The 'Laws' of Medicine

“In his 1934 book, The Logic of Scientific Discovery, the philosopher Karl Popper proposed a crucial criterion for distinguishing a scientific system from an unscientific one. The fundamental feature of a scientific system, Popper argued, is not that its propositions are verifiable, but that its propositions are falsifiable–i.e., every theory carries an inherent possibility of proving it false. A theory or proposition can only be judged “scientific” if it carries within it a prediction or observation that will prove it false. Theories that fail to generate such “falsifiable” conjectures are not scientific. If medicine is to become a bona fide science, then we will have to take up every opportunity to falsify its models, so that they can be replaced by new ones.”

~ Siddhartha Mukherjee, The Laws of Medicine

Replace ‘medicine’ with ‘nutrition’ or ‘fitness’ and this quote still seems to ring true.

I don’t do book reviews and recommendations often enough on Skill Based Fitness, but I had to share with you some wonderful thoughts that brewed in my head over this book.

Coming in at a whopping 70 pages and easily digestible in an hour of reading this book will give you a wonderful reference for the limitations of medicine.

It’s a quick description of 3 laws as Mukherjee, a prominent haematologist (blood) and oncologist (cancer) researcher — also known for the pulitzer winning Emperor of All Maladies: A Biography of Cancer — could identify in his line of work:

Law #1 

A strong intuition is much more powerful than a weak test.

Law #2

“Normals” teach us rules; “outliers” teach us laws.

Law #3 

For every perfect medical experiment, there is a perfect human bias.

For more, I highly recommend getting your own copy. Here’s what I drew from the read as a fitness professional.

Law #1

Contrary to popular opinion, Medicine (to some degree fitness and nutrition are both medical/health related disciplines…or at least they should be…) is not so much an “exact science.”

Blood tests, CT scans, MRI’s, X-Rays, all of the complex logistical equipment we’ve developed over the years for assessing potential problems, can also lead to false positives.

Most tests are notoriously difficult to administer, whether due to cost or equipment availability, or just the need for a very skilled eye to analyze the data after the tests.

Most tests are not even ordered, without a physician first making an educated guess based off an initial line of questioning and physical examination (symptom analysis).

As is the nature of medicine, many tests that are run within the fitness and nutrition world are also notoriously weak. A good coach (like physician) is really hunting clues and then making a judgement call.

If you’re not filling out a detailed questionnaire when you start in with your coach, I’d suggest rethinking your coach (or gym).

Where I feel many coaches go wrong is testing EVERYTHING, despite a lack of need as indicated by the existing situation. I was guilty of this five years ago, if testing is good, then more tests is better right? Probably not, and most probably you’re just wasting time and money.

Take for instance the ever popular Posture assessment, which yes, according to those in the evidence based medical community has yet to materialize into a truly valid repeatable testing process. I’d agree with that generalist, if not somewhat nihilistic view.

Ask 50 fitness or rehab professionals to look at the posture of an individual and you’re likely to get 50 different (though maybe somewhat similar) results. Most will argue about how much each major observation matters, the smart ones will want to see posture through movement (to see how someone actually moves…) rather than just in a static position and down the rabbit hole you go.

There isn’t much concrete evidence suggesting that static posture matters a lot in the grand scheme of things, but does a quick look at a weak (and easy/cheap) test make it useless? I’m not so sure…

And yet, what it does provide all the same are some clues as to what might be worth pursuing further via muscle testing or structural assessment. Both of which are equally likely to yield different results from different practitioners.

What the the nihilist view on the value of assessing comes down to, is that the tests themselves aren’t very well validated, but they aren’t exactly falsified either, and perhaps the actual process of assessing leads to better intuition.

i.e. the tests themselves might not matter, but the process of testing does. 

Six or seven years ago a women came to see me about her hip. Generally I’m not a pain expert, so I refer out when the apparent need becomes obvious.

What I can do as a fitness professional is come up with workarounds for clients in pain and that’s generally what we do while I help get the medical issue sorted out with Chiropractors/Physiotherapists/Massage Therapists/etc…

After weeks and several referrals within my network, this woman had probably gone through about as much poking and prodding as anyone would like to deal with and still no solution.

As a last resort one of us referred out to someone with more experience in this specific type of pain.

It took one rehab professional (out of 5) all of 10 minutes to look further up than any of us had based on strong intuition to discover the root of the problem and ultimately solve it. It was a spinal issue in the mid-back.

She had a better intuition about the nature of the problem due to experience and knew where to look.

My take away: The answer isn’t always where you think it will be based on previous experience, and most of the time complicated problems require thinking outside of your comfort zone. Experience will often trump even a good test, provided you consider Law 2 and 3. You typically have to do a lot of research in these cases and you use tests to confirm your intuition.

Law #2

Is the hardest for me to rationalize and put in a fitness context because as it’s worded it might not make much sense without the context.

Let’s say you put 100 people on a 2×2 program for 16 weeks to achieve muscle growth, a notoriously difficult objective for many skinny dudes out there.

It might work exceptionally for 12 of them, or who might be called hyper-responders, who gain almost twice what the average weight gain is. It works about as expected for 84 of them (an average of say 3-4 lbs of lean mass in a month) and 6 of them struggle to see any change at all, let alone a pound or two of gains in a month, or hypo-responders.

Those aren’t specifics to be expected mind you, the hyper-responders could be more or less, as could the hypo-responders.

So long as the majority of people see a statistically relevant enhancement over people on another program or as a control goup do no exercise, I can then say with certainty the approach works for the average person.

Most research is conducted like this, we look what happens to the average person based on a singular manipulated variable (ideally) and most of my advice stems from this law of averages.

From a series of similar studies we can extrapolate best practices for the average person and right now this is all kind of best case scenario for recommendations.

What about the people who perform better or worse than average though?

This is part of what makes research useful, and part of what makes research incredibly difficult. In many instances, newer research will try to identify hyper- and hypo- responders within the group, and clearly label it in the paper, but that’s about all we do with it.

A better thing to do in these instances might be to sequence their genome, use doubly labelled water, conduct psyche evaluations, take fecal or blood samples and look for other potential reasons why certain individuals respond really really well, while others respond poorly.

All of which is expensive and very time consuming to worry about.

This is starting to happen more and more, as more genetic code is made available to us and computers can handle a great deal of this big data problem behind the scenes, and/or many of these assessments get cheaper and cheaper to conduct.

That’s the next big frontier of fitness (and research for that matter), more personalized answers to outlier questions.

Why do some people gain muscle more easily than others?

Why do others lose weight more easily than others?

Why does exercise seem so hard to some but not others?

How do some people instinctively ignore highly palatable processed foods?

These are the bigger questions that modern science will be looking at more in depth in the future.

My take away: If someone isn’t responding the way I would expect based on ‘averages’ I need to take a closer look at the confounding factors. Are there things I’m overlooking? Does this have outlier potential? Maybe they need more exercise or less exercise than is most commonly recommended to the ‘average?’ Are things that could be influencing the process that aren’t obvious?

As a last point, most people who are frustrated in their weight loss pursuits (and I’ve met MANY), would probably be best served by focusing on this fact. Not so much that you’re so much different, but rather you probably didn’t account for something. One of the biggest recurring problems, is counting calories and assuming that you’re in an energy deficit when the scale says otherwise. Just because it says so on paper, doesn’t mean the body is experiencing that.

There are other common ones…

• Not eating enough (the body slows resting metabolism to adjust to intake, if it’s too low…)
• Doing too much exercise, or assuming you’re doing a lot because of energy readouts on machines (which aren’t in addition to your regular output…)
• Not getting enough sleep
• Not accounting for the quality of the food you take in (assuming a calorie, is a calorie)
• Not counting things that don’t seem like they should count (a few bites here or there of someone else’s food, like your kid’s food, or not counting the caloric beverages you drink…)

Don’t just assume you’re an outlier, assume your information is wrong. Most information is deceiving, and just because calorie counting works for the average person doesn’t mean it will work for you.

Law #3

Ironically reading the Laws of Medicine in the first place kind of highlighted this law indirectly. I’ve been trying to step outside of fitness to learn more and more about related disciplines because I worry about my own bias’ and those of the people I trust for information within this field.

When I am learning about fitness, more and more it’s directly from a piece of research.

When I come back to think of the painful situation with my experience in Law #1, it now seems incredibly obvious that we — and the people that I often refer to — were incapable of solving this particular problem, because of our pre-existing bias’.

We all looked upstream and downstream as is conventional wisdom, at the muscles of the trunk and the lower spine, as well as the knee and to a certain extent the ankle but no further, and certainly not in greater depth.

The things that all seemed probable, didn’t work, and as the therapist responsible for the discovery told me, I was probably making it worse.

On the other hand, this particular therapist had the right intuition (bias?) to find the solution. Bias is a double edged sword.

Now certainly I have a very different understanding of pain, but at the time I was very locked in to conventional wisdom.

I worry sometimes about the groupthink that inevitably pops up when you work with the same people for a long period of time. You share the same information, read the same books, go to the same or similar workshops, and ultimately start to approach problems the same way.

Finding ways to avoid that is particularly useful as it relates to law two. It’s natural and generally useful to build models or frameworks (as 2×2 or White Belt Fitness are) to help explain information in succinct patterns that can apply in the majority of situations.

Except when the models don’t fit. That’s why outliers help you form better laws around models and consequently why I think my systems are better than most. There is flexibility built into these systems for that reason.

Unfortunately (at least the experts perhaps) we should have at least some vague notion that not all problems fit the system. Or perhaps, more importantly you can’t fit all existing problems to existing systems. It’s unwise to bias yourself to a system that can’t be flexible.

That’s why I don’t buy into the notion of just using barbells, or just using kettlebells, or just using machines as some people obsess over. Sure it makes things seem simple, maybe even easy, but it also creates a strong bias, where it might be unwise to be biased.

That’s why most ‘diets’ are just flat out bad. They rely on inaccurate premises from the get go, usually blaming one type of food or macronutrient for all that ails you.

Word to the wise: You probably want to avoid diets of this nature.

It sounds convenient and easy to say that all of these foods are bad and should be avoided, and all of these foods should be eaten more. Some may group foods further, into ‘eat with caution’ or ‘eat sparingly.’

The reality being that there are rarely dangerous exercises or unhealthy foods, but rather appropriate applications and inappropriate applications based on risk assessments and probabilities.

Eating Omega-6 dominant refined cooking oils here or there is unlikely to be a problem, but when those fats start to make up a significant portion of your diet and displace Omega-3 fatty acids significantly, suddenly you have a problem.

Most problems are nuanced, which completely goes against common approaches to fixing them.

My take away: Assume you’re being biased, because frankly you probably are. That’s why the quality of the research you’re doing matters, it’s also why people like Colin T. Campbell (author of The China Study) or William Davis (author of Wheat Belly) ignore data that conflicts with their bias, and why their research largely only supports their preconceived notions. They never write anything that conflicts with their general beliefs. This approach to science is holding us back from truly developing. The only way to overcome your natural bias is to be vigilant in looking for them in yourself. Study bias‘ but realize that you’re not exonerated from them just because you know of their existence.  

I just read an 2016 meta-analysis on Ego Depletion, something the research as far as I was aware seemed to indicate was a thing, I even wrote about it a number of years ago.

The theory of ego depletion still makes sense to me, and to a certain extent I still think there is something to it, even in the presence of new information that suggests otherwise.

My take away means that I need to be open to the fact that even if it makes sense, I could still be wrong and simply bias’ to believe a theory that seems to make sense but hasn’t really been scientifically proven (it’s just a good theory).

What I’m most willing to concede however, is that there is something going on, even if it’s not easily or rationally explained as willpower working as a muscle. There are probably confounding factors like sleep duration, sleep quality, amount of physical activity, etc…etc…

I was tired after landscaping in school, even though it was mostly manual labour autopilot work, and I am tired after a day of sitting in front of a computer screen writing with a lot of cognitive thinking. One requires a lot of brainpower, the other physical power, and both often result in the temptation to have a beer or watch TV, which I typically manage to out-skill, rather than outwill but that’s another story.

I’ve seen people outwill things before, it seems to work at least in the short-term. I’ve seen light switches just go off in people in a way that leads to massive change (even though I am largely an advocate for the slow deliberate approach to change), sometimes you just need to right motivation or circumstance.

Clearly there is more going on than JUST ego depletion. I’ve been wrong many times before (like the hip pain problem) and I expect that I’ll be wrong many times more in the future.

Doesn’t mean I’m not good at what I do (something I used to think), it just means I have more to learn.

The Big Takeaway

The book was an eye-opener, in that it described far better than I ever could, my skepticism and acceptance of science.

Medicine isn’t an exact science (any more than fitness or nutrition is), and questionably can be rooted in assumptions just as much as science.

I also realized how hard it is to transition from a reactive health care system to a proactive one (we simply don’t know enough), something I’ve perhaps wrongly been an advocate for.

Many people out there believe for instance that nutrition can just cure problems better than medicine, or that nutrition can be used as medicine, and while it can, there are big limitations. Nutrition is more like the bass player laying down a rhythm, it’s important sure but all the instruments together make up a symphony.

You often need nutrition changes in tandem with medical ones (or movement ones).

We know a lot less than we think we do. Medical research (like nutrition and fitness research) is really just the broad strokes of the canvas, we’re not painting anything that resembles anything yet. Not by a long-shot.

We can’t be afraid to challenge and throw out old long-held ideas (like Calorie Counting!), not because they don’t work, but because often there are better methods out there, or at least a variety of methods that work differently for different folks.