More Than Proof


Here are two facts.  I love Malcolm Gladwell and I am a cynic (realist). 

In one of Gladwell’s most recent podcasts, entitled “Burden of Proof”, he explores the concept of proof influencing dramatic action.  Specifically, Gladwell argues ample proof exists in regards to football players with Chronic Traumatic Encephalopathy (CTE) and the risks of depression and suicide.  As always, Gladwell insightfully articulates a point about the amount of proof necessary before dramatic social action is taken.   

How many football players must die by suicide before dramatic action is taken?

I think of this argument often when addressing the ongoing epidemic of clinician suicide, as a result of the environmental work hazards of these professions. 

How many more clinicians must die by suicide before dramatic action is taken?

The problem with the argument of proof is that it is a myopic argument in a vacuum.  Proof refers to providing evidence in the process of establishing a fact.  Proof exists in the realm of the expansion of knowledge.  Proof is solely about facts.   Proof never independently influences appropriate dramatic social action. 

Dramatic action is a social concept requiring a collective change in behavior.  Dramatic action is much more complicated with cultural influences, personal dynamics including emotions, social pressures, and risk/benefit analyses by all of the involved parties in the construct being defined. 

Dramatic action requires a balancing of the influences above or a predominant driving force capable of overcoming an imbalance.  The risk/benefit analyses are actually separate from the burden of proof, and almost always weighted on a scale of gold. 

The problem with applying the concept of proof to CTE and/or clinician suicide should be obvious because we have already established enough proof.  The problem is in accepting the argument that proof should lead to dramatic action, because ironically, this relies upon two facts 1) an assumption that people value and/or care about the truth 2) the risk/benefit of accepting this truth weigh in favor of the parties involved in making the decisions for dramatic action. 

The risk/benefit for the individual and the institution are often inversely related. 

An individual football player takes almost all of the personal health risks while balancing the financial, social, educational benefits of playing a team sport.  Individuals do benefit, in many facets, from playing this sport.  Yet, it would be easy to argue that lifelong disability and premature death would be risks that some individuals view as significantly greater than the benefits.  Some individuals like Chris Borland, who retired from the NFL at the age of 24, publicly declared the risks of CTE and lifelong disability were greater than the benefits of playing the game he loved. I say some intentionally, because the risk/benefit is different for every single individual and some individuals may feel they have less of a choice.  Some individuals view the risk of physical injury pales in comparison to the benefits of financial peace of mind.  In this case, individual dramatic action was taken by Borland, but the game itself goes on.  Next man up. 

I speak to caregivers all over the country about this very topic and the same issues ring true.  For many, there is an ongoing internal turmoil in weighing the risks/benefits of continuing on in a career that carries a significant risk of addiction, mental health crises, and suicide.  Yet, it can be a lucrative and distinguished career, while also acknowledging that a lot of individuals feel trapped by 300-500k of student loan repayments. I have several colleagues that have critically weighed this risk/benefit and found a way out of medicine.  Reflecting that the risks far outweigh the financial, social and educational benefits.  Although still working in medicine today, I continue to critically analyze this ratio as well.  I will walk away tomorrow if the risks outweigh the benefits again. 

In football or in medicine, Individuals in this cauldron have the ability to analyze truth in making these decisions while weighing the risk/benefit for themselves.  Proof therefore can influence dramatic action on the individual level, in individuals changing their own behavior, but this is still far from the norm. 

On the institution level, NFL or healthcare systems, the risk benefit analysis looks completely different.  Institutions do not possess individual autonomy and are submissive to a capitalistic model of business bottom lines.  I do not say this maliciously, I say it because it is an American ideal and simply true.  The risk of losing a handful of individual football players to suicide is a blip on the radar of a multi-billion dollar business.  Even a 765 million dollar lawsuit to compensate players/families diagnosed with CTE is a drop in the bucket of a cash machine business.  Social pressure may exist but not in a volume that can overcome the revenue stream.  The same concepts are true in healthcare, a business that has now reached 17.9% of the Gross Domestic Product (GDP) of the United States.  The cost of losing one physician to suicide is conservatively 500k (lost revenue, recruitment and replacement).  This financial loss is also a drop in the bucket when referring to a multi-trillion dollar healthcare industry.  400 suicides a year equals a 200 million dollar loss.  The game goes on.  Next man up. 

Neither of these ongoing national epidemics are now about ample proof of the pathology in relation to the evolving epidemic.  Now, both epidemics are solely about proving we care more about individual, suffering human beings than we care about money.