Freedom of Speech Is Also Needed in Health and Medicine

John Mandrola, MD


October 30, 2017

The First Amendment gets a lot of attention these days.

Turmoil spreads through many US universities over what can be said and taught. Smart people disagree on the line between absolute freedom of speech and speech that harms people.

The Pulitzer-prize winning journalist Bret Stephens recently defended University of Chicago president Robert Zimmer for taking a strong stance on free speech. Stephens lauded UC's openness to ideas and debate. "If you can't speak freely, you'll quickly lose the ability to think clearly," Stephens wrote.

Decreasing academic freedom isn't only a political and societal problem. Intolerance of ideas is also relevant to health and medicine. Rational debate in medicine seems to be growing more sclerotic. I'm afraid illiberalism in society has spilled over into medicine—to the detriment of progress.

Let's start with editorials in medical journals, which, because they are often written by key opinion leaders, carry great influence. The problem is that clear-language critiques of flawed science or hyped results are increasingly rare in today's leading journals.

The reason is clear: Most editorialists are clinician scientists who depend on two things: industry funding of research and friendly editorial review in the future.

Publication in big journals is the currency of success in academic medicine. Thus, frank critique or controversial opinions remain either unwritten or severely toned down. The passive voice, bloated prose, and positive spin help diffuse contrarian ideas and dodgy studies. In the past, doctors might occasionally hear plain speaking at medical meetings, but with the advent of social media and smartphones, candor is suppressed there too.

Employed Clinicians Don't Make Waves

Control of speech also infects the front lines of medicine—the practicing clinicians. More and more clinicians are employed by big hospitals. Employment contracts come with strong no-compete clauses and warnings about harming the brand.

The need to keep one's job decreases a worker's candor. Seniority offers little protection. Look at what happened to an esteemed surgeon who spoke out on double-booking in the OR. Hospital leaders fired him.

The irony of the employed-clinician model is that many embraced it for job security but have ended up feeling more vulnerable than before. And feeling vulnerable means making less noise. The danger is obvious: Clinicians become clock-punching workers rather than leaders; bad policies persist; outlier doctors continue working unabated, and low morale becomes the new normal.

Suppression of provocative ideas in medicine has also emerged in the online space.

Social media cuts both ways. On the one hand, the new democracy of information allows anyone to control a message. Good ideas, humanness, candor are sticky on social media. Reducing medicine's vertical hierarchy is good because the value of an idea should be based on its merit—not its source.

But social media has its thought police, too. Health and medicine have online danger zones. For instance, rebuke of anything "alternative or complementary" comes swiftly, often with hefty doses of vitriol. I do not support quackery, but the possibility of a black-swan event, such as chelation therapy[1,2] for patients with diabetes and atherosclerosis, holds the promise of tamping down such hubris. Vaccines, checklists, patient safety, and quality measures are other areas in which debate seems unwelcome.

There's great wisdom in the crowd of clinicians. But we tend to be risk averse, at least when speaking publicly. Being chastised for all to see can have the effect of suppressing debate. It shouldn't be this way. The philosopher Karl Popper believed that science progressed through falsification.[3] The accepted "truth" that supplemental oxygen provides benefit to patients with myocardial infarction[4] and stroke[5] did not stand up to falsification. Nor did hormone-replacement therapy prevent cardiac events in menopausal women[6]. Not challenging science is actually antiscience.

No Middle Ground

As a writer, I've also discovered the middle ground can be a contentious place.

Much like our now polarized politics, medicine has its left and right, skeptics and believers, slow adopters and innovators. Both sides see themselves on the right (as in correct) side. Both sides can be guilty of intolerance of ideas.

I lean toward the slow-adopting and skeptical side. Marketing and hype combined with therapeutic exuberance among clinicians has led to waste of healthcare resources, overdiagnosis, medicalization of the human condition, and overtreatment. I despise iatrogenic harm. Fooling people into buying a broken-down car is one thing; fooling them into buying valueless healthcare is egregious and a sin against our profession. This view makes me friends on one side, but it raises the ire of others.

I am also a cardiologist. We use innovative high-tech tools—which don't make themselves. It should not be controversial to see the benefits of industry and clinicians working together. But sometimes it is. A public statement or a column that favors industry can inflame some of my more skeptical friends.

Healthy Debate

Despite these problems I remain (somewhat) optimistic.

The stranglehold that journals hold over freedom of thought seems ripe for disruption. Preprint servers and crowdsourcing of peer review are just beginning. Sci-Hub may be illegal, but it is destroying the closed-subscription model of scientific publication. Good riddance. Once the publish-or-perish model for success diminishes, freedom of thought in academia may improve. Not now, but perhaps in the future.

On the front lines of healthcare, direct primary care gains steam because people (patients and clinicians alike) have begun to recognize the monetary value of seeing a clinician who has time for making a human connection. And someday soon bundled payments for conditions such as atrial fibrillation will make careful and kind care more profitable than procedural care.

Finally, although the connectivity of social media has brought both benefits and harms, I believe the democracy of information and increased transparency will prove to be a net benefit for progress (at least in the realm of science and medicine).

So let debate continue. Remember what Christopher Hitchens wrote: To be in opposition is not to be a nihilist.


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