The apostles of “less is more”

Gnosticism in medicine

Gnosticism describes a religious movement flourishing at the beginning of the current era, as Roman paganism was foundering but before Christianity became firmly established.

The main belief of the Gnostic sects was a doctrine of “Salvation by Knowledge (gnosis),” the idea that a privileged class of human beings can, by special insight, obtain possession of the mysteries of the Universe.

Gnostics held a deprecating view of the material world, and favored instead the spiritual realm.  Gnostic elites would profess a severely ascetic lifestyle as the path to enlightenment, although some have been accused of hypocrisy for shunning the austere discipline they would demand of their followers.

American medicine in the 21st century bears resemblance to the Gnostic movements of old.

To begin with, we follow a doctrine of “Salvation by Evidence,” a belief that a medical opinion is of no value unless sanctioned by specific rituals called clinical trials.   These rituals consist in subjecting large numbers of women and men to pharmaceutical interventions, to surgical proddings, or simply to an extended period of scrutiny, so that an outcome of interest may be observed.

From such rituals, we gain Evidence—although never enough, it seems, to satisfy the Demiurge: “More studies are needed!”

The Knowledge gained is not within immediate reach of the masses.  A priesthood of experts must first appease the Aeons of Statistics with esoteric incantations and with praises for the p-value, the confidence interval, and the multivariable regression. But through the intercession of Cox, Bonferroni, Kaplan and Meier, the priestly caste can predict the future and more confidently guide us in our daily practice.

Those who stray away from Gnostic orthodoxy are immediately chastised: “You ignore the Evidence!”

Those who propose novel ways to care for patients are rebuked: “What is your Evidence?!”

Armed with the Truth of statistical significance, our leaders exhort us to a regimen of asceticism: fewer stents, fewer mammograms, fewer doctor visits.  Fewer everything is the doctrine of the day.  The optimum number of stents, mammograms, and doctor visits, however, cannot be revealed.  It must remain shrouded in perpetual mystery.

Spreading the message of this austere gospel, the apostles of “Less is More” condemn wasteful spending and demand that we Choose Wisely.  But will they conform their actions to the nihilistic words they profess or, following the example of their Gnostic ancestors, will they sadly succumb to the temptations of the flesh?