Yves here. This KLG offering on the state of education in medicine sets up a discussion on statins that he will continue in his next post.
To add to what KLG describes, a good friend, a biomedical engineer and daughter of an MD whose first job was at the NIH, said, “Medicine is a medieval art.” Yet the teaching of medicine does not acknowledge its limited scientific foundations.
By KLG, who has held research and academic positions in three US medical schools since 1995 and is currently Professor of Biochemistry and Associate Dean. He has performed and directed research on protein structure, function, and evolution; cell adhesion and motility; the mechanism of viral fusion proteins; and assembly of the vertebrate heart. He has served on national review panels of both public and private funding agencies, and his research and that of his students has been funded by the American Heart Association, American Cancer Society, and National Institutes of Health
For most of my professional working life I have been a biochemist and molecular cell biologist whose interests did not require any serious acquaintance with biomedical science as applied to the actual practice of medicine. I was interested in protein evolution, structure, and function; how cells move; and how they evolved to form complex multicellular organisms. I taught graduate students and directed the projects of graduate students in a similar vein.
My professors, both undergraduate and graduate, had little interest in understanding or teaching “human biochemistry,” which is now one of the most useful science courses taught at my home institution. They generally looked down on the subject, which in retrospect was more than a bit precious.
This all changed for me when I moved to my current institution and began tutoring first- and second-year preclinical medical students in small groups. I learned quickly that although I was comfortable understanding the basics of metabolism, nutrition, heart disease, and cancer from 20,000 feet, things changed when I had to introduce emergent physicians to the molecular and cellular intricacies of Type 1 and Type 2 diabetes, cancer progression, hematology, and cardiovascular disease.
In retrospect, it is somewhat embarrassing that I might have known at one time the intricacies of glycolysis and the TCA cycle and muscle contraction, while at the same time having not one meaningful clue about the biochemistry and cell biology of diabetes. Many of the canonical medical textbooks seemed[1] to go around their subjects instead of getting straight to the heart.
So, I began to do what I had been taught when faced with a new problem and a new project: Dig into the literature and build a foundation for the new knowledge and understanding my students required of me. And this led, after a few false starts and sojourns in a cluttered desert to my question: What if medicine were taught like a science?
At first glance this is a perfectly ridiculous thing to ask. Of course, medicine is taught like a science! After all, except for students at NYU, premedical students must master General Biology, General Chemistry, Principles of Physics, and Organic Chemistry in preparation for medical school.
Nevertheless, I found that much of the current teaching and practice of medicine shows that the principles of the biomedical and human sciences are not as foundational in the teaching of medicine as they should be, and this perhaps can be illustrated by the hegemony of evidence-based medicine (EBM). I hope to cover this in more depth as this series continues, but the more I reflect on EBM, the more it seems that the inverted pyramid of EBM, with the meta-analysis viewed as the source of true knowledge, is analogous to the inverted totalitarianism Sheldon Wolin uses to describe our “managed democracy.” Granted, that is a bridge too far for now, but it is not a bridge to nowhere.
Anyway, how can this be? An answer, if not the complete answer, finally dawned on me when my continuing education led me to read The Case Against Sugar, by Gary Taubes:
History is critical to understanding science and how it progresses. Moreover, in many (all) scientific (scholarly) disciplines – physics (biology), for example – the science is taught with the history attached. Students learn not only what is believed to be true and which conjectures have fallen by the wayside, but on the basis of what experiments and what evidence, and by whose authority and ingenuity…Medicine today though, as with related fields such as nutrition is taught mostly untethered from its history. Students are taught what to believe but not always the evidence on which those beliefs are based, and so oftentimes the beliefs cannot be questioned…(nevertheless) Students of any science need to know why they are being asked to believe a particular idea, or why not, and on what grounds. Without the history of the idea, there’s no way to tell, and by implication, no reason to ask.” (modified, p. 21-22).
If we are telling the students what is true, then we are not teaching them to understand. Thus, all understanding develops from the history of a discipline. Which is not to say that every practitioner must know the complete history of her discipline, which is impossible, but she must understand the foundations of the practice, where they are strong and where they are weaker.
The scientific foundation of medicine is alive and well in some places, such as cancer biology as illustrated in The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee. Dr. Mukherjee covers the history of cancer, but more importantly this book describes the progress made and in the treatment of cancer, what works and what doesn’t.
What doesn’t work: The radical mastectomy, first performed by William S. Halstead, one of the four doctors who founded the Johns Hopkins Hospital. A similar operation was 100 years old at the time, and 100 years later it was still largely a futile and violent gesture visited upon women, for no good reason.
What does work, on the other hand, is the treatment of childhood leukemia, which came out of the long and difficult work of Sidney Farber and colleagues beginning in the late-1940s. Many other cancer treatments also work, such as the combination of chemotherapy and focused radiation on oropharyngeal squamous cell carcinoma. The use of imatinib (Gleevec) was a revolution in its targeting of oncogenic protein kinases, although resistant mutants of the Abl tyrosine kinase are sometimes a complication leading to recurrence.
One of the most important points to remember regarding successful cancer treatments is that if remission/cure is the goal, the clinical endpoint is exact and the patient lives. However, it does seem that the clinical endpoints in cancer therapy have been fairly mobile lately, if the commercials I see when I (seldom) watch television are indicative.
One might also say, correctly, that clinical endpoints have been mobile during the current pandemic, which is not over and has not been blunted particularly well by mRNA vaccines that are repeatedly described as “safe and effective,” even if they do not prevent infection and transmission of SARS-CoV-2.
Here we will be concerned with the practice and teaching of nutrition and the health consequences of same over the past 60+ years using the following sources: Gary Taubes, Good Calories, Bad Calories: Fats, Carbs, and the Controversial Science of Diet and Health and The Case Against Sugar[2]; John Yudkin, Pure, White, and Deadly: How Sugar is Killing Us and What We Can Do to Stop It; Nina Teicholz, The Big Fat Surprise: Why Butter, Meat & Cheese Belong in a Healthy Diet; Richard David Feinman, Nutrition in Crisis: Flawed Studies, Misleading Advice, and the Real Science of Human Metabolism. Each of these books is available and all are accessible, with good bibliographies for those like me who go down rabbit holes.
The primary focus here is what can be called the Diet-Heart Hypothesis, which for the past 60+ years has been a (the) ruling framework for understanding diet and health. The history of the Diet-Heart Hypothesis is straightforward, with several landmarks, of which your choices may vary, but the results remain mostly the same:
(1) 1955: President Eisenhower has his first heart attack and widespread attention was focused on heart health. Nevertheless, his “melba toast diet” did not work, except to make him miserable for the next and final 14 years of his life.
(2) 1957: Seven Countries Study led by Ancel Keys of the University of Minnesota
(3) 1961: Ancel Keys is on the cover of Time
(4) 1968: Minnesota Coronary Study
In the Seven Countries Study, Ancel Keys, who was a leading nutritional physiologist of his day (World War II K-rations were said to be named after him) and his coworkers reported results from Italy, Yugoslavia, Greece, Finland, The Netherlands, Japan, and the USA. Their data (minimally) supported the hypothesis that a diet high in fat led to heart disease.
The subsequent history of the Seven Countries Study has been fraught, including criticism of the methods (e.g., Greece was studied during the extended Orthodox Lent when most of the subjects were fasting) and speculation about why these seven countries were included and others, such as France, where a rich diet high in fat did not lead to and increased burden of heart disease, were excluded.
From 1968-1973, the Minnesota Coronary Study compared the typical “American Diet (eggs, bacon, meat, whole milk, butter, cream, one starch-one vegetable)” with a “Cholesterol-lowering Diet.” 9,000 men and women participated in the study, which found no correlation between heart health and diet. Over the course of the study, 269 deaths were recorded in the Experimental Group (cholesterol-lowering) while 206 deaths occurred in the control group on the American diet. The results were not published until 1984. When Ivan Frantz, Jr., the principal investigator for the project, was asked why it took so long to go public, he replied, “We were just disappointed in the way it came out.” An analysis of the recovered data published in 2016 showed:
(1) No mortality benefit for the intervention group
(2) A 22% higher risk of death for each 30 mg/dL decrease in serum cholesterol
(3) No evidence for protection against cardiac atherosclerosis or heart attack
(4) No evidence of benefit on mortality from coronary heart disease
(5) No support for the hypothesis that replacement of saturated fat with linoleic acid[3] translates into a lower risk of death
(6) Incomplete publication[4] “has contributed to overestimation of the benefits of replacing saturated fat with vegetable oils rich in linoleic acid.” Nevertheless, the unquestioned dogma became “eat fat, get fat, have a heart attack.”
In 1993, the Women’s Health Initiative (a study of 49,000 post-menopausal women) spent $725M (approximately $1.3B in current dollars, or enough to support approximately 1000 NIH research grants, 5 years each at $250,000 per year) on the health consequences of a low-fat diet, hormone replacement therapy (HRT), and vitamin D/calcium supplementation.
The results ranged from underwhelming to alarming. Dietary modification did not reduce the risks of coronary heart disease (CHD), stroke, cardiovascular disease (CVD), colorectal cancer, or breast cancer. Vitamin D/Calcium supplements did not reduce the risk of hip or other fractures while showing a small improvement in bone density and may have had a marginal effect on the risk of colorectal cancer. HRT did not reduce the risk of CHD. HRT did increase the risk of breast cancer in some subjects, however. When these results came out, Elizabeth Nabel, then Director of the National Heart, Lung, and Blood Institute (NIH) stated, “The results of this study do not change established recommendations on disease prevention.” (Good Calories, Bad Calories, p. 75). Okay, then. What might, one could ask…
While Ancel Keys was closing the circle on the conclusion that fat is bad and must be replaced, necessarily by carbohydrates, John Yudkin was working independently in the Department of Nutrition of Queen Elizabeth College (Kings College, London) on the largely correct, in my view, Carbohydrate Hypothesis that heart health was harmed by the overconsumption of carbohydrates, particularly refined sugar. For various reasons, Keys was lionized while Yudkin was marginalized. The (High Fat) Diet-Heart Hypothesis won out while the Carbohydrate Hypothesis languished. Alas. The Carbohydrate Hypothesis (short version) can be summarized as follows:
(1) Dietary lipids (including cholesterol, which is not a lipid) are demonized based on little more than “That makes sense: Eat fat, get fat (and die of a heart attack). The public follows the Great American Food System (sic), because it has no real choice, and fat calories in the diet are replaced by refined carbohydrates present in food-like substances marketed by Big Agriculture and Big Food.
(2) Insulin dysregulation ensues in a large subset of otherwise normal, healthy people.
(3) Obesity, Type-2 diabetes, and Metabolic Syndrome are the result, which we can see all around us.
Which brings us to the work of Gerald M. Reaven, who introduced Metabolic Syndrome (Insulin Resistance Syndrome) to the world. In a nutshell, people with metabolic syndrome have 3 of 5 of the following: (1) waist circumference greater than 40 inches in men/35 in women, (3) elevated triglycerides, (3) reduced HDL – “good” cholesterol, (4) elevated blood glucose, and (5) elevated fasting glucose. The pathobiology Metabolic Syndrome can be summarized in this frank but useful oversimplification:
(1) Metabolic Syndrome is caused by dysregulation of the glucose – insulin axis.
(2) Our (recommended, inescapable, default) high carbohydrate diet leads to the chronic elevation of insulin.
(3) Insulin is our major anabolic hormone[5].
(4) When insulin levels rise our bodies are in the fed state and the storage of energy in the form of fats (fatty acids in triacyl glycerol).
(5) Chronic elevation of insulin eventually leads to insulin resistance, which results in an abundance of the unhealthy diagnostic criteria for Metabolic Syndrome listed above.
Insulin resistance is a hallmark of Type 2 Diabetes[6], which is responsible for much of the “diabesity” seen where the “Western Diet” is common.
So, which diet is healthier? The balanced diet that includes protein, fat, vegetables, and dairy, which is the healthy diet those of us of a certain age were taught to eat? Or our current diet in which calories from the demon fat have been replaced by carbohydrates?
Another useful oversimplification, but one that is based in biochemistry is this: The 2-cabon fragments obtained from fatty acids are used as acquired, especially in the never resting heart, while the 3-carbon fragments obtained from carbohydrates, when consumed in abundance are stored as fat.
My view is that we have basically been poisoned by Big Ag and Big Food for the past 50+ years. As an example, when I was in elementary school a full serving of Coca-Cola was 6.5 ounces in reusable(!) bottle (about 75 calories). That has increased to 140 calories in a 12-oz (perhaps recycled) can, 280 calories in a 20-oz. single-use(!) plastic bottle, and as much as 400 calories in a Super Big Gulp (styrofoam cup), depending on how much ice you add. The way back to health is to return to that balanced diet, which will also have positive environmental impacts, as soon as we prohibit the industrial production of meat, a coming story for another time. Also on deck is that other demon of our diet, cholesterol, which I have mostly left out of the current discussion.
Finally, there is the question of carbohydrates themselves. Are they toxic? Is there such a thing as “carbotoxicity”? A well-written perspective article, Carbotoxicity – Noxious Effects of Carbohydrates,” appeared in the journal Cell[7]in October 2018 addressing this very question:
Modern nutrition is often characterized by the excessive intake of different types of carbohydrates ranging from digestible polysaccharides to refined sugars that collectively mediate noxious effects on human health, a phenomenon that we refer to as “carbotoxicity.”
Epidemiological and experimental evidence combined with clinical intervention trials underscore the negative impact of excessive carbohydrate uptake, as well as the beneficial effects of reducing carbs in the diet. We discuss the molecular, cellular, and neuroendocrine mechanisms that link exaggerated carbohydrate intake to disease and accelerated aging as we outline dietary and pharmacologic strategies to combat carbotoxicity.
This paper appeared shortly before I began considering the nature and causes of our epidemic of obesity and ill health that is surely connected with our diet and our so-called “food system.”
I was particularly interested in the potential toxicity of fructose. Like glucose, fructose is a 6-carbon sugar molecule. Sucrose – table sugar – is made up of one molecule of glucose connected to one molecule of fructose, making sucrose a disaccharide. The history of sugar as a commodity is a fascinating subject, and it appears that the biochemistry of sugar during metabolism may be just as interesting, but with immediate interest to everyone who consumes sucrose.
This paper introduces fructose as a potentially toxic molecule and covers the subject well. Perhaps by following the lead of these authors, the nature of fructose and high-fructose corn syrup, which was replaced sucrose in many of our processed foods, will be revealed. Fineman in Nutrition in Crisis disregards this idea as “fructophobia,” but I think he is wrong. The fructose found in an apple is not present in the same dose and the fructose in a Super Big Gulp, and “the dose makes the poison.”
“Carbotoxicity” also considers the benefits of the ketogenic diet, which is rich in fat (those 2-carbon units from fatty acids are used to make the ketones during ketogenesis). A consensus has not been reached, and the article has been cited only 41 times in nearly 4 years. A modest response, but the truth sometimes takes a while to come out, especially in the era of Evidence-Based Medicine. As time allows and I read the references in this paper, I am increasingly confident the authors (all European, and that is not a coincidence) are on to something that will make a very big difference.
But this difference will be felt only when medicine is once again taught like a science and not considered an edifice of received wisdom.
_________
[1] Too harsh. Upon repeated reading they are generally good, but they tend to leave out too much of the foundational detail. The only way around that is for the teachers of medical students to add that back.
[2] Included as judicious review of both the book and the evidence. We all have our priors. The key is to recognize them. Mine are that the dysregulation of the insulin response is the culprit in obesity, heart disease, and metabolic syndrome. Correlation and causation can be linked by a plausible mechanism, which is the primary take-home lesson of Nutrition in Crisis, Chapter 13.
[3] Saturated fatty acids have no double bonds in their alkyl side chains, which means they are “saturated” with hydrogen atoms. Linoleic acid is the 18-carbon “polyunsaturated omega-6 fatty acid” with two double bonds. Unsaturated fats are widely believed to be healthier, according to the labels in the nutrition supplement store.
[4] Which is a hallmark of EBM as practiced then and now.
[5] Insulin rises immediately after we eat a sugar/glucose/carbohydrate-rich meal, and this causes the glucose to be taken up by the liver and skeletal muscle where it is stored as glycogen (glucose polymer) for later use. Excess glucose is ultimately converted into fatty acids and then transported to fat cells where it is stored.
[6] Type 1 diabetes mellitus (T1DM, previously caused juvenile diabetes) is the result of insulin insufficiency caused by the autoimmune destruction of the beta cells of the pancreas, where insulin is produced. It commonly presents at age 8-10 but can appear at any age. Type 2 diabetes is caused by insulin insensitivity, in which cells and tissues that are supposed to take up plasma glucose are unable to do so because they do not respond to insulin. T2DM is distinctly an age-onset disease.
[7] I am loathe to support any kind of argument from authority, but for a variety of reasons,mostly good, Cell, founded in 1974, is considered to be the best and most important journal in cell and molecular biology.
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Ancel Keys had the great misfortune / cunning to run his experiments on dietary and serum cholesterol in the rabbit, which we know is the only common lab animal (including man) to exhibit a pronounced change in serum cholesterol based on diet.
When people complain about being told to eat a rabbit food diet, that statement at least is good science, even if the recommendation itself is not.
Clinical nedicine (as opposed to biomedical science) is black magic and thus a social science. Treat the patient, not the disease. This is also why it should be learnt on the job, in a master-pupil fashion.
The NHS is an opportunity with its centralised data to run medicine as a continuous clinical trial. Not a randomised controlled trial but an observation study, in cases prospective, of the effects of different treatment strategies. I am not sure we will ever take the chance though….
That’s why doctors are general practitioners rather than medical scientists.
I’ve detected an alarming amount of creeping taylorism in GP work these days.
The very enemy of learning through experience.
Yep. About Taylorism: My latest visits to the doctor indicates that my GP had 15 minutes set aside for each patient – including the time to document the visit and walk the patients in and out of the office. The second visit began with the reading up of the documentation from the previous visit, a good thing since it gave the patient opportunity to correct but with more time for the first visit then maybe the risk of needing corrections might be reduced.
So little time to diagnose that it seems inevitable with repeat visits (which needs to be paid for of course, reduced price but still). Not sure anyone but the PMC in charge is happy with the situation.
As an ‘informed’ consumer I suppose it is my responsibility to find a doctor who has more time to diagnose but since all doctors are under the same kind of pressure then finding a better one might be very difficult.
Scientific curiosity is needed to gain knowledge, the Taylorism in medicine does seem to make it impossible to do science.
Excellent discussion. I have been in neuroscience since the 1980s, and have also taught medical students at Georgetown University. Medical students are now mostly taught diseases and treatments (especially drug treatments), with a little anatomy thrown in. Many show little interest in basic sciences since they have enough on their plates already. Teaching biomedicine as a science would not go over well with many medical students that I have taught. But who knows, if done well, it might win some of them over.
Half of all deaths in the 1st world are related directly to clots. Heart attack, stroke, PE. Cancers are associated with clots.
Clots are easily dissolved with enzymes, such as nattokinase, serrapeptase or lumbrokinase, all available, OTC, from eBay, Alibaba or local healthfood shops.
Viruses rarely kill the host. That way lies extinction. The immune system relies on clotting. That protects the species even if it kills the individual. Selfish DNA.
My view is that we have basically been poisoned by Big Ag and Big Food for the past 50+ years.
https://tonyisola.com/2022/10/perverse-incentives-obliterate-our-health-and-wealth/
The incentives found in the healthcare, food, and finance industries are anything but customer friendly.
There are valid reasons why 73% of Americans are obese or overweight. Health at any size is ingrained in our culture.
….
A system based on billing codes determined by never-ending stays on prescription medications is core to the problem.
….
Forty percent of The American Diabetes Association’s budget derives from Pharmaceutical companies. Is it any wonder costly medications, not lifestyle changes, are the preferred treatment method?
The ADA receives millions from food companies like Coca-Cola.
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When you get right down to it, soda pop is poison. If we had the political environment we have now back in the 60’s, there would have been no warnings about cigarettes…
…fruit juices rival soda pop for sugar concentration. As the article notes, “the dose is the poison.”
Diet AND (real) exercise seem essential elements of a healthy body.
I believe there is one more factor to consider in addition to poison and dosage — I would add to these factors the rate of subject uptake of the poison. And I might also add some measure of each human subject’s innate ability to neutralize the poison. This model comes to mind after cursory thoughts about the way poisoners in the past built up an ability to ingest poisons at dosages that killed their target.
Exercise especially ‘real’ exercise as a means to control weight seems misplaced. I believe exercise is more important for other reasons — such as strength, endurance, a feeling of well-being and personal confidence. The notion of ‘real’ exercise conjures notions of exercise relating it to ‘work’ and concepts like “no-pain-no-gain” and other paeans to the miracle of ‘work’ — especially as a palliative for the miseries of the lower classes. Try dance as an exercise. It can be fun, very pleasurable, and as ‘real’ as other forms of exercise, and dance can be joyous.
The Illness Industry is one of the world’s largest. Very profitable.
The key is to define illnesses and then offer ‘treatment’ but not cure. The case in point is the stomach ulcer.
Cure for ‘cancers’? Great research, even if only half is genuine. But cancers are less healthy than normal cells.
Antioxidants kill them. Vitamin C was recommended, intra venously, by Linus Pauling, two times Nobel winner. The most powerful antioxidant is =C=N, aka cyanide. Anthocyanins contain the cyanide complex, which is an oxymoron, as there are fewer simpler molcules.
All medicines are by definition, poisons. Most have no antidote. Cyanide has two. One is oxygen and the rate of effect of cyanide is measurable by pulse oximeters, costing a few dollars. Use two or three to verify. Google the other antidote.
Cyanide is not a recognised medicine …. yet strichnine and botox are! Vitamin ‘B17’ has the cyanide complex. Of course it and bitter almonds are both banned in the USA.
This comment is wrong factually about many things.
The commentariat here is smart enough but please, nobody believe that cyanide is a prudent treatment for anything except household pests!
Been awhile since I saw it but there was an Aussie doco made called “That Sugar Film” which was pretty devastating. Here is the first ten minutes of it-
https://www.youtube.com/watch?v=GAtDjwdo524 (10:19 mins)
During that doco (which is mentioned in that clip) there was the dispute between Yudkina and Keys. And the trigger for this was the heart attack that Eisenhower had in 1955. To cut a long story short, it was the sugar industry that threw the meat industry to the wolves by claiming that it was fats that were responsible for this happening which led to the low-fat theory – while sugars ended up getting a free pass. So as these corporations removed fats from their foods they had to substitute something else to replace the loss of tastiness and frequently they used sugars.
Thank you, KLG, and Yves, for bringing this up for discussion.
Monday evening, we were talking with our neighbor, who was deploring the fact that his two adult daughters were obese and they could not seem to do anything to remedy this. I observed that, with 40% of the US population clinically obese (BMI 30 or higher,) the problem might not be one of personal responsibility, but a structural/social one.
Yesterday, the NYT published the results of a national report on diabetes presented to Congress (ok, stop guffawing!) which summarized: ” There is no device, no drug powerful enough to counter the effects of poverty, pollution, stress, a broken food system, cities that are hard to navigate on foot and inequitable access to health care, …. ”
The report mentions the pervasive presence of some form of sugar in almost all our foods and recommends steps that government could take to remedy the problem (ok, stop with the eye-rolling …. Congress might actually do something!) This includes changing labelling so sugar content is expressed in teaspoons, rather than in grams: So, a 16 ounce Starbuck’s frappuccino contains 11 teaspoons of sugar!! And we’re still throwing pot dealers in jail!
I had pineapple with kefir for breakfast. Should I be avoiding sweet fruit like pineapple because of the fructose?
Probably no, but not a whole one everyday.
Reminds me of a passed on apocraphy, about shipwrececked sailors washed up on a pineapple rich island, who started rotting from the inside because of it’s sweet acids.
All the evidence I’ve seen is that when fructose is consumed in its natural packing – i.e. plant fibre – its healthy, unless you take too much too quickly (e.g. make a fruit smoothie and swallow it down quickly, so sending your insulin response through the roof).
I know of a doctor in Honolulu who has cured various ailments with his principal prescription: pineapple juice. (Once, for a patient mysteriously wasting away in the hospital, who failed to respond to medications, he added potato chips. The patient recovered.)
Once when I was telling this story, I was overheard by a Bengali interpreter, who said that his mother always have her children pineapple juice at the first sign of sickness.
Bromelain?
Yes, you should be avoiding sweet fruits like pineapple, which contain sucrose (disaccharide of glucose and fructose), fructose alone, and glucose alone. Sugar is a cumulative poison in our diet. It leads to metabolic syndrome (high blood pressure, heart disease, stroke, diabetes/prediabetes, and many other ailments including many of the cancers). A meat diet does not. Suggest you read one of Taubes’ excellently researched books mentioned above, or his somewhat briefer “Why We Get Fat.”
Most of his advice is against prevailing wisdom, so you have to study it and think it through for yourself. Most people don’t, and thus we have an epidemic of diabesity, metabolic syndrome, colorectal and pancreatic cancers, etc.
I look forward to your series on EBM. I’ve always viewed it with deep suspicion based on who is supporting it – but its hard to argue past the basic principle of using evidence as a basis for decision making rather than long established practice. As so often, you need to dig deep into the epistemology to find the problems.
Dietary advice is now of course horribly confusing, with the public health science establishment not having helped itself for all the reasons outlined above. I’d also highlight the very confused and confusing science around supplements. Several key Cochrane reports that seem to dismiss the use of multivitamins seem to be based on dubious assumptions. Or put simply, if you have an underlying bias in thousands of studies, carrying out a meta study will simply replicate the underlying problem. But its a complex area. I think the evidence is increasing that its a major mistake to take a too reductionist approach to diet. For example, the studies into taking more vitamin D have been disappointing, but it does seem that a combination of D, K2 and magnesium provides measurable benefits. Or you could just eat your greens and take lots of walks in the sunshine.
As for fats – my understanding is that current advice (again, based on Cochrane meta studies) is that eating cholesterol or fats is not bad – what is bad is saturated fat, and there is indeed (so far as I’m aware) a pretty well established connection between certain fats – trans fats obviously – but also saturated fats from red meat and dairy with cardiovascular disease. But obviously refined carbs and sugar is almost certainly worse for your health. I’d also add that a major finger seems to be pointing to seed oils as a huge problem in our diets. Or put another way, replacing butter or lard with olive oil is good – replacing it with cottonseed oil, canola or sunflower seed oil may well be a big problem. I don’t think its a simple matter of saying ‘carbs are bad’. There are extremely healthy populations around the world (in parts of Africa for example) where the consumption of carbs is very high. Indeed, it was very high for Roman gladiators too, and it didn’t seem to do them any harm.
As Michael Pollen says ‘Eat food, mostly plants’.
Saturated fats are good, look at the inuits or the masai.
They eat food, solely, saturated fats.
I don’t know where it is right now, but there is a credit suisse (!?) report on their advantages over what they refer to as ‘solvent extracted fats’
(reflecting the industrial processes in these previously unused chemicals)
Here it is, straight from the pinstriped heretics’ mouths.
The idea that the Inuit did not suffer from excess cardiovascular disease historically appears to have been a myth, based on some badly designed early studies.
The mortality from all cardiovascular diseases combined is not lower among the Inuit than in white comparison populations.
If it is not lower, then they have at least been doing fine all these years on mostly fat.
As most of the ‘good’ studies have been done in an increasingly westernised population, you would not expect them to differ.
Conclusions. Our results indicate high rates of diabetes, undiagnosed diabetes, pre-diabetes and metabolic syndrome among adult Alberta Métis Settlement dwellers.
Diabetes, while very much a moving target(pre diabetes) is generally viewed as contributing towards cardiovascular problems.
Don’t eat anything your grandmother wouldn’t recognise as food.
PlutoniumKun,
I often read your comments, and I have concluded that your knowledge is much more worldly than my own. Nevertheless, did you notice that your first three (insightful) paragraphs skew towards nutritionism – which I believe both you and I are deeply skeptical of – but Pollan’s quote is simple and sensible unscientific advice? Of course, comments that are about the science (or pseudoscience if you prefer) of nutritionism are most apt in this article by KLG.
My areas of research revolve around sensory sensations, neuropathic pain, and addiction. I haven’t quite delved into nutrition science yet. Nevertheless, I do recommend that we talk about diet in plain English. Please eat lots of vegetables and fruit. You should not be eating any industrial food with food-like additives such as sweeteners or processed fats like soy lecithin. When you go to the grocery store (or even better the farmers market), you should not even bother walking up and down the aisles and aisles of canned soup, frozen food, cereal, potato chips (crisps), sports and energy drinks, and pastries. Please buy things in the produce section without any packaging or nutrition labels and see if you can cook a meal out of just vegetables. If you do buy meat, get the fanciest stuff you can find. No, not bacon. Not ground beef. Ideally, you use meat or seafood to flavor the rest of your dish, instead of eating meat for the sake of eating meat.
American citizens should be furious that powerful vested interests (Big Ag, Big Food) tricked us into believing the dogma of dietary fat causing cardiovascular problems when studies like the Minnesota Coronary Study and the Women’s Health Initiative suggest otherwise. The Minnesota study ended in 1973, but the results were not published until 1984 with a recovered data analysis published in 2016? Whiskey tango foxtrot? Why didn’t these two studies test if dietary sugar is problematic? Surely, $725M could have been allocated to answer whether or not sugar is dangerous. Incidentally, I have noticed an unusual number of studies about dietary sugar emanating from Minnesota. Here is one example: Sugars and Sweet Taste: Addictive or Rewarding? Can I trust these scientists who put scare quotes around “addiction” when referring to sugar consumption? In KLG’s previous post about Alzheimer’s, Dr. Lesné and Dr. Ashe from University of Minnesota were implicated in fabricating images to support the amyloid plaque hypothesis. UMN again?
I read this and the comments and can only conclude, yet again, how broken and dysfunctional our society is, and how this is only one example of the many that demonstrate how captured the entire system is.
The lack of moral outrage is a feature, not a bug.
While I wish it were otherwise, all the perverse incentives to retain or double down on what isn’t working leads me to conclude it is likely that change will only occur when things are finally broken, beyond repair.
The distance this run to oblivion has covered intact shows how resilient and blind we can be. We, as a species, keeps doing more of the things that will bring about our demise. The plates keep being spun educationally and academically, economically, scientifically, politically and governmentally, corporately, and socially.
Story after story here removes what is hiding and exposes the “naked” truth of our plight. The similarities and connections become visible.
While there is clearly so much good in the world, evil keeps advancing it stranglehold to whose benefit? No mine. I expect not yours either.
cheer up, malcolmx, martin luther king and even jeremy corbyn had these moods.
I would propose as an addtion to the bibliography,dr malcolm kendrick’s ‘statin nation’ as an excellent and concise summary of the history of scientitious dietary fads, especially the ostracised yudkin and the lauded keys.
His most recent, ‘The clot thickens’, is awaiting my attention (but following his blog I am familiar with) and the penultimate, ‘doctoring data’ should be available in every medical class, and practice waiting room.
Two years back, my husband, then age 65, excellent health, athletic (decades of long distance and commuting bicycling,) normal cholesterol levels, normal to low blood pressure, was prescribed a statin. Just because. His provider even sent in a prescription to the pharmacy, despite husband protesting vigorously. He refused to pick up the prescription. Health care providers must be under enormous pressure from their institutions and Big Pharma to make their numbers.
Statins seem to have ruined my mother’s health,so i am royally pissed off and biased, but and as they have an official end point efficacy, lowered cholesterol, which has no discernible benefit, they are basically snake oil.
Despite being a blockbuster drug, data is locked away, so it is very difficult to understand how good or bad they are.
Thank you DLG, it’s a thought provoking post.
My Mother was a big Adelle Davis fan, my sister and I were raised to a large degree on organic foods, soda pop allowed twice a year when camping.
She was also an organic gardener starting in the late 1940’s
I have never had a McDonald’s hamburger, they smell bad.
Those eating habits have stayed with both my sister and I, and I believe it has made a significant difference in the quality of our lives.
And when it comes to “Treating the Patient” I have idiosyncratic drug reactions and a complex medical history, a Physician who has acquired an intuitive understanding of both people and their discipline through talent and a lot of hard work is a life saver.
Literally in my case.
Thank you Patrick G.Devlin MD .
I am eagerly looking forward to reading this series on EBM. I’m fascinated with biochemistry, and the (f)actual study of human health, diet, and medicine.
Excellent; I look forward to your post on statins.
It’s easy to go down the wrong rabbit hole, as the author has. The diet debate is about as settled as the debate about global warming. The problem is industry funding is so overwhelming, they are all following big tobacco playbook spreading doubt and misinformation. The fact that the author references Gary Taubes and Nina Teicholds who are well known industry hacks is troubling. Gary Taubes writes books spreading good news about your bad habits, because that sells. Nina Teicholds is well known to be funded by the beef industry. These are not credible people. Perhaps a better source would be Marion Nestle (NYU nutrition), and Pekka Puska (took Finland from highest heart disease rates in the world to lowest)
the rot runs deep. thanks for clarifying that I hadn’t checked his sources yet.
I don’t think dismissing Taubes and Teichold as hacks without supporting evidence is helpful.
Here is a very interesting multipart discussion on the evidence for obesity having a non-nutritional origin (environmental / non-food diet).
https://slimemoldtimemold.com/2021/07/07/a-chemical-hunger-part-i-mysteries/
They have been debunked by plenty of people, in long form. Admittedly there’s a youtube video “debunking” just about everyone. Critical thinking helps to separate the wheat from the chaff.
References, then, please! Intoning “it is debunked” is sacramental rather than Socratic.
Well you could look at Weston A.Price who has always struck me as a good egg.
And, as one looks around the sucrofised world, was john yudkin so wrong?
john yudkin was not wrong. pure sugar (sucrose) is not a health food, pure fructose is even worse. The common denominator is processed food. fructose in fruit is laced with fiber and in relatively small portions compared to processed food, hence fruit is a health food. The issue is that somehow these people pivot from processed food/sugar is bad to all carbs are bad so eat more fat/animal protein. It’s dishonest.
I’d stay away from Weston A. Price foundation they are on the carnivore spectrum, and have been thoroughly debunked as harmful noise.
That is why I referenced the person,not the foundation.
But then, I probably might have not found the person without the foundation, who might be a little cranky.
…but a little critical thinking can go a long way, quite widely.
“The diet debate is about as settled as the debate about global warming.”
The scientific debate about anthropogenic global warming is as unsettled as the debate on smoking and health. The political debate continues ad infinitum.
Hacks? Regarding Taubes and Teicholz as journalists and their priors, this is why I included Footnote 2 as the link to The Case Against Sugar; it is a review of the book by Daniel Engber from The Atlantic and covers Taubes and Teicholz and associated issues very well.
I stand by my thesis that Gerald Reaven is correct regarding the obesity epidemic as a result of dysregulation of the insulin – glucose axis caused by the replacement of fat calories with carbohydrate calories in the “Western Diet” for the past 50 years. Given that insulin is our primary anabolic hormone, this makes perfect physiological sense and the literature on metabolic syndrome supports this. Our medical responses have tended to pharmacology rather than fixing our diet, however. This is included in the Carbotoxicity review, but “more and better” drugs cannot be a sustainable (to use a keyword of the day) solution to the problem. A good case has been made that processed food is a/the culprit, but this processing includes adjusting Salt, Sugar, Fat content to make these food-like substances more or less addictive. New Coke contained more sugar and that made those surveyed like it better than “Classic Coke” at first taste, but not later…and then there is the Lay’s Potato Chip. When I open the bag they all disappear.
Marion Nestle is great, and I heartily recommend her. I also imagine Big Ag and Big Food have called her a hack.
For a brutal debunking of all this Meat is bad nonsense peddled by vegan ideologues, I would suggest Prof. Bart Kay.
https://youtu.be/JszSYeco7-M
“glucose axis caused by the replacement of fat calories with carbohydrate calories”
Though some people argue that glucose resistance is caused by a high fat diet, even if they were wrong and your thesis was correct, the emphasis should on *refined* carbs, such as added sugars. Fundamentally there is nothing wrong with complex carbs from whole plant foods as evidenced by the fact that the longest living people on the planet in the “blue” zones, get something like 80 percent of their calories from carbs, and don’t suffer from type 2 diabetes or obesity. The added sugar in processed food is the problem and nobody argues processed food is good for you. The salt, sugar, fat book you cited is fantastic at illustrating this point.
“The scientific debate about anthropogenic global warming is as unsettled as the debate on smoking and health.”
There is still undoubtedly research going on in both fields to tease out various nuances, however the science is settled that smoking is bad for your *overall* health, and the earth is warming and it’s anthropogenic. That is pretty much settled science and has been since around 1970 if not earlier. This much even big oil and big tobacco agree on since around 2010.
web search yeilds:
exxon knew about climate change
cdc on smoking
big tobacco court ordered campaign to tell truth about smoking effects
Taubes’ Good Calories, Bad Calories is an incredibly well researched book. His exploration of the politics in science literally rocked my world. I picked it up thinking I would get a good perspective of the fat vs. carbs debate. Not only did I get that, I got a peak behind the curtains at what I naively had still believed to be balanced science. I was somewhat cynical before that book, I knew about citation societies (you quote me and I’ll quote you) but I had no idea that scientists of all people would support something they knew to be false if they were on the right side of their institution’s agenda. The personalities and cliques and politics of science were something so wrong to me and literally led me along the path of critical thinking, questioning and complete and utter disappointment in the world that I now have. Without Taubes’ book I would likely have never made my way here to NC. Not a direct connection but just a new way of thinking that made me look beyond conventional wisdom (now there’s an oxymoron). I have a friend who in many ways is a typical member of the PMC, a scientist, actually an epidemiologist. Huge believer in low fat eating. I knew that she would not be a fan of the Taubes book but risked mentioning it because his research was thorough and so overwhelmingly convincing. She never picked up the book. Instead she found a review that indicated that Taubes said you don’t have to exercise and went no further. Any reviewer who could get that out of Taubes book didn’t read too closely. What he said he said is that it is not technically necessary to exercise to lose weight. The guy is a runner, he understands the benefits of exercise. If people like that reviewer are the kind of people claiming Taubes is an industry hack, I would argue that they are just continuing the practice of choosing a side based on faith, politics and which side of your bread is buttered rather than trying to understand or practice scientific method.
My husband and I keep a list of quotes and sayings that we imagine putting on T-shirts some day. One of my favourites is “Ansel Keys was an asshole”
What industry is Gary Taubes “hacking” for? He worked for the New York Times at one point in his career, so is it the news industry? He no longer works for them, but does publish books, so is it the publishing industry. Or perhaps the freelance science writers “industry”? True, if he were working for meat producers it could be a conflict of interest, but I see no evidence of that. On the other hand, he cites very ample evidence (“The Case Against Sugar,” pp. 128-9) that two of the leading proponents of the cholesterol hypothesis, Ancel Keys and Fred Stare, were funded by the sugar industry!
I don’t know Nina Teicholds.
You make good points. It’s true that Ancel Keys was funded by the sugar industry (I’ve never heard of Fred Stare). Thus his research should be scrutinized. My understanding is that his 7 countries study has stood the test of time and has been corroborated and improved upon. It’s not like his study is one of it’s kind and hasn’t been followed up on in the past 50 years. People attempt to discredit him because he is associated with the idea that cholesterol is bad.
Just because Gary Taubes is not on the payroll of big Beef doesn’t mean he’s not a hack, which is to say selling snake oil. There are many people in the nutrition industry who write “good news about your bad habits”. They do so because these books sell! If you think writing for the New York Times automatically endows one with truth and integrity, you are on the wrong site.
Thank you for this thought provoking essay. I’m a clinician (anesthesia) in my early 60s, I remember well how biochemistry in first year was an exercise in memorization, devoid of insight and understanding. In anesthesiology, the history of the specialty was revered, and the limits of our understanding of central nervous system physiology respected (I have been away from the academy for >25 years now).
When I first heard the phrase ‘evidence-based medicine’ decades ago, I knew it was trouble; from the start, a program for deception and marketing. I never connected Sheldon Wolin’s inverted totalitarianism description to EBM and it’s beloved meta analysis, but of course that is spot on.
I could go on at length with more ‘right ons’ as reaction, based on my experiences, but I will look forward to your next piece. Thank you KLG.
I can’t reference it, but I once read a GP’s awed account of how a cardiovascular professor employed the stethoscope.
He had,through application and experience, an almost perfect diagnostic method, he could tell what was irrelevant or not, just using this archaic tool.
I was examined as part of my induction to universsity and the useless hack detected a murmur.
I spent a week agonising over every slight noise in my chest until the specialist told me I had never had anything to worry about.
Sometimes, practice is perfect.
In my previous institution I sometimes worked with a retired pediatric cardiologist who was in her 80’s at the time. She was renowned for her skills. Before every heart surgery performed on a child, she would examine and listen, for as long as necessary. She would then tell the surgeon exactly what would be found during the surgery. This continued even as echocardiography and other imaging techniques improved. Healing hands are very real, when they are allowed to function.
I heard similar stories when I worked graveyard switchboard at a couple of hospitals while going to college — cardiologists who could diagnose things like kidney problems from reading cardiograms to cardiologists who were challenged to calculate a patient’s pulse rate from reading cardiograms. Until Humankind can discover, learn, and apply a much larger body of Knowledge than available at present I believe Medicine is and remains an art.
“Science” as a study of what doesn’t work (and why not), even if epistemologically sound, runs directly contrary to the idea of “science” held by most people, especially those who consider themselves educated. To too many people, science is valuable because it is “true,” something that can’t be challenged because it just is–in a way, analogous to “2×2=4” in the words of the Grand Inquisitor (Dostoevsky), something that is true because it just is and there’s no arguing against. “Science,” as popularly understood, belongs in the realm of parareligion, not really “science,” and, I suspect medicine is actually taught like “science” in this sense.
I don’t know if “science” as epistemology is something that most people can be taught easily, though. The contrast between Orwell and Dostoevsky, in this dimension, is pretty staggering, and Orwell was more cynical than most Westerners. Even he had trouble grasping why “2+2=4” was not just true because it was self-evidently so. The idea that the Big Brother could possibly use the self-evidently “2×2=4” to silence potential critics never occurred to him. But “science as epistemology” can’t rest on the argument that X is true just because it is and should never resort to teaching simply that X is true and that’s that, no matter how self evident X seems. (I started thinking about this given how faithfully some/many people “believe in” the efficacy of radical mastectomy and have themselves mutilated, and in addition to feeling good and proud of it, feel justified in prodding others to do the same because it is “the truth.”)
I dunno. The idea that scientific investigation is an unbiased exploration of a question through experimentation was a concept that I grasped pretty easily in school. Our physics teacher taught us to ask questions and was always clear that her answers were based on what science had discovered to date, not what was ‘true’. We did our experiments and it was our written reports, the step by step records of what we did that were as important as our method and results.
If you see my other post about Gary Taubes’ book, Good Calories, Bad Calories, you’ll see how disillusioned I was to learn that scientists are not unbiased explorers. The other book that was a huge wake up about politics and personality science was Norman Doige’s The Brain That Changes Itself – about the discovery of neuroplasticity. The guys who believed that areas of the brain were responsible for certain things and once damaged by injury or stroke that process was altered or gone for good were believed and respected long after neuroplasticity, the idea that the brain builds new pathways and can relearn things, was a credibly proven thing. I forget names now but the chief proponent of the brain as unalterable was a hugely respected neuroscientist, with a huge ego and he more or less bullied his way to remaining the preeminent brain scientist long after his due date. It was crazy to me that a scientist couldn’t accept that new things had been discovered and that his approach was now wrong. To his credit in the end he did admit that he’d been wrong and apologized to the neuroplasticity guy.
What did someone say recently about the pandemic… Q: what do you get when you mix science and politics? A: Politics!
I think there’s a bit of conditional hierarchy in what passes as “self-evidently obvious” (so that it does not require unbiased exploration through experimentation) for different people and different circumstances.
To the “specialists” who have invested their career into certain ideas, like unalterable brains, steady state universe, etc, their existing ideas are, or must be, so true that the contrary ideas need truly extraordinary proofs that are likely very hard to attain (thus the talk about science progressing at the rate of, what, one obituary at a time, as per, I think, Planck?). But, at least, scientists are willing to accept that their preexisting ideas can be wrong when presented with a certain amount of evidence (even if the standards are almost impossibly hard to meet) and they are willing to change their mind when that threshold is reached.
To the people who fancy themselves (probably justifiably) well-informed but are not scientists, the problem seems fundamentally different: they consider themselves well-informed not because they do science but because they “know” things. They do not “know” things because they understand how they arrived at the things that they think they know because of evidence and the causal mechanism but because these things are simply “true” and they read them (or learned of them through other means) in the sources that tell the truth…because they do. So their idea of “self-evidently true” is not based on scientific evaluation of the empirical evidence, but because of the faith in their “books” (whether Loudon’s OChem or Griffith’s Electrodynamics or, for that matter, Neil deGrasse Tyson talking about stuff.) This group has to far outnumber actual “scientists” (broadly defined) pretty much everywhere and I have the sense that a lot of doctors actually fall into this crowd. Further, I think people who are actual scientists in their own field are inclined to be mere “informed people” in areas not of their expertise.
When you mix science and politics, you wind up empowering the latter group even over the former. It would be hard enough to convince old scientists that their beliefs are wrong given the amount of evidence required…but as long as they are still doing science, it is doable. But the latter don’t really take critical evaluation of evidence at all–X is true because important and smart people say so. Not only because there are so many non-scientists at any time, on any given topic, than there are scientists, but because the people who have invested their time into activism, or, indeed building political and social influence have not spent time doing science earlier in their lives (not a knock on them–time is limited after all). So if a “scientist” wants to gain influence with them, it becomes necessary to appeal to their preexisting beliefs about what is “true” and leverage their political/social skills/assets. You can’t talk “evidence” with them because their knowledge is not really built on evidence as such, but faith in the people/sources that they trust.
Makes you wonder why monasteries (or eccentric rich people) naturally become the centers of scientific advancement at so many times in history, doesn’t it? If science (or faith therein) becomes the path of accumulating social and political power, science degenerates since it has to bow to serve the interests of those who presume themselves well-informed who happen to be in positions of power.
I am not a fan of Kuhn. Science does NOT advance one funeral at a time — ‘science’ does. Scientific hegemony too, advances by funerals. Wealth, Power, and Fame only rarely advance Science. The current flows of funding lines for research greatly contribute to the problem Kuhn identified … but that problem is not characteristic of Science or the Scientific Method.
What a splendid essay.
Here’s a guy who discovered that human’s glycemic index (the rate at which we digest food to make glucose) varies widely. I’d still bet high fiber foods are the way to go, even if they have glucose or fructose within them, but apparently some people can eat ice cream without a spike in their blood sugar, others cannot.
It will be interesting in a few years when Apple rolls out Continuous Glucose Monitoring on the Apple Watch. We will finally see the real data on fruit/plant based diets and fibre. I suspect it will not look very good and Lo-carb/keto/carnivore will continue to look better and better.
Peter Attia is an excellent source for a scientific approach to medicine.
Don’t eat anything your grandmother wouldn’t recognise as food.
KLG I can’t wait to read your exploration of Evidence Based Medicine. I worked as a librarian at a community college affiliated with one of the founding homes of EBM, McMaster University in Hamilton ON. My college jointly offered a nursing program with McMaster. In order to help the nursing students in the library we had to understand EBM. I was not sceptical of it at first, seemed an interesting and useful approach. But the zeal with which profs and mds approached it gave me pause. It seemed much more a belief than a science. Kinda weirded me out. But humanities was my thing and I didn’t have a whole lot to do with our science library so never really got beyond those slight doubts. NC is the first place where I encountered outright questioning and criticism of EBM and I thought, ah ha! maybe my spidey senses weren’t wrong! Again, can’t wait to read the series so I can understand from a scientific perspective. Thank you so much!
Thus, all understanding develops from the history of a discipline.
I may well be misunderstanding the author’s point but I have very little faith in scientists having much knowledge of the history of a discipline beyond what tales they heard from their adviser.
A recent “rant” at The Renaissance Mathematicus, one of many, suggests most scientists make poor historians .
This post bothers me greatly. I believe this post conflates the practice of Medicine with Medicine as Science. I believe Medical Practice should be based on Science — but it is NOT Science. I very strongly believe that it is an Art.
This post ranges over many topics. It is difficult to separate topics but I will try. The “the state of education in medicine” is very much tied to how the u.s. selects those who would become physicians. It has been many years since I was at college. One of my roommates was pre-med, as were many of my friends. Their entire curriculum consisted of a series of “wash-out” classes. There were undergraduate sequences including physics, calculus, and basic chemistry to weed out the unworthy, followed by the junior-year sequences of O-Chem, Bio-Chem, and Genetics Lab, and others I am not aware of because they did not trouble my roommate. I believe there were wash-out classes for senior year pre-med but by senior year most of the cohort hoping to become physicians had already washed-out and the applications, interviews, and recommendations filters were in full play. My roommate had already lost out by then, although that did not stop him from applying to med-schools.
I am not sure my roommate would have made a good physician. However, I make that judgment
based on other criteria than his grades. He wanted to practice as a plastic surgeon and genuinely wanted to practice repairing things like harelip and similar juvenile injuries and afflictions … and I believe his desire was quite genuine and not inspired by $$$. [He later went back to school to get a degree in social welfare so he could find a job as a social worker.] My judgment of his suitability is solely based on never seeing any indication that he had ability or interest in sculpture, or indication that he had remarkable dexterity. Those are capabilities, interests, and skills I would look for in a plastic surgeon. He was also unable to recognize the realities of his situation and plead for his suitability as a general practitioner based on his very real compassion and care. I believe he would have made an excellent General Practitioner … WHY? My roommate genuinely cared about people and would have cared deeply about caring for his patients. As far as I could tell big-$$$ held little interest for him.
Aside from the highly questionable way candidates for medical school are selected, I strongly object that medical schools have been allowed to inflate the amounts they charge for the training and partial certification they provide. College should be funded as a Common Good. Medical School Training partially funded by what amounts to indenture of the students selected is, in my opinion, beyond criminal. Intern and resident exploitation and hazing, as currently practiced, is unconscionable, abusive, and costly to patients. The way physicians and specialists are allowed by most[/all?] states to set their own standard fees for various practices and treatments … is unconscionable, abusive, and costly to patients and to our Society. The trends toward Neoliberal privatization of the practice of ‘medicine’ are appalling. The ancient profession of physicians has grown monstrous and misshapen but its ongoing Neoliberal privatization … I have no words to describe my FEAR and disgust. I strongly disagree with any idea that the Practice of Medicine should be taught as a Science. I do not want my physician to be excellent at O-Chem or Bio-Chem but unable to listen to me, question what I say, and care — really care about me as a patient.
Medicine should be studied and advanced as a Science. Medical Practice should and must be taught as an Art. Medical Science must be freed from the predations of Neoliberal Markets. There is too much to know for anyone to avoid the ancient Wisdom of not trusting to experts. Knowledge has grown too large and too diverse to avoid trusting to experts. [However, each of us must always question what we are told/sold and always attempt to become experts sufficient at least to ask pointed questions.]
Thank you. I hope you come back and look again.
I think we agree on much more than we disagree; maybe that will come out in the second post in this series of two. Including our view of Thomas S. Kuhn (comment below), whom I encountered as an undergraduate about 15 years after The Structure of Scientific Revolutions was published. If I never hear “paragigm” again that will be too soon. One of the best books I have ever read on the philosophy of science is The Ashtray (Or the Man Who Denied Reality). Alas, Saul Kripke, who figured large in Morris’s book died last month. But who knew that one of our best documentary film makers was a philosopher of science at heart? At one time.
I highly recommend Dr Greger
Nutritionfacts.org
His book https://nutritionfacts.org/book/how-not-to-die/
covers the top 10 causes of death and discusses the diet and nutrition issues for each.