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IYIs, Uninformative Medical Diagnoses, and Interventionism

I recently completed Nassim Taleb’s latest book, Skin In The Game, and its implications for medical providers are constructive, particularly the relationship it explores between interventionism and “intellectuals yet idiots” (IYIs).  Skin In The Game analyzes the interplay between risk asymmetry, ethical boundaries, theorizing, and tinkering.  When faced with a problem, even an ambiguous one, there is usually a compulsion to do something.  Intervening seemingly assures us that we are taking measures to rectify the matter.  The issue with intervening to “fix” a poorly understood problem is that the “solution” itself can be costly and difficult to quantify even well after the damage is done.

Unintended consequences, the cost of which may or may not be desirable, are an emergent property of complex systems.  The potential for catastrophic events, predictable or unpredictable, including those resulting from interventions guided by noble intentions, is what Taleb refers to as “tail risks”.  Throwing shit at the wall and seeing what sticks might be fine in some situations but the mess that’s left behind is usually difficult to clean up following unnecessary military and medical interventions, as examples.  Ironically, the solution in security policy and medicine is often to throw even more shit at the wall to override the stench from previously calamitous interventions.

IYIs confound complex situations with complication.  Complex systems are those in which the interactions between the constituent elements cannot be predicted, quantified, or “hacked”. Hence why the term “biohacking” needs to be relegated to a tombstone.  Complicated systems are more linear and additive; the whole is the sum of the parts.  A complex system can be more difficult to manage than a complicated system that has more parts, assuming the former can even be definitely compartmentalized.  IYIs have a propensity for adding unnecessary parts to an already complex system.  Complicated systems can be reverse engineered, complex ones cannot.  IYIs apply reverse engineering to complex systems.

In any complex system extremes are maladaptive; they decrease the chance of survival.  Ventricular fibrillation and aystole are polar opposites in terms of the electrical activity they reflect in the heart.  Both rhythms are deadly, however, as they present the tail ends of electrical chaos and rigidity respectively.  Leadership models that are strictly top down or bottom up usually are not adaptable in moments of organizational stress.  Skin In The Game also explores the boundaries between tinkerers and theorists.  At the extremes, tinkerers care only about the ends and theorists about the means.  IYIs represent the extreme end of the latter continuum and pursue an understanding of the means to the point of intellectual hubris.

IYIs fabricate overly complicated theoretical models to explain what they don’t understand.  IYIs’ “main skill is to pass exams written by people like them”.  In other words, they effectively invent their own internal language to validate their existence.  Every profession is guilty of this type of theater to some extent.  IYI legitimacy is contingent upon unnecessary complication and an “expertise” not derived from competence or utility but from acceptance among fellow members of their echo chamber.  They create systemic noise and cannot connect any dots.  They are overly specialized and fail to recognize emergent patterns and pertinent questions that unite seemingly disparate disciplines.  IYIs use complexity as their shield.  When they guess (though they’d try to make you believe they don’t guess) correctly, it is because they are astute.  When their pleas for aggressive intervention end in chaos or catastrophe, complexity is to blame; nobody could have seen it coming.

IYI is in all of us. We desperately want to believe our own stories.

In foreign policy, complexity enables one to evade responsibility for advocating the removal of a dictator or dictators who stabilize a geographical region in favor of “moderates” whose ideology is more repressive than the party in power because…democracy.  Here, obstinate adherence to theory creates a gaping asymmetry between the means, democracy as practiced in the west, and the consequences, greater suffering and disorder.  In medicine, IYIs create meaningless diagnostic labels that burden the health care system and perpetuate a cycle of at worst harmful and at best unnecessary treatment directed at fixing something that was incidental but not clinically significant.

Medicine works well when symptoms can be traced to a definitive pathology, things like broken bones, isolated tumors, or diseases that target a specific receptor.  Atraumatic, seemingly “musculoskeletal” pain diagnoses leave much to be desired though.  “Patellofemoral pain syndrome”, “sacroiliac dysfunction”, “shoulder impingement”, and “trochanteric bursitis” are IYI constructs, however; fancy ways of saying a particular body part hurts but without providing any insight into how to remedy the problem or improve actual function.  Pathology can be the reason why something hurts, just not all the time.  When pain must always be accompanied by a pathoanatomical diagnosis, the treatment (if “treatment” is even the appropriate word) plan will necessarily be misguided when pathology is non-existent or incidental.

Atraumatic, non-acute “musculoskeletal” pain that can ultimately subside without surgery doesn’t warrant a pathoanatomical diagnosis.  Only a surgeon can repair compromised anatomy. Medical providers are no different than anybody else.  They/we feel better when things have a singular cause.  Again, we’re uncomfortable with uncertainty.  So when someone’s knee hurts and there’s no traumatic mechanism of injury we can tell her that she has “patellofemoral pain syndrome”.  Now that we have a pinpoint, explanatory diagnosis, we can strengthen the one muscle that fixes patellofemoral pain syndrome, the vastis medialis.  Wait, that was fifteen years ago.  Now, it’s the gluteus medius.

The muscle all-star team keeps growing but there’s a different MVP every few years mainly because someone decides to measure something novel and publish the results.  We can use EMG studies to find the “best” exercise for every muscle.  In Skin In The Game, Taleb questions whether studying components of the brain in isolation, like a neuron, promotes a greater understanding of how the brain works as a system; “so far we have no f***ing idea how the brain works”.  He refers to the seduction of reductionist neuroscience as “brain porn”.  In fairness, studying components of the brain can be medically necessary and has led to important clinical discoveries.  However, beware of commercial vendors who provide just enough “science” to market products that “hack the brain” or “ramp up the nervous system”.  Sports medicine professionals are equally seduced by “muscle porn” and EMG is typically the director.  I’m not convinced that more exercise EMG studies are going to revolutionize sports medicine, rehabilitation, and performance training.

When someone’s lower back hurts we can do complicated palpation tests with limited diagnostic reliability and validity to detect a pelvic fault in all three planes of motion.  Even better, these faults have three letter acronyms.  We can also do sophisticated postural analyses so that when someone’s earlobe deviates from a gridline by a fraction of a millimeter we can find something to fix. When training the magic muscle doesn’t achieve the desired result there are more invasive treatments awaiting to fix the pathology that wasn’t actually the problem.  As it currently stands, the manner in which atraumatic musculoskeletal conditions are diagnosed promotes therapeutic dysfunction.  In the absence of medical red flags, seeking to identify pathology shouldn’t be the default for things like knee pain or lower back pain.  IYIs are really good at finding the right answer to the wrong questions, questions only they care about.

Moreover, pathologizing all types of pain drains the health care system and reduces competition from lower cost but potentially effective practitioners from non-medical disciplines.  Once something becomes a “medical” problem it is subject to regulation and political lobbying among licensed providers.  This political infighting often creates an artificial safety hierarchy in which professions with more years of specialized education (even that which isn’t related to medical screening or triage per se) and stronger lobbies are considered more “safe”.  “Unsafe” providers, the rhetoric goes, are more likely to cause further damage to somebody in pain.  This argument can only be valid when structural damage or pathology is the primary pain generator.  When it is not, however, there is a downside to unnecessarily pathologizing something even if it can be politically and financially self-serving.

Via negativa is the idea that in the absence of obvious cause and effect, acting by removing is less error prone than acting by adding or “the good is not as good as the absence of bad” (Taleb). There’s certainly a value judgment to be made here.  When faced with uncertainty, which necessarily means the “optimal” solution (even optimal exists on a continuum) is not knowable, should the default be to err on the side of doing more or doing less?  The liberal prescription of opioids is illuminating here.  It’s one thing to administer an opiate when a soldier is wounded in battle or to anesthetize a patient for an invasive surgery.  It’s another to prescribe an opiate in less dire situations simply because one doesn’t really know what else to do.  To be clear, medical providers who prescribe opiates for things like persistent pain likely aren’t trying to turn their patients into addicts.  Their education and training condition them to look at things through a pathological lens, however. They also spend proportionally more time learning about opiate receptors than they do about risk management, ethics, and normal physiology/adaptation.  Consequently, systemic checks are needed to minimize the cost of predictable educational and political biases or as Taleb states, “Leave people alone under a good structure and they will take care of things.”  Such systemic checks or “good structures” need not refer to more professional regulation as the current regulatory measures have been gamed to minimize competition and the exchange of ideas.

Additionally, medical providers alone should not monopolize the pain conversation.  Medical people, even those with the best intentions, see things as medical problems.  Medical problems warrant medical interventions.  Medical interventions generally have the potential to harm, an acceptable risk when genuine pathology in need of “fixing” exists or when the tail risk of doing nothing is high.  Hence the importance of reformulating diagnostic labels associated with pain that is presumably musculoskeletal in nature.  Otherwise, the potential for IYI syndrome is strong; sophisticated solutions are generated from unhelpful, overly complicated underlying assumptions.

In Skin In The Game, Taleb details the difference between knowledge and wisdom.  IYIs are lacking in the latter and possess an overabundance of the former.  Wisdom is transferable across multiple domains while knowledge is compartmentalized.  The pursuit of knowledge is necessary as knowledge and wisdom can be symbiotic with appropriate incentives and systemic constraints. Not everything is knowable right now, however, and few things are more dangerous than an asymmetry between knowledge and wisdom.  Unnecessary complication creates the façade of wisdom. IYIs lack the humility to concede that which they don’t understand and continually manufacture more knowledge and specialized language to comfort themselves.  In military and medical matters, intervention poses the risk of unintended consequences whose downside can be far worse than the emergent order.  Resisting the compulsion to do more is often more powerful than any intervention, despite how uncomfortable it can be to do less.

To be clear, a healthy reluctance to avoid meddling in things we don’t understand and risk aversion are different things.  Risk aversion that borders on risk avoidance promotes fragility. Systems adapt when they are disturbed, albeit at a manageable level.  High altitude high opening (HAHO) parachuting is a means of infiltration for tactical teams in the military.  Jumping out of a plane from 10,000+ft at night is inherently risky.  Adhering to continually refined (tinkered) procedures and systemically introducing risk in controlled doses (proper training) mitigates risk and the potential for catastrophic tail events.  Controlled risk is a component of sound preparation.  Sound preparation enhances safety and performance.  Even the most highly trained military freefall teams, however, don’t parachute to an objective when they can infiltrate undetected by helicopter and foot patrol instead.

Channeling our inner IYI requires humility and comfort with uncertainty.  Deference to via negativia reduces the appeal of approval from professional colleagues and members of our intellectual tribe.  People rarely receive credit or attention when less is done.  Dwight Schrute, Assistant To The Regional Manager at Dunder Mifflin Paper Company Scranton (PA) branch, was on to something when he said, “Whenever I’m about to do something, I think would an idiot [which includes IYIs] do that and if they would I do not do that thing”.

Dwight got it right…