A Focus on Fees: Why I Practice Evidence Based Medicine Like I Invest for Retirement

He is the best physician who knows the worthlessness of the most medicines."  - Ben Franklin

This blog has been highly critical of evidence, taking every opportunity to strike at any vulnerability of a trial or research program.  That is because this is serious business.  Lives and limbs hang in the balance, pharmaceutical companies stand to gain billions from "successful" trials, investigators' careers and funding are on the line if chance findings don't pan out in subsequent investigations, sometimes well-meaning convictions blind investigators and others to the truth; in short, the landscape is fertile for bias, manipulation, and even fraud.  To top it off, many of the questions about how to practice or deal with a particular problem have scant or no evidence to bear upon them, and practitioners are left to guesswork, convention, or pathophysiological reasoning - and I'm not sure which among these is most threatening.  So I am often asked, how do you deal with the uncertainty that arises from fallible evidence or paucity of evidence when you practice?

I have ruminated about this question and how to summarize the logic of my minimalist practice style for some time but yesterday the answer dawned on me:  I practice medicine like I invest in stocks, with a strategy that comports with the data, and with precepts of rational decision making.

Investors make numerous well-described and wealth destroying mistakes when they invest in stocks.  Experts such as John Bogle, Burton Malkiel, David Swenson and others have written influential books on the topic, utilizing data from studies in economics (financial and behavioral).  Key among the mistakes that investors make are trying to select high performers (such as mutual funds or hedge fund managers), chasing performance, and timing the market.  The data suggest that professional stock pickers fare little better than chance over the long run, that you cannot discern who will beat the average over the long run, and that the excess fees you are charged by high performers will negate any benefit they might otherwise have conferred to you.  The experts generally recommend that you stick with strategies that are proven beyond a reasonable doubt: a heavy concentration in stocks with their long track record of superior returns, diversification, and strict minimization of fees.  Fees are the only thing you can guarantee about your portfolio's returns.

Tell Them to Go Pound Salt: Ideology and the Campaign to Legislate Dietary Sodium Intake

In the March 28th, 2013 issue of the NEJM, a review of sorts entitled "Salt in Health and Disease - A Delicate Balance" by Kotchen et al can be found.  My interest in this topic stems from my interest in the question of association versus causation, my personal predilection for salt, my observation that I lose a good deal of sodium in outdoor activities in the American Southwest, and my concern for bias in the generation of and especially the implementation of evidence in medicine as public policy.

This is an important topic, especially because sweeping policy changes regarding the sodium content of food are proposed, but it is a nettlesome topic to study, rife with hobgoblins.  First we need a well-defined research question:  does reduction in dietary sodium intake:  a.) reduce blood pressure in hypertensive people?  in all people?  b.) does this reduction in hypertension lead to improved outcomes (hypertension is in some ways a surrogate marker)?  In a utopian world, we would randomize thousands of participants to diets low in sodium and "normal" in sodium, we would measure sodium intake carefully, and we would follow the participants for changes in blood pressure and clinical outcomes for a protracted period.  But alas, this has not been done, and it will not likely be done because of cost and logistics, among other obstacles (including ideology).