Who Needs Organic Chemistry?
In a world of centralized, censored, mandate- and media-driven, algorithmic, impersonal, 'evidence-based' medicine, why would doctors need to think?
The New York Times tells the story of New York University’s firing of organic chemistry professor Maitland Jones. Jones taught ‘orgo’ for decades at Princeton, before retiring in 2007, and then teaching on one-year contracts at NYU. He wrote a major textbook, now in its fifth printing. Organic chemistry, the study of substances containing carbon, is a famously tough weed-out course at most schools. In recent years, however, some NYU students began complaining Jones’s class was too difficult. It was ruining their med school plans. They petitioned the school. His chemistry colleagues supported him. NYU sided with the students and let him go.
The number and nature of reactions to this article suggest most people – even more than I suspected – believe something’s gone terribly wrong with higher education. They say we’re dumbing down college, coddling students, lowering standards for important fields like medicine, where orgo is a pre-med requirement, and undermining expert educators who are doing their jobs even if students don’t appreciate it.
“I don’t want my job back,” [Professor Jones] said, adding that he had planned to retire soon anyway. “I just want to make sure this doesn’t happen to anyone else.”
These are all important points. But I want to explore another angle of the story: In our current healthcare environment, why would most physicians need to know anything about organic chemistry? Before you recoil, let me say I think basic scientific knowledge, including organic chemistry, would in fact be important if medicine were not so dysfunctional and were instead more agile, personal, entrepreneurial, technological, and, well, scientific.
Alas, I think medicine is headed in the wrong direction. The last two and a half years proved large health systems, public health officials, and both government and ‘private’ insurance payers – all reacting to or imposing perverse incentives – have turned too much of healthcare into top-down box-checking.
“Organic Chemistry Is Absolutely Useless”
Medical professor Vinay Prasad wrote down four reactions to the story. Among them:
No matter what happened with Maitland Jones, we have to acknowledge that organic chemistry is absolutely useless as a prerequisite for medical school. 99% of practicing doctors could not pass an elementary organic chemistry exam, because it is not necessary or pertinent to the day-to-day practice of medicine. Being able to assess information, reading studies, talking to people, solving problems, those are vital skills.
That’s probably true for the majority of doctors today, given the way our healthcare system works. Was that also true 20 or 50 years ago? I think that’s less certain. Was orgo always merely a signaling mechanism? A way to ensure only the smartest undergrads made it to med school? Maybe so.
Division of Knowledge
What does the healthcare system want from medical schools today? As healthcare approaches 20% of U.S. GDP, it necessarily diffuses across endless tasks, both medical and administrative. The range of jobs and skills grows wider, and specific jobs and skills get narrower. Long ago, individual doctors were diagnosticians, detectives, counselors, prescribers, surgeons, scientists, home visitors, community leaders, and managers of their practices. Today, these tasks are spread across many more people. The proportion of people in healthcare who need to know ‘orgo’ – whether for substance or signaling – goes way down.
The natural progress of healthcare gives us more nurse practitioners and physician’s assistants (PAs), more ultrasound, radiology, and lab technicians, and many, many more business administrators. More physicians go into research and technology. Surgeons hyper-specialize, doing larger numbers of specific procedures. We also get more scientists and engineers discovering bio mechanisms and delivering bio technologies, knowing they will never treat a patient face-to-face. Decades ago, many of these people would have been clinical MDs. Yes, drug discovery requires more knowledge of organic chemistry than does dermatology.
The precision and quality of today’s surgeries are light-years better than several decades ago. Many drugs truly change people’s lives for the better. Embedding knowledge (including organic chemistry) into technology and protocols allows the best ideas to scale to more people. This is the beneficial advance of a growing industry.
The specialization of knowledge and division of labor is mostly a good thing. If it follows an organic process of innovation, and, I’d argue, if we still allow room for the generalists and skeptics. Are we specializing into truly useful tasks and skills that deliver better health at lower cost? Or does the web of highly regulated and confusingly remunerated providers and payers dictate specialization into more bureaucracy? I’d argue we’ve got too little of the former and way too much of the latter.
Champagne for Revenue-Generating Codes
There’s growing scrutiny, for example, of the Medicare Advantage program, which was supposed to inject private sector efficiency into the giant U.S. healthcare system for those over 65 (“ ‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions”). The Advantage program is popular with seniors and insurers, and has probably generated savings along some axes. In other ways, however, the program is inevitably falling prey to its own perverse incentive structure.
At first, Advantage paid the same for all patients, healthy or sick. Naturally, insurers recruited healthy patients. Then Advantage adjusted, and now pays insurers more for sicker patients. So the insurers have been scouring patient records going back decades to find old illnesses, and sometimes making up new illnesses out of thin air. They pay doctors and database archeologists to help them – sometimes, according to the New York Times, doling out Champagne if they find more revenue-generating codes.
The entire U.S. healthcare system is full of similar mis-incentives, wasteful behavior, cross-subsidies, and far worse.
Covid-19 reeked of these mandates, perverse incentives, and demotion of individual physician agency. Despite the novelty of this coronavirus, federal and state regulators acted as if they knew, from day one, exactly what every doctor across the health landscape should, and should not, do. Despite all previous experience where speed matters, they discouraged early treatment with widely available, safe, generic drugs. Wait until you can’t breathe, and then go to the hospital, they insisted, wasting the crucial first week. Once at the hospital, the public health officials and regulators, most of whom were not clinicians, told doctors what to do with every patient, regardless of circumstance. They embedded their (non)treatment protocol into blanket reimbursement rules. For example, health systems received:
a bonus payment for each positive Covid-19 diagnosis;
a bonus payment for each Covid-19 admission to hospital;
a large bonus payment for mechanically ventilating a Covid-19 patient;
a 20% multiplier of the Covid-19 patient’s entire hospital bill if the hospital administered Remdesivir;
a bonus payment if the patient died with (not necessarily from) Covid-19;
Guess what? Health systems had little incentive to treat people early and avoid hospitalization. Once admitted, hospitals tried to ventilate and give Remdesivir to as many patients as possible. Even after we learned 80% of vented patients were dying.1 Even after we figured out Remdesivir was, at best, totally ineffective, and more likely was contributing to patient downward spirals.2 (No set of government incentives can ever be perfect. But what if we’d rewarded health systems for successfully keeping patients out of hospital, off ventilators, and alive?)
At the same time, FDA, CDC, and NIH, health systems, medical societies and boards, along with Big Media and Big Tech, demonized and erased the few brave doctors who bucked this bad advice and offered better strategies and treatments.
This was top-down medicine. The health results were awful. The money flows were big.
Evidence-Based Bureaucracy
Who could oppose ‘evidence-based medicine’? Does anyone oppose evidence-based law or evidence-based science? Standards and best-practices based on data and experience can scale good ideas across any field. The questions, however, are the quality of the evidence, the level of openness to better explanations and ideas, and ‘who decides.’ Today’s evidence-based medicine presumes a small number of authorities should impose singular answers across the entire medical landscape. At least until three huge RCT’s, or a charismatic NIH director, dictate new base of evidence. If it appears in the New England Journal of Medicine or is endorsed by Kaiser, it works, and it’s mandatory. If not, you can’t try it.
We will never fully overcome the tension between efficiency (and minimized legal liability) on the one hand and innovation on the other. Giant health systems wouldn’t be possible without evidence-based bureaucracy. If everyone’s doing it, no one can be wrong.
In the early debate over the use of ventilators to treat hospitalized Covid-19, some ICU doctors contended that the conventional protocol to combat acute respiratory distress syndrome (ARDS) wasn’t working. Most patients weren’t struggling to inhale and exhale, as in typical ARDS, yet they weren’t getting any oxygen. Other doctors insisted they stick with the existing playbook, where anyone with a checklist of signs and symptoms, including low blood-oxygen saturation, was automatically intubated and vented. Here’s one example from spring 2020.
We’re using an early intubation strategy here….I’m arguing for evidence-based medicine. Which is something we all purported to agree with before this outbreak hit. We have large, randomized, controlled trials. The patients in those trials had met the same diagnostic criteria that our current patients meet. We should apply the results of the trials.
That was checklist medicine.
The more curious and imaginative doctors who questioned the orthodoxy were closer to the truth as we now understand it – that micro-coagulation and inflammation caused by vascular endothelial damage from the Spike protein was interfering with oxygen exchange. On March 31, 2020, in an initially famous but now-forgotten YouTube video, Dr. Cameron Kyle-Sidell proposed that Covid-19 wasn’t respiratory failure. It was oxygen failure. Most ICUs deploying evidence-based best practices to combat ARDS may be relying on a failed paradigm, he warned. Ventilation is an aggressive escalation and can damage lungs. It should only be used when absolutely necessary.
Who knows if Dr. Kyle-Sidell was good at organic chemistry? Whatever it was that led him to question the orthodoxy in an emergent scenario, and to get fired, we need more of it.
Organic chemistry probably doesn’t help you follow orders from the Ascension or HCA executive suite, nor spot clever ways to game the billing codes for United Health or Kaiser. In fact, if orgo gives you deeper insight into emergent medical phenomena and the potential shortcomings of existing treatments or policies, it probably makes you a less compliant and more problematic employee. What does this tell us about what the health firmament will ask of colleges and medical schools in coming years?
Where is this going?
The increasing mis-use of technology and information by top-down forces suggests we need (1) far more accurate and transparent data; (2) institutions which can ensure robust debate and viewpoint diversity; and (3) a new legal regime to protect a modern set of civil rights and to promote decentralized decision-making and innovation.
We’ve just experienced a multi-year health disaster where the top public health agencies, big medical journals, revered medical schools, and giant health systems, along with Big Media and Big Tech, operating in lockstep, made half a dozen catastrophic mistakes on major questions of science and healthcare. They hoarded data, pushed propaganda, and disallowed discussion and dissent. Censorship boomeranged and blinded them to their many blunders.
A.I. and machine learning will deliver tremendous advances, helping solve, for example, the deepest mysteries of molecular biology. DeepMind’s AlphaFold is making giant leaps in protein folding. A.I. also promises to help providers (and patients themselves) better understand the highly particularized nature of individual health and deliver personalized treatments.
But A.I. can also supercharge the centralizing tendencies of EBM, RCTs, and the institutions of Big Medicine. Like EBM and RCTs, which are supposed to elevate data above human biases, A.I. can also be hacked. Big Tech firms are already injecting politics and social policy into machine learning tools, often under backwards rationale that they are removing human bias. In the future, instead of referring to the bogus epidemiological models of Imperial College–London to justify lockdowns, they might refer to the super-human authority of ‘AlphaPandemic.‘ How could a mere physician, even an organic chemistry genius, argue? Especially when California’s new law (AB 2098) bars physicians from spreading “misinformation.”
If, on the other hand, regular people, individual physicians, and entrepreneurial health firms are allowed to use both A.I. and their own minds and tongues effectively, it may undermine the one-size-fits-all mandates of Big Medicine. The struggle over data and information tools will thus likely intensify. In such a world, we probably need many more people who understand organic chemistry.
We learned that for most Covid-19 patients, ventilation to support tired lungs wasn’t the chief issue, as with traditional pneumonias or ARDS. Most hospitalized Covid-19 patients suffered reduced gas-exchange because of micro-coagulation and hyper-inflammation, not necessarily because of traditional respiratory distress. Recall the New York City doctor, Cameron Kyle-Sidell, who early on, in March/April 2020, delivered a plea to his fellow physicians on YouTube. His patients were suffering something more like altitude sickness, not traditional ARDS. Ventilators weren’t working and were likely making many patients worse.
In the above-linked video, another doctor argued for sticking with the pre-pandemic protocol for dealing with ARDS. “I’m arguing for evidence-based medicine. Which is something we all purported to agree with before this outbreak hit. We have large, randomized, controlled trials. The patients in those trials had met the same diagnostic criteria that our current patients meet. We should apply the results of the trials.”
Gilead’s investigational anti-viral Remdesivir was originally tried against ebola in 2019. But when 53% of the patients died, Remdesivir was halted in the middle of the clinical trial. NIH then grabbed it off the shelf in early 2020, conducted a quick trial in which they altered and hacked the end-point in mid-stream, then essentially mandated it for every hospitalized Covid-19 patient. It didn’t make much sense. Remdesivir is an anti-viral, which might be effective early in the infectious, viral-replication phase of Covid-19. By the time most Covid-19 patients are admitted to hospital, however, the viral replication phase is largely over. They are now into the second and third stages of Covid-19, suffering hyper-inflammation and hyper-coagulation with related complications. In this scenario, Remdesivir is at best useless. But we also know Remdesivir is toxic to the kidneys and liver. Drs. Paul Marik (Norfolk, VA) and Joseph Varon (Houston, TX), among several other intensive care specialists, were getting far better hospital results with a protocol designed to fight inflammation and hyper-coagulation, and which excluded Remdesivir and avoided mechanical ventilation. Their protocol was at least 50% more effective at preventing death than the Remdesivir/vent approach. Yet Remdesivir is, to this day, the federally approved “standard of care” with large financial incentives for its use.