For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.
But today, nine years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine: burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.
People emigrated to this country to escape oppression by the well-educated upper classes, and as a nation we never got past it. Many Americans have an ingrained distrust of “eggheads”. American anti-intellectualism propelled the victory of Dwight Eisenhower over Adlai Stevenson – twice – and probably helped elect Bill Clinton, George Bush, and Donald Trump.
Don’t make the mistake of thinking that American anti-intellectualism today is exclusive to religious fundamentalists and poorly educated people in rural areas. Look at the prevalence of unvaccinated children in some of America’s most affluent neighborhoods, correlating with the location of Whole Foods stores and pricey private schools. Their parents trust Internet search results over science and medical advice.
Remember when physicians were heroes?
For a long time, physicians were exempt from America’s anti-intellectual disdain because people respected their knowledge and superhuman work ethic. The public wanted doctors to be heroes and miracle workers. The years of education and impossibly long hours were part of the legend, and justified physician prestige and financial rewards. Popular TV series in the ‘60s and ‘70s lionized the dedication of Ben Casey, Marcus Welby, Dr. Kildare, and Hawkeye Pierce. In real life, heart surgeons Michael DeBakey, who performed the first coronary bypass operation in 1964, and Christiaan Barnard, who performed the first heart transplant in 1967, became famous worldwide.
The unofficial mantra of silicon valley entrepreneurs may well be fake it ‘til you make it, an approach of resilient bravado that’s led to a slew of ultimately successful tech giants – and also to frank deceptions like Theranos.
Recently, I heard from VC Marc Andreessen (on the a16z podcast, here) what must be the most forthright explanation of this approach, a sales technique Andreessen calls “evangelistic selling.”
Andreessen was responding to a question about how do you sell into businesses that aren’t intrinsically receptive to change (i.e. essentially every large established business, including those dominating healthcare).
The Evangelistic Sale
First, you can see why some view Silicon Valley denizens as merchants of hype – this is, if not explicitly what Andreessen is championing, perhaps an inevitable outcome of his approach: entrepreneurs and (other) salespeople talking up an often-fantastic vision of a yet-to-be realized future.
Andreessen also points to the example of Elon Musk and Tesla; Musk is often criticized for overselling, says Andreessen, but argues Musk had to paint a vision not only of a car you could plug in, but also a whole system of superchargers along freeways, and his vision had to be compelling enough so he could actually sell enough cars “into that vision” to afford to start installing the chargers he described, and enable the vision to become a reality (which, initially, it wasn’t). Andreessen likens it to selling the first fax, which obviously wasn’t especially useful until and unless it was adopted by others.
Steve Jobs: “Taking LSD was a profound experience, one of the most important things in my life. LSD shows you that there’s another side to the coin, and you can’t remember it when it wears off, but you know it. It reinforced my sense of what was important – creating things instead of making money, putting things back into the stream of history and of human consciousness as much as I could.” (ref 1)
Woodstock (Chip Monck): “To get back to the warning that I received. You may take it with however many grains of salt that you wish. That the brown acid that is circulating around us isn’t too good. It is suggested that you stay away from that. Of course it’s your own trip. So be my guest, but please be advised that there is a warning on that one, OK?” (ref 2)
Warning: The final few paragraphs of this post contain language that some may find offensive. I included it for a reason. In 30 years of practice and in my real life – I have found that many people talk this way. If profanity offends you don’t read the end of this post.
Everywhere I turn these days – whether it is a blog or more traditional media I am struck by the same stories on hallucinogens. If you believe what you read out there, hallucinogens are magical drugs in that they are almost totally benign, consciousness expanding, and they can treat your anxiety or or depression. They have been actively discriminated against like other illegal drugs and that is the only reason we have not done the research to prove that they can treat many problems. Back in the 1970’s we would have said that “The Man” is restricting access to valuable consciousness expanding drugs and if “The Man” was overthrown – the world would be a much better place. I have briefly reviewed the same lines of rhetoric that occur with cannabis. I have not heard similar arguments with ketamine, probably because fewer people have experience with it and it is a more difficult drug to use, even in a medical setting where the drug has a known concentration and purity.