Stabbed in the Back: Confronting Back Pain in an Overtreated Society


To live a year without a backache is abnormal.

Backache is an intermittent predicament of life. No one is spared for long. Furthermore, no approach to avoiding the next episode has proven effective when submitted to scientific testing. To be well is not to avoid backache; it’s to have the wherewithal to cope effectively and repeatedly. 

Almost all of the people we will be talking about in this book were afflicted with regional backache, and that is the only type of backache we will consider here. I coined that term for an editorial in The New England Journal of Medicine over twenty years ago.1 Regional backache is the back pain experienced by people who are otherwise well. It comes on inexplicably, usually suddenly, in the course of activities that are familiar, and customarily comfortable. This is the common, everyday backache. We will spend some time considering some of the more frequent complications of a regional backache, particularly the “pinched nerve,” which can cause pain to radiate down the leg. We are not going to consider the unusual causes of backache such as metastatic cancer, infections, or inflammatory diseases of the spine. Nor will we consider the back pain that can result from accidents and other traumatic events.

While I am talking about what this book is not, let me say that it is not a self-help manual. Nor is it a medical textbook. Backbone is an exposé of a contrived “disease” and the enormous enterprises it has spawned that conspire to its “cure” and provide fall back when a “cure” is elusive. That industry has developed a life of its own despite a robust and compelling body of scientific investigation that points toward backache as a socially constructed ailment. The American notion of health, the American’s wherewithal to cope and persevere, and the American pocketbook are paying a heavy price. 

Continue reading

Enriching Data Can Impoverish Reality


Medical historian Stanley Reiser wasn’t kidding when he entitled his best-known book, “Medicine and the Reign of Technology.”  To a large degree, technology has taken over medicine.  I am not talking primarily about our increased reliance on such technologies as advanced imaging equipment or assistive procedural devices.  In such cases, the technology remains largely a tool, and the wielder remains basically in charge.  I am talking about a far more pervasive and insidious form of technology whose very name tells a good part of the tale – health information technology.

Many physicians and other health professionals find health information systems clunky, perverse, and intrusive, but their problems go far deeper.  Underneath unwieldiness lies the temptation that we begin relying on such indicators to such an extent that we stop attending to our internal resources.  Consider the case of the patient said in his admission note to be “status post BKA” – below the knee amputation – but who turns out on rounds to have ten toes.  What happened?  DKA – diabetic ketoacidosis was mis-transcribed into the medical record as BKA, and the error simply propagated like a virus.

At stake is what we mean by knowledge.  Is what we know defined by our own experience – what we have seen, heard, felt, and perhaps even intuited in the presence of the patient?  Or do we instead rely on what is represented on a computer screen?  Which is a more likely occasion for us to exclaim, “That can’t be right!” – when what the computer screen indicates does not comport with what we have observed of the patient, or when what we have observed in the presence of the patient does not jibe with what the computer is telling us? 

Continue reading

Digital Transformation and the Health Care Biz: My (Somewhat Skeptical) Takeaways For HBS


I’m deeply skeptical that I have much knowledge to impart to Harvard Business School (HBS) students.  After all, they’re the ones clever enough to pursue a two year advanced degree (“six months of education crammed into two years,” they joke), while across town, my classmates and I ran gels, plated cells, memorized structures, and took call for a decade or more (in some cases) — and all for the privilege of eventually working for our fleece-vested colleagues (see also this 2011 Scott Gottlieb piece, and my 2012 Forbes post).

Even so, I was recently invited to appear as a guest on a new podcast out of HBS called “Under The Datascope,” where I answered questions about my experiences and perspective as a physician, scientist, technologist, drug developer, and investor. The episode (here),released today, is part of a series hosted by Gabriel Eichler and sponsored by the Kraft Precision Medicine Accelerator (Go Pats!) at HBS, featuring interviews with people working on and thinking about data, analytics, and precision medicine.

There’s a lot of content packed into the nineteen minute episode, and I thought it might make sense to capture some of the highlights – though I suspect the entire episode, and the series more generally, is likely to be of interest to readers.

Biomedical entrepreneurs drive science into durable application. After struggling during my clinical and research training with the persistent gap between promising science and clinical application, I came to appreciate that biomedical entrepreneurship represents the distilled essence of the translational impulse. (See this 2005 Nature Biotechnologycommentary, for example, this related version that was published in the San Francisco Chronicle, and this and thisfrom Forbes.)

Biomedical entrepreneurship requires humility and humanity, not tech fetishization and solutionism. Driving science into application requires not only the best (more precisely, the most suitable) technologies that are available, but also a deep sense of, and respect for, the complexities of biology and what I described as the “humanistic center of medicine and patient care.”  (Regular readers will recognize this as a recurrent theme of this column — e.g. this 2011 post, “What Silicon Valley Doesn’t Understand About Medicine”).

Good doctors have always customized care. The mantra of precision medicine – “right drug for the right patient at the right time” – is not a radical new idea, peculiar to the molecular age. Admirable doctors have long tried to individualize treatments based not only on the biology of disease, as best it could be understood, but also based on the physician’s knowledge of the patient’s circumstances and preferences. It’s also critically important not to be excessively reductionist, and to recognize a person isn’t just the sum of their molecular mutations; everyone exists in a much broader context. See hereand here as well.

Continue reading