PoH Pt VI: Nuance

Medicine Is a Best Guess. Act Accordingly.

The honest answer to most clinical questions is: it depends.

That's not a cop-out. That's medicine. "Evidence-based medicine" sounds reassuring until you realize what it actually means — it's the intersection of available data, a provider's clinical experience, and the patient's own preferences. The consensus answer might be correct on average and still be wrong for you specifically.

The Evidence Problem Nobody Talks About

Only about 10% of medical treatments are backed by randomized controlled trials. Separate reviews have estimated that roughly 80% of medical treatments have low evidence supporting them. So when a provider says "we follow evidence-based medicine," there's roughly an 80% chance that statement doesn't hold up.

This isn't a knock on providers. It's a structural problem. Running a proper RCT costs upwards of $20 million and takes five or more years. Only commercially motivated research tends to get funded. That leaves enormous swaths of clinical practice running on expert opinion, educated guesswork, and observational data — all dressed up in authoritative language.

The downstream consequence is worse than just weak evidence. It means providers who defer entirely to guidelines stop asking the more important question: why does this patient have this condition in the first place? Algorithms don't do root cause analysis.

The Exercise Guideline Problem

Here's a friendly example. The American College of Sports Medicine recommends 150 minutes of moderate cardio per week, plus two to three days of resistance training. Solid goal. But if you do the math honestly — commute to the gym, shower to remain socially acceptable afterward — you're looking at roughly eight hours per week. If you're obese by BMI standards, some guidelines suggest doubling that.

Congratulations, you now have a part-time job you didn't apply for.

For a single parent or a primary caregiver, that's not a recommendation. It's a fantasy.

So here's what I tell patients who have one or two hours per week: exercise one or two hours per week. That's incongruent with the guidelines. It's also better than zero. Make those hours count — work hard during them — but more importantly, keep the habit alive. A sustainable imperfect routine beats an optimal abandoned one every time. This is the same logic as index investing over stock picking: consistency and low friction beat theoretical perfection.

Medicine Is Playing Poker, Not Chess

A 2016 Johns Hopkins study concluded that medical errors cause over 250,000 deaths annually in the United States — placing it third, behind only heart disease and cancer. To offer the counterpoint: more conservative estimates put the number closer to 25,000–30,000, with an additional 400,000 hospitalized patients experiencing some preventable harm each year. Even the low end is staggering.

The CDC doesn't require reporting of deaths caused by medical errors through billing codes, so the official cause-of-death rankings simply don't include it. Out of sight, out of mind, underfunded.

What this tells you is that medicine — even well-intentioned, well-executed medicine — operates with real uncertainty. A bad outcome doesn't always mean the thinking was wrong. You can make the correct probability call in poker and still lose the hand. You can call the right play and get stopped at the line. The unknown variable exists, and pretending otherwise doesn't make it go away.

Who's Actually Responsible Here

No provider will ever know you better than you know yourself. No one has more context about your life, your constraints, your history. That's not an indictment of the healthcare system — it's just the reality of what a 20-minute appointment can accomplish.

This means the responsibility for your health sits primarily with you. A good care team is valuable. But if you have a significant condition, you're going to need to do some of your own digging. AI is genuinely useful here — it's rapidly changing what's possible for patients doing literature searches on their own clinical situations. The bottleneck in medicine has always been time, and that bottleneck is loosening.

The 70% Rule

Don't hold out for certainty. It won't come. When you reach roughly 70% confidence on a health decision, make the move. The bigger the decision, the more time it's worth spending — but the target is still confidence, not certainty.

Some patients now regret having bariatric surgery 20 years ago, wishing they'd waited for GLP-1 medications instead. That's an unfair comparison. Those drugs didn't exist. Judging past decisions by present information is irrational — and it misses the lesson, which is that technology changes, new options emerge, and the best you can do is make a reasonable decision with what's available right now.

The medicine of today will look primitive to the medicine of 2045. Make your best call, stay curious, and update as the evidence does.

3-Point Summary

• Only about 10% of medical treatments are supported by strong trial evidence, which means "evidence-based medicine" is more aspirational than actual for most clinical decisions.

• Medical errors are estimated to cause 250,000+ deaths annually in the U.S. — a figure that doesn't appear in official CDC rankings because it isn't required to be reported.

• No provider knows your full context the way you do, which means you bear ultimate responsibility for your own health decisions.

3 Practical Takeaways

1. Don't let perfect be the enemy of consistent. If you only have two hours a week to exercise, exercise two hours a week. A habit you actually keep beats a guideline you perpetually fail to meet.

2. Do your own research — seriously. If you have a significant health condition, don't outsource all the thinking to a 20-minute appointment. Use AI tools to dig into primary literature. The information is accessible and the gap between informed patients and uninformed ones is getting wider.

3. Decide at 70% confidence. Waiting for certainty means waiting forever. Gather enough information to feel reasonably confident, make the call, and stay open to updating it as you learn more.