The opposite of crazy isn't institutionalism, it's reason and evidence
There are more crazy ideas than good ones. You can write a textbook about how to practice good medicine, but you can't write a textbook for how to practice bad medicine. It would be too long. There are too many bad ideas, and not enough paper in the world to write them all down.
How does one tease apart good medicine from bad medicine? Well done studies are important, reason is important, understanding the strengths and limitations of epidemiology is important. Often, you have to get into the weeds. It is hard work. It often goes hand in hand with publishing research. It takes years. It's a grind.
For some topics, there are very few people who even understand the intricacies of the issues to comment meaningfully. This was certainly the case with cancer screening. Where for decades they were few thoughtful commenters. Gil Welsh, Barry Kramer, Bill Black, Rita Redberg, Peter Gotzsche pushed the field in ways that were unpopular. They were ultimately vindicated.
If you're not good at analyzing evidence, you can cheat. A simple heuristic to cheat is to be an institutionalist. On average, Western allopathic medicine delivers a higher proportion of things that work than any other form of medical thinking in human history. It has more randomized trials than any other type of medical thinking, and it has more successes. So if you didn't want to evaluate individual ideas, but wanted to tie your wagon to the camp that gets more things right, you could just default to the institutionalism.
The problem of course is the institutionism is not perfect. There are many medical practices that are incorrect, promulgated for years with false rhetoric. In our investigations on medical reversal, culminating in our book, we have detailed hundreds of instances of such practices. There are tens of thousands, perhaps hundreds of thousands of practices that have never been evaluated rigorously. We simply don't know. So the heuristic of trusting institutions is imperfect.
Now add on the layer of something new and unprecedented. A novel coronavirus pandemic upends all this. In the heat of the moment, trapped at home, riddled with anxiety, the number of bad ideas may swell. The ratio of good ideas to bad ideas will change.
By necessity, institutions will have to make some choices. Many of those choices, perhaps even most, maybe incorrect. There are two things they could do to help themselves. One, not talk with false certainty. They clearly fumbled that ball.
Two, have a process to recognize and document errors and course correct. They also screwed that up.
So enter the two types of medical thinkers. The person who independently evaluates evidence on a given topic is likely to disagree substantively in times of crisis. The person who understands the strengths and limitations of epidemiologic studies is likely to see many practices or widely recommended based on scant evidence, with few opportunities for improvement.
Meanwhile, the amateur, the person who's not quite good at thinking about medicine, who defaults to institutionalism is going to be in deep trouble. They have no way to separate the institutional truths from fictions. Instead, they drift into religious thinking. Scientific debates take on moral overtones.
That's exactly what happened with COVID. On masking 2-year-olds. EUA for vaccinating kids. Bivalent boosters. Paxlovid. The list goes on and on. Institutionalist (Of course, only when the correct political party is in charge) got all these issues wrong. The root failure. They just weren't good at thinking about medicine. They never were. They only fooled you because they bet on Tom Brady. He had a higher winning percentage. But even he can't keep it up forever.
Interesting post. But, you left out one important factor. Since the 19th century, MDs, through the main organizing group, the AMA, have put physician income above everything else. I know this is easily forgotten, but it is factual. From driving out women to take over birthing babies, to use of licensing requirements to limit other types of medical practitioners, to limiting the size of medical schools and until WW2 to limit women or non-white folks from medical school, medical practice has been a controlled endeavor that attempts to keep other groups from acceptance. There is plenty of literature that talks about the intentional destruction of any and all groups that might offer alternative ways of doing or thinking medicine. The main tools have been propaganda and political coercion, even jail terms for the heretics. So while I won't disagree with you on the overall depth of success of modern industrial medicine, I will note that none of the alternative thinking, either within medical industrial complex or outside of it, has been given a chance to compete in the world of ideas. When mistakes are made (not just by doctors but by pharma too), they are either covered up (Thalidomide, Over prescribing of opiates, antibiotics), normalized (cesarian sections, TV ads for a variety of prescription drugs), lied about (LSD,Marijuana, psilocybin, etc.), and/or used as social control (ritalin, adderall, electroshock therapy, prozac, Zoloft, etc.) (I must add that in a small amount of cases all these modalities of treatment can be beneficial, but the large amount of usage is the result of forces that have nothing to do with helping people). All these ideas are well documented at this point and point to people more interested in prestige and income, than in any search for the best way to help people.
Cynical? Yes. But truthful.
Your ideas are rich, complex, and meaningful.
A sizeable portion of institutionalists are more comfortable parroting fluff social issues de jour rather than working through your complex questions.
The government sets the agenda by dangling massive amounts of dollars and encouraging funding dependence and accreditation dependence (exhibit 1: TJC and ACGME requiring DEI (*insert gagging here*) programs likely in perpetuity).