A valued mentor once distilled something which has stuck with me for nearly 30 years: “we practice to make people feel better, or live longer…that’s it”.
So “prevention”….even primary prevention where NNT tend to be high and pts have no symptoms (yet)….has a role (dependent on clinical trial outcome evidence).
But I’m all in with the constrained vision, and to not only focus on potential benefits, but to acknowledge costs, potential risks, and potential harms. As Thomas Sowell has famously said elsewhere, “there are no solutions, only tradeoffs”. “Pt values and preferences” is where they individually decide whether any tradeoffs are worth it or not, for themselves.
My minor quibble here is that an 8% annual risk of stroke means a 92% “annual” chance of no stroke. That risk calculus means different things over 1 year, vs (for example) over 10 years.
Thanks for your comments John. We don’t ignore high blood pressure, obesity, and diabetes. Of course we treat these patients. But the problem is that most physicians end up treating them forever. That has become our profession’s business model: making money by managing chronic disease rather than helping people overcome it. Instead of making ourselves obsolete by addressing root causes, we perpetuate the cycle of sick → medication → sick → medication.
In my practice, I use medications only as a temporary bridge to stabilize patients. The bulk of my work focuses on uncovering and addressing the lifestyle and environmental factors that caused the disease in the first place. This approach works—remarkably well. Yet our medical system does not reward it. We are paid to treat illness, not to restore health.
Some believe that the solution is to do “more”—more testing, more monitoring, more lifelong medication to prevent bad outcomes. But doing more can easily become doing harm. We don’t need endless testing and permanent prescriptions for every patient. What we need is a fundamental shift from a disease-treatment model to one centered on prevention, healing, and genuine wellness. Our profession is losing credibility with the public because we refuse to confront this truth.
For the past 15 years, I have served as a full-time volunteer physician. That means I have no financial incentive to keep patients dependent on medications or ongoing treatments. My only priority is helping each patient rediscover the changes that lead to a long, healthy, and joyful life. What a shocking concept—restoring wellness.
Though I understand the authors point I am still troubled. “Constrained thinkers believe that before we intervene on healthy people who complain of nothing, we should have strong evidence of benefit.” Step one is to know if people are healthy. Not complaining doesn’t mean they are healthy as my friend who just underwent triple bypass could attest. By the time he felt a problem he was well along the path of CVD. With heart disease, don’t many appear healthy and feel ok until they have a heart attack?
I don't view these as different philosophies, but of different interpretations of risk. And personally I believe that science supports the constrained approach. The unconstrained approach tends to look at risk and benefit as much higher, and harm as much lower than is supported by science and research. By so doing they are not giving patients true informed consent.
Excellent article! What bothers me about the unconstrained thinking physician who fires their patients is that there is no consideration for those patients' values. If I'm fully educated regarding my choice of treatment, and my physician disagrees, they should still be supportive of me. It would appear Adam's disgruntled "I know better than you" attitude is more about ego than patient care. A person's value system regarding their care and treatment is more important than what a physician wants for them, and it doesn't make the patient wrong for wanting a different treatment or no treatment.
There's a particularly German cruelty, precise and almost surgical in its irony, embedded in the word verschlimmbessern - a verb that means
"to try to improve something and inadvertently make it worse". It's a term made for overfunctioners, for perfectionists disguised as healers, to understand, this is to really understand the natures who we really are. The major healer is Nature who is often excluded from modern medicine. Our medicine refuses to even look at Nature.
PS, why is it on thesealgorithms that all of us use that, Anthony Fauci his name gets capitalized? Yes, it always does, yet the true healer nature never does.
In other words, if we use any computer any social media anything we are being mind controlled. It’s very difficult to find a healer who is not mine controlled. 99.9% of the doctors are totally mind control.
And yes I’m being very melodramatic I know it’s not 99.9, but maybe that number will raise the thinking process and one can ask the question. What in medicine is highly successful? and what in medicine it’s highly detrimental?
You’re even understating your case. People cannot afford health care any more. Premiums plus out of pocket is > $30k/yr for a family of 4 and climbing. Health care is devouring the middle class largely due to the unconstrained vision and all who benefit from it including hospitals, device makers, pharma and some specialists are influenced by financial self interest as well as a medical belief system. Benefit>harm is too low a bar. We don’t have the money for every health care intervention with a positive net benefit.
I love your recognition that 8% risk of event = 92% probability of no event. I rarely find this recognition.
I will note that these types of framing tend to focus on minimizing risk of adverse events, rather than maximizing the well-being of patients. A key factor contributing to patient well-being is quality of life, which includes having to live with the adverse side effects from drugs prescribed to minimize the probability of adverse events. While clearly preventing more dire events -- which may or may not happen -- is important, so too is the lower quality of life associated with living with side effects -- especially for polypharmacy patients -- experienced in their everyday lives.
This is a profoundly insightful breakdown of the core philosophical conflict in modern medicine: the Unconstrained Vision (that perfect prevention is possible) versus the Constrained Vision ("Shit Happens").
You beautifully articulate the risks of the Unconstrained drive toward maximization.
However, to move this debate forward, we must integrate two often-missed perspectives:
1. The Societal Vision (The Third Philosophy): Your framework focuses on the doctor and the individual patient. But prevention is fundamentally a societal act. The Unconstrained vision drives public health initiatives (vaccines, clean water) that benefit populations, even if the individual risk is low. The benefit isn't just saving one person, but the collective social and economic yield of reduced population burden. We need to distinguish between maximizing personal benefit (where Constrained thinking excels) and maximizing public good.
2. The Ethics of 'Do Nothing' Arm: You advocate for a "do nothing" arm in the next LAAC trial, which is essential for constrained validation.
But we must acknowledge the tyranny of the available option. Once a preventative treatment exists, the ethical and psychological pressure on doctors and patients to use it becomes immense, regardless of trial evidence.
The challenge is fighting the human instinct that intervention equals care, making true "do nothing" randomized trials ethically and financially difficult to execute.
Constrained thinking is not pessimism; it is a higher form of patient advocacy that respects complexity, individual autonomy, and the cost of intervention. It reminds us that medicine’s greatest service is often wise restraint.
Final Thought: If the purpose of medicine is to reduce suffering, and suffering comes from both disease and unnecessary intervention, how do we ethically quantify the suffering caused by the over-treatment driven by the Unconstrained Vision?
Thanks for your insights. I have had intermittent atrial fib for over 20 years. I had several failed ablations and took blood thinners for several years. About 10 years ago, I switched to high-dose omega-3 for the antiplatelet effects and stopped the blood thinners. So far, so good.
I Love this!! Yes, you're right, and the more I see of the drugs and intervention machine pattern, the more I go back to basics that always work, for 16 years.
Wish I could post at times, and there's an orange flag about that. But I'm not a doctor, so I leave that to you. My research is on a very small scale, but I read Everything I can find, on how to help people live longer happier lives in old age.
It also bothers me, the inefficiency of what I call the medical machine.
My small SoFL Assisted Living (house) has been home to what seems like too many people in only the past 16 years. That's because they come to me at 64 (youngest and lived 8 years, having been in a nursing home and several ALFs already) to as old as 94 (lived to 99 years)
We provide 'end of life care' so much better than hospice. One of my current residents, a diabetic, came to us with 34 units of insulin and 3 metformin pills daily.
We give them High-dose omega 3 and the best diet I've yet seen, as well as daily hydration, sunlight, exercise and meaningful engagement. Vitamins B, C, D, magnesium, probiotics (many strains known to help brain health)
After 3 months he was down to 15 units Lantus and 2 lower dose metformin. Two more months, metformin gone, 10 units insulin nightly.
I'd begged the MD to kick pantaprazole & thinners or at least cut them or the aspirin, bc bruising/bleeding, but sunlight & exercise helps there too.
Hospice said they'd pay only insulin, laxative and protonix - which is low cost anyway. I now continue to pay his pca meds, eye drops for glaucoma & now for conjunctivitis b/c those are not needed for 'palliative care'... Also I pay test strips & needles b/c they're part B and he no longer has that. No more PT b/c you know, he's dying and hospice brings someone out if they're in fetal position in bed, but not before then... Dear Lord restrain me from profane thoughts.
But they tell the family it's best and that they "take care of everything", a bit like the vet's office you don't have to see us put dad down, and the ALF gets help. If he were Stronger as he was Before removing the PT by the way the Taxpayer Still pays the Entire budget to the hospice company, so it's not like we're saving money. I still buy the other drugs, but they're happy to begin giving him morphine as soon as I say the "p-word" (pain)
Funny thing, if your only tool is a hammer, everything looks like a nail.
In 16 years, I've Never had a patient on hospice with any clarity, any capacity to really say goodbye... OTOH, the ones whose family said no to morphine unless They saw it was needed, have been amazing uplifting experiences that kept me going even through the over-regulation and the statist approach of the early Covid time.
You are doing wonders for people who need sound advice about how to live out the last part of their lives. Medication is clearly not the answer. I am currently developing a consulting telemedicine service that helps people achieve optimal health by avoiding the traditional medical approach and focusing on diet, exercise, targeted supplements, socialization, and meditation.
Congratulations you’ve taken your healing into your own hands and that is where most people have been mind controlled into thinking that modern medicine has all the answers.
I always ask myself what’s the downside, how close os it to zero. In review, natures bounty has so many wonderful healing modalities and the downside are very close to zero.
A valued mentor once distilled something which has stuck with me for nearly 30 years: “we practice to make people feel better, or live longer…that’s it”.
So “prevention”….even primary prevention where NNT tend to be high and pts have no symptoms (yet)….has a role (dependent on clinical trial outcome evidence).
But I’m all in with the constrained vision, and to not only focus on potential benefits, but to acknowledge costs, potential risks, and potential harms. As Thomas Sowell has famously said elsewhere, “there are no solutions, only tradeoffs”. “Pt values and preferences” is where they individually decide whether any tradeoffs are worth it or not, for themselves.
My minor quibble here is that an 8% annual risk of stroke means a 92% “annual” chance of no stroke. That risk calculus means different things over 1 year, vs (for example) over 10 years.
Thanks for your comments John. We don’t ignore high blood pressure, obesity, and diabetes. Of course we treat these patients. But the problem is that most physicians end up treating them forever. That has become our profession’s business model: making money by managing chronic disease rather than helping people overcome it. Instead of making ourselves obsolete by addressing root causes, we perpetuate the cycle of sick → medication → sick → medication.
In my practice, I use medications only as a temporary bridge to stabilize patients. The bulk of my work focuses on uncovering and addressing the lifestyle and environmental factors that caused the disease in the first place. This approach works—remarkably well. Yet our medical system does not reward it. We are paid to treat illness, not to restore health.
Some believe that the solution is to do “more”—more testing, more monitoring, more lifelong medication to prevent bad outcomes. But doing more can easily become doing harm. We don’t need endless testing and permanent prescriptions for every patient. What we need is a fundamental shift from a disease-treatment model to one centered on prevention, healing, and genuine wellness. Our profession is losing credibility with the public because we refuse to confront this truth.
For the past 15 years, I have served as a full-time volunteer physician. That means I have no financial incentive to keep patients dependent on medications or ongoing treatments. My only priority is helping each patient rediscover the changes that lead to a long, healthy, and joyful life. What a shocking concept—restoring wellness.
Though I understand the authors point I am still troubled. “Constrained thinkers believe that before we intervene on healthy people who complain of nothing, we should have strong evidence of benefit.” Step one is to know if people are healthy. Not complaining doesn’t mean they are healthy as my friend who just underwent triple bypass could attest. By the time he felt a problem he was well along the path of CVD. With heart disease, don’t many appear healthy and feel ok until they have a heart attack?
Very good. I appreciate your thoughts.
I only have high bp in the doctor’s office. It’s normal at home. It’s hard for them to accept that I don’t need meds.
I don't view these as different philosophies, but of different interpretations of risk. And personally I believe that science supports the constrained approach. The unconstrained approach tends to look at risk and benefit as much higher, and harm as much lower than is supported by science and research. By so doing they are not giving patients true informed consent.
Excellent article! What bothers me about the unconstrained thinking physician who fires their patients is that there is no consideration for those patients' values. If I'm fully educated regarding my choice of treatment, and my physician disagrees, they should still be supportive of me. It would appear Adam's disgruntled "I know better than you" attitude is more about ego than patient care. A person's value system regarding their care and treatment is more important than what a physician wants for them, and it doesn't make the patient wrong for wanting a different treatment or no treatment.
Love this!!!
Love the Thomas Sowell reference.
'Conflict of Visions" should be a foundational text for many disciplines of study and vocational practice.
There's a particularly German cruelty, precise and almost surgical in its irony, embedded in the word verschlimmbessern - a verb that means
"to try to improve something and inadvertently make it worse". It's a term made for overfunctioners, for perfectionists disguised as healers, to understand, this is to really understand the natures who we really are. The major healer is Nature who is often excluded from modern medicine. Our medicine refuses to even look at Nature.
PS, why is it on thesealgorithms that all of us use that, Anthony Fauci his name gets capitalized? Yes, it always does, yet the true healer nature never does.
In other words, if we use any computer any social media anything we are being mind controlled. It’s very difficult to find a healer who is not mine controlled. 99.9% of the doctors are totally mind control.
Yes, I was in medicine since 1975 and still trying to run some clinical trials that are not based on big Pharma, which is next to impossible.
And yes I’m being very melodramatic I know it’s not 99.9, but maybe that number will raise the thinking process and one can ask the question. What in medicine is highly successful? and what in medicine it’s highly detrimental?
'We excel most when we treat people who ask for our help."
And when we have the courage and wisdom to say that our treatment may well not help.
OMG constrained vs unconstrained vision entered discussion!
You’re even understating your case. People cannot afford health care any more. Premiums plus out of pocket is > $30k/yr for a family of 4 and climbing. Health care is devouring the middle class largely due to the unconstrained vision and all who benefit from it including hospitals, device makers, pharma and some specialists are influenced by financial self interest as well as a medical belief system. Benefit>harm is too low a bar. We don’t have the money for every health care intervention with a positive net benefit.
Thank you for your well-reasoned analysis.
I love your recognition that 8% risk of event = 92% probability of no event. I rarely find this recognition.
I will note that these types of framing tend to focus on minimizing risk of adverse events, rather than maximizing the well-being of patients. A key factor contributing to patient well-being is quality of life, which includes having to live with the adverse side effects from drugs prescribed to minimize the probability of adverse events. While clearly preventing more dire events -- which may or may not happen -- is important, so too is the lower quality of life associated with living with side effects -- especially for polypharmacy patients -- experienced in their everyday lives.
This is a profoundly insightful breakdown of the core philosophical conflict in modern medicine: the Unconstrained Vision (that perfect prevention is possible) versus the Constrained Vision ("Shit Happens").
You beautifully articulate the risks of the Unconstrained drive toward maximization.
However, to move this debate forward, we must integrate two often-missed perspectives:
1. The Societal Vision (The Third Philosophy): Your framework focuses on the doctor and the individual patient. But prevention is fundamentally a societal act. The Unconstrained vision drives public health initiatives (vaccines, clean water) that benefit populations, even if the individual risk is low. The benefit isn't just saving one person, but the collective social and economic yield of reduced population burden. We need to distinguish between maximizing personal benefit (where Constrained thinking excels) and maximizing public good.
2. The Ethics of 'Do Nothing' Arm: You advocate for a "do nothing" arm in the next LAAC trial, which is essential for constrained validation.
But we must acknowledge the tyranny of the available option. Once a preventative treatment exists, the ethical and psychological pressure on doctors and patients to use it becomes immense, regardless of trial evidence.
The challenge is fighting the human instinct that intervention equals care, making true "do nothing" randomized trials ethically and financially difficult to execute.
Constrained thinking is not pessimism; it is a higher form of patient advocacy that respects complexity, individual autonomy, and the cost of intervention. It reminds us that medicine’s greatest service is often wise restraint.
Final Thought: If the purpose of medicine is to reduce suffering, and suffering comes from both disease and unnecessary intervention, how do we ethically quantify the suffering caused by the over-treatment driven by the Unconstrained Vision?
“tyranny of the available option”. Great turn of phrase.
The essence of great medical care is the provision of as much nothing as possible. Taught by the great Fat Man.
Thanks for your insights. I have had intermittent atrial fib for over 20 years. I had several failed ablations and took blood thinners for several years. About 10 years ago, I switched to high-dose omega-3 for the antiplatelet effects and stopped the blood thinners. So far, so good.
I Love this!! Yes, you're right, and the more I see of the drugs and intervention machine pattern, the more I go back to basics that always work, for 16 years.
Wish I could post at times, and there's an orange flag about that. But I'm not a doctor, so I leave that to you. My research is on a very small scale, but I read Everything I can find, on how to help people live longer happier lives in old age.
It also bothers me, the inefficiency of what I call the medical machine.
My small SoFL Assisted Living (house) has been home to what seems like too many people in only the past 16 years. That's because they come to me at 64 (youngest and lived 8 years, having been in a nursing home and several ALFs already) to as old as 94 (lived to 99 years)
We provide 'end of life care' so much better than hospice. One of my current residents, a diabetic, came to us with 34 units of insulin and 3 metformin pills daily.
We give them High-dose omega 3 and the best diet I've yet seen, as well as daily hydration, sunlight, exercise and meaningful engagement. Vitamins B, C, D, magnesium, probiotics (many strains known to help brain health)
After 3 months he was down to 15 units Lantus and 2 lower dose metformin. Two more months, metformin gone, 10 units insulin nightly.
I'd begged the MD to kick pantaprazole & thinners or at least cut them or the aspirin, bc bruising/bleeding, but sunlight & exercise helps there too.
Hospice said they'd pay only insulin, laxative and protonix - which is low cost anyway. I now continue to pay his pca meds, eye drops for glaucoma & now for conjunctivitis b/c those are not needed for 'palliative care'... Also I pay test strips & needles b/c they're part B and he no longer has that. No more PT b/c you know, he's dying and hospice brings someone out if they're in fetal position in bed, but not before then... Dear Lord restrain me from profane thoughts.
But they tell the family it's best and that they "take care of everything", a bit like the vet's office you don't have to see us put dad down, and the ALF gets help. If he were Stronger as he was Before removing the PT by the way the Taxpayer Still pays the Entire budget to the hospice company, so it's not like we're saving money. I still buy the other drugs, but they're happy to begin giving him morphine as soon as I say the "p-word" (pain)
Funny thing, if your only tool is a hammer, everything looks like a nail.
In 16 years, I've Never had a patient on hospice with any clarity, any capacity to really say goodbye... OTOH, the ones whose family said no to morphine unless They saw it was needed, have been amazing uplifting experiences that kept me going even through the over-regulation and the statist approach of the early Covid time.
You are doing wonders for people who need sound advice about how to live out the last part of their lives. Medication is clearly not the answer. I am currently developing a consulting telemedicine service that helps people achieve optimal health by avoiding the traditional medical approach and focusing on diet, exercise, targeted supplements, socialization, and meditation.
Congratulations you’ve taken your healing into your own hands and that is where most people have been mind controlled into thinking that modern medicine has all the answers.
I always ask myself what’s the downside, how close os it to zero. In review, natures bounty has so many wonderful healing modalities and the downside are very close to zero.