We have been called critics, haters, nonbelievers, or our least favorite—nihilists. We prefer the term “medical conservative.” We believe this is the ideal approach to patient care.

We set out the tenets of the medical conservative now because the rapid pace of innovation and the marketing powers afforded by digital media has tested the resolve of slow-adopting skeptical clinicians.

A conservative is someone who stands athwart history, yelling Stop, at a time when no one is inclined to do so, or to have much patience with those who so urge it. 1 Buckley J.W. Our Mission Statement. Our choice of the term “medical conservative” does not imply a political philosophy, although William Buckley Jr’s definition of conservatism aligns well with our approach to patient care:

Here is what we believe:

2 Mensah G.A.

Wei G.S.

Sorlie P.D.

et al. Decline in cardiovascular mortality. Medical conservatives are not nihilists. We appreciate progress and laud scientific gains that have transformed once-deadly diseases, such as AIDS and many forms of cancer, into manageable chronic conditions. And in public health, we recognize that reducing exposure to tobacco smoke and removal of trans fats from the food supply have contributed to the secular decrease in cardiac event rates.Indeed, medical science has made this era a great time to live.

3 Foy A.J.

Mandrola J.M. Heavy heart: the economic burden of heart disease in the United States now and in the future. Figure The case for being a medical conservative. Based on diminishing utility function in economics: Point A represents high value care as spending leads to big gains in outcomes. Point B represents intermediate levels of gain based on additional spending. Point C represents low value care, in which additional spending is not associated with significant improvement in patient outcomes. This is the “flat of the curve.” The medical conservative, however, recognizes that many developments promoted as medical advances offer, at best, marginal benefits. We do not ignore value. In a plot of spending vs outcomes, we define marginal advances as “flat of the curve” gain Figure ). On the flat part of the curve, additional spending, whether it be on a new drug, device, or diagnostic test, confers little benefit to individual patients or society.

4 Smith Q.W.

Street R.L.

Volk R.J.

Fordis M. Differing levels of clinical evidence: exploring communication challenges in shared decision making. The medical conservative adopts new therapies when the benefit is clear and the evidence strong and unbiased. Cardiac resynchronization therapy for patients with systolic heart failure and typical left bundle branch block, direct acting oral anticoagulants for prevention of arterial and venous thrombosis, and rituximab for lymphoma are therapies that sell themselves. Most medical decisions, however, come with far less certainty. The BMJ clinical evidence team reviewed 3000 treatments used in the UK's National Health Service and found that about one half were of unknown effectiveness and only 11% were clearly beneficial.

The medical conservative knows that even when clinical studies show that a drug, device, or surgery reaches a statistical threshold, the actual benefit derived by an individual can be far less than what is advertised or publicized. We resist the urge to conflate benefits of a therapy to a population vs benefit to the individual. While acknowledging that widespread uptake of statin drugs for primary prevention might prevent many nonfatal cardiac events in a population, the conservative clinician deals with one patient at a time and is careful to communicate the absolute benefits/harms of the drug for that individual.

The question we ask is simple: Would an unbiased patient, who had perfect knowledge of an intervention’s tradeoffs, voluntarily choose to adopt it, and taking into account differing patient resources, pay for it?

This desire for better decision quality drives the medical conservative to care about the growing commercialization of medicine. When money is at stake, the risk of hype increases. Not only does hype propagate low-value care, but it also erodes the public’s trust in medical science. Medical conservatives vigorously oppose hype in all its forms.

Some may mistake the medical conservative’s concern about commercialization of medicine as opposition to private enterprise, capitalism, the accumulation of wealth, and more generally, against medical progress for the sake of it. This is not true. Instead, we oppose medical progress, and the accumulation of private wealth that accompanies it, when it occurs under the pretext of "science", without meaningful improvement in patient outcomes.

To determine genuine progress, medical conservatives endorse evidence-based medicine and critical appraisal. While we neither embrace nor reject the concept of expertise, the medical conservative is most concerned with the process and quality of critical appraisal.

Robust critical appraisal may put the medical conservative at odds with “content experts” who may oppose our skepticism on the grounds that it is not informed by deep expertise in the particular issue at hand. Yet the medical conservative remains steadfast in drawing a sharp distinction between content-level expertise and expertise in critical appraisal. These 2 may not go together, and the value of each must be judged on a case-by-case basis. For instance, the expert at placing implantable cardioverter-defibrillator (ICD) devices may or may not be the most reliable expert in answering the question of “when is it best to implant an ICD.” Too often, content expertise becomes a synonym for devotion to the prevailing model or theory.

At the core of this tension is that content experts are often enthusiasts for whatever content they are expert in, whereas the medical conservative is enthusiastic only for that which has been proven to improve human health. When genuine benefit exists for an intervention, it easily withstands critical appraisal. No one debates the value of antibiotics for bacterial infection, percutaneous coronary intervention for acute myocardial infarction, or repair of femoral head fractures.

5 Turner E.H.

Matthews A.M.

Linardatos E.

Tell R.A.

Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. The medical conservative sees benefits from the confluence of interests between profit motives of industry and progress in research; we do not oppose industry–physician collaboration. But these dualities of interest must be considered in determining the quality of evidence for or against new interventions. For instance, an incomplete evidence base due to selective publishing of “positive” studies can inhibit true knowledge of an intervention’s net benefit.

The medical conservative, therefore, is pragmatic about human nature and the prevailing business model of medical science. To wit, content experts, professional societies, or journal editors who too harshly criticize an industry product jeopardize future funding. Motivating biases need not be considered nefarious, only considered.

In the end, the medical conservative stands in awe of the human body. We recognize that our knowledge and best models only rarely predict the success of a new intervention. We see true medical progress as slow and hard, in large part because nature has provided the human body with inherent healing properties.

The wisest of conservative physicians understand and embrace how little effect the clinician has on outcomes. While many may call this frame of reference nihilistic, the conservative clinician sees it as protective against our greatest foe—hubris.