Understanding Establishment Bias in Medicine

Author: Jeffrey Wacks, MD

Consider the following statement:

Official testing and/or treatment recommendations should be strictly followed because they are unlikely to be wrong since they are developed by experts who are reviewing all of the relevant scientific evidence in a manner that is unbiased. 

Do you agree? The vast majority of healthcare professionals and a large proportion of the population agree with this statement. Certainly, there is some element of truth to it. To those who either do not have the time or expertise to review the full body of scientific literature on a given topic, it makes sense to put trust in our official institutions who are able to develop a consensus among experts in the field. However, we argue that the statement goes too far. It is example of establishment bias, which is the tendency of the medical community to favor certain research, practices, and treatments over others based on the prestige of the institutions that recommend them rather than solely on the basis of scientific evidence. 

For example, consider a poll of 100 primary care doctors asked the following question: is it reasonable to prescribe berberine as a first-line treatment of type 2 diabetes? The majority of them would likely respond "No" because it is not recommended by the any medical institutions (e.g., American Diabetes Association, American Association of Clinical Endocrinology, etc.). This is despite the fact that a 2012 meta-analysis by Dong et al. looked at the hypoglycemic effect of berberine versus oral hypoglycemic medications (e.g., Metformin) in patients with type 2 diabetes and showed that berberine was just as effective at lowering blood sugar that the medications. Interestingly, this study also showed that berberine had significantly better ability to lower cholesterol. Establishment bias stops us from even looking at the data. 

The idea that establishment medical institutions cannot be wrong or biased is a naive view of the world. Institutions are run by people and people are subject to overt corruption, conflicts of interest, political influence, and greed. "The devil's greatest trick is to convince the world he doesn't exist." An honest reflection of the state of our world can only lead one to conclude that of course these things can occur. 

Thus a more nuanced version of the above statement might go something like this:

Official testing and/or treatment recommendations should generally be the default position because they are developed by experts in the field; however, if evidence is presented that argues to the contrary, individual healthcare providers can and should do their own review of the scientific literature.

In the Preface of Volume 1 of the training manual, we discuss the idea that our program attempts to seek the truth, regardless of whether or not it aligns with the status quo. We are at a point in time where establishment bias is holding us back from moving forward. What we are doing now is not working. We are spending more and more money on healthcare and the patients are getting sicker and sicker. Recognizing and addressing establishment bias is crucial for advancing medicine in a way that truly benefits all. As patients, practitioners, and policymakers, we must foster an environment where science is not just about the consensus but also about challenging it when necessary. This journey towards a more unbiased medical landscape will not only improve patient care, but ensure that medicine evolves with integrity and openness.