providing customised treatment options. 

The physicians become indoctrinated, automated and machined. By proxy, they are not expected to research or study any further about the condition or search the www for the latest research on the matter. Even if they decide to do this, it’s irrelevant as the guidelines do not advocate thinking alternatively. Trial and error no longer exist in medicine as guidelines steer the way and are frighteningly risky to deviate from. Also, time is of the essence in a busy doctor’s life, and anything that is time-saving, convenient and risk-averse seems like a brilliant idea. It’s little surprise that the medical community is so enamoured by guidelines and enchanted by the experts who created them.

Perhaps most importantly, the practice of Defensive Medicine (read this article here) has delivered the most significant blow to our current model of automated medical practices. We live in a litigious world today where even thoughts can be considered as crimes. Medical Defence Organisations funded by the practitioner’s fees & supposedly meant to be in the doctor’s defence are, unfortunately, fully collaborating with the system and the regulatory agencies. MDOs would offer no assistance if a doctor were to stray off the guidelines of managing a condition. The regulatory board (and the MDO) come down forcefully on the physician, leaving them frightened, stranded and scarred for life.

Today, many medical practitioners are under suspension by the medical board for petty ‘crimes’ such as issuing vaccine exemptions for COVID injections, prescribing safe drugs such as Ivermectin for treating the COVID illness (an over-the-counter medication in third world countries with scientists receiving the Nobel prize for its discovery & a safety profile that outdoes Paracetamol), Vitamin C infusions and other supplement treatments offered for sick patients during the pandemic period, for suggesting that the COVID shots may have unknown adverse effects (which is now an undisputed fact) and the list goes on. Benign actions but malignant outcomes. All this is when the reckless sex offenders and the drug abusers among these doctors return to work with a slap on the wrist.

Most, if not all, of the treatments mentioned above, were outside the guidelines at the time, which did not leave room for exceptions and were considered violations of public health mandates. Politicians & health experts involved in creating these guidelines at the time remained disconnected from the average physician and GP on the floor battling the crisis, many of whom held different views on how public health was managing the issue. Matters were made worse by AHPRA, the Australian medical regulatory authority, releasing its position statement on March 9, 2021, forbidding any alternate views or concerns about the COVID-19 vaccine program that could create vaccine hesitancy among the public (see here).

Promptly, medical defence organisations, such as the Medical Indemnity Protection Society (MIPS), released statements to its members that shocked many in the profession.

Giving clear “obey or face the consequences” instructions, the emphasis given to the last assertion states the unthinkable for 21st-century democracies; ‘that it would not matter even if the physician’s assessment and concerns were evidence-based’. Subsequently, many front-line doctors who raised concerns about public health guidelines were, without debate, suspended by their medical boards, and their careers were sacrificed at the altar. With these consequences, the rest of the dissenters zipped up and fell in line, never to be heard from again. They chose to go along to get along.

Desperate times need desperate measures. Empathetic doctors, researching available treatments, did what they thought was best for their patients during a crisis when no one knew the right treatments. Using available knowledge and their combined experiences, clinicians and physicians had to assess the situation and make difficult decisions, juggling patient safety and well-being, a mammoth task in a novel crisis. Instead, voices opposed to the prevailing narrative were silenced, censored across all platforms, and advised strictly to follow orders or be prepared to walk. 

Were global public health measures indeed about public health, or was it politics game day as usual, mixed with inflated egos & unbridled pomp that took the lead? Does the public need to be concerned when the same group of individuals in authority issuing orders also instruct them to follow public health guidelines because they would be their only ‘source of truth’, as did ex-New Zealand Premier Jacinta Ardern? With these threats now lurking permanently, would a doctor dare break the ground rules & risk falling into the frightening abyss of the unknown? 

I dare not and would prefer to mind my business and relinquish all personal medical autonomy. If following the expert’s guidelines is the compromise I have to make to work, care for the family, pay the mortgage, and settle bills, I will sadly do so, even if it shatters my integrity as a doctor.

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