The Unscientific Practice of Medicine
I tip my hat to likes of Orac, Sandy, and Robert Centor. They don’t shy away from a debate or a contraversial topic; in fact, they seem to greet it with open arms. This takes a frame of mind that I find difficult to hold for very long - one that thoroughly examines the details of issues and comes up with a defendable position. I think this type of debate and scrutiny of issues is very important in that it attacks dogma and challenges assumptions, forcing us to make sure evidence is good for the things we are doing. But if I spend much time doing this, I find myself reaching for the Tylenol.
In a recent post in his blog, Centor challenges the dogma of getting the hemoglobin A1c down below 7.0, questioning whether the benefit of getting diabetics to that level is worth the risk of using medications like the thioglitazones (of which Avandia is presently the most famous).
The truth is, these kind of questions make me feel quite uncomfortable, given that I am a practicing physician who has used this class of drug to get diabetics to that very goal. Challenges like this are not just of academic interest to me, they would drastically change the way I practice medicine if my practices (the accepted medical practices) were found to be false.
The problem is that I am a doctor, not a scientist. I practice applied science, not science. I do realize that this statement is a generalization, and some of what I do is, in fact, scientific, but the majority of what I do is based on other people’s experiments, analysis, and opinion. I don’t have time to scrutinize all of the literature as to the benefit of lowering the A1c, nor do I have time to see all sides to an argument. Just like my patients, I get confused as to how to interpret two intelligent opposing opinion. In fact, such arguments quickly give me a headache.
The problem is that I must decide, where others don’t have to. An academician can argue all they want and not come to a conclusion, but I must decide if I am going to bring my diabetics to goal or not. I must form an opinion because they are coming to see me in the office for that very opinion. So instead of looking over all the evidence myself and forming an opinion, I do the following:
- I look to “expert” panels as to recommendations on what should be done. For instance, I look on UpToDate.com and ACP medicine to see the reasoning of A1c lowering.
- I rely on my past experience. For example, the child with the rash looks much like one I have seen before.
- I use statistics. Doctors have a billion statistics in their head. I use them in my choice of medicine and my decision to order tests. When someone comes to me with chest pressure that radiates down the arm, I ask myself: ‘what is the likelihood that this is heart disease?” If I think a story is very consistent with true cardiac angina, I may recommend a patient get a cardiac cath instead of a stress test. A lower risk person would get a stress test, and a very low risk person would be reassured and sent home - all with the same story.
- I avoid worst-case scenarios. This is particularly true in pediatrics, where we do a spinal tap on young children simply for a fever. Yes, you know it is unlikely to be meningitis, but the simple fact that it could be makes you do a very invasive test.
- I try to adhere to best practices. Best Practices are the generally accepted medical care at the present time. If you deviate significantly from best practices, you had better have a reasonable explanation for why you did not do the “normal” thing, or you will be liable for consequences - deserved or not.
So these challenges to my dogma really put me in a conundrum. I have to choose what to do. Do I really want to hear the possibility that what I am doing is wrong? Do I really want to know that Statin drugs may not be helpful, that obesity may not be as harmful as some say, that good diabetes control may not be as important as I am told?
It certainly is worth debating.
But it really gives me a headache. I am a doctor, not a scientist.
September 14th, 2007 at 12:03 am
I couldn’t agree more. It is a challenge to assimilate all of the data regarding complicated issues like that and many more. As physicians we have to trust certain sources even though we are painfully aware of circumstances when they have been wrong in the past.
I can especially relate to the avoiding worst case scenarios approach to pediatrics. I do this on an almost daily basis. Twice today in fact. It is very difficult explaining to a parent that the their child almost certainly doesn’t have sepsis but we are going to stick a needle in their back and take him away to the Level II anyway.
September 14th, 2007 at 12:08 am
I’ll add that the difficulty in contemplating one’s illogical thinking,especially regarding a deeply held belief, is so great that some of the smartest people in history have been unable to do so. Linus Pauling immediately comes to mind but there are a host of others. Here is a podcast on this very subject: http://www.pointofinquiry.org/?p=126
September 14th, 2007 at 12:29 am
Hi Dr. Rob,
Thank you for this. I’ve never quite understood why physicians invariably choose to prescribe a drug over, say, fish oils for cardiovascular problems, blood thinning, depression etc. as a first line of treatment, when to me it seems obvious that there would be far less chance of harm and so many potential benefits to overall health. Now I understand. I should have been able to figure it out, I suppose. After all, I would go with what I know too, if I were the doctor.
Vreni
Health and Vitality Coach
September 14th, 2007 at 5:55 am
Are we joined at the psychic hip or something? Great post, and you’re right; it does correlate with mine.
September 14th, 2007 at 9:17 am
Nice post Dr Rob!
September 14th, 2007 at 10:10 am
This reflection matches up nicely to your post about “reasonable doubt,” too, I believe. You are questionning the dogma that seems to issue from current research . . . and you know-for-an-indusputable-fact that reasearch doesn’t always match up to practice.
I have 2 diabetic friends that I speak to quite often. Neither can comfortably keep their sugars as low as the research suggest they should be kept–both women feel faint and dizzy when they get their sugars below 100, or even below 125. So, even if their endocrinologists do not agree with them, they feel they must keep their sugars higher than the recommended range . . .
There are 2 good things about this–one, that their range must be individualized for them; and secondly, that they are partners in their health care–they get to make some of the final decisions. Sometimes, docs act as if it is all up to them, and then they die young because the burdens of the world (or at least all their patients’ issues) are on their shoulders.
When I reflect on this, I add my own conviction that the original design cannot have that many design flaws–that we may be deluded into thinking that we can improve greatly on the original design. In other words, I believe in the natural . . . and wonder what complex things have gone into making the natural so disrepected. Cultural things? Our own arrogance? Or ??? I ask myself these questions, in the spirit of “reasonable doubt”.
Chris and Vic
September 14th, 2007 at 12:32 pm
Disease is clearly a step away from the way things were “designed.” We have done great in adding years to people’s lives and I feel like I do help people. It is just that I sometimes feel like reading more just clouds things - yet I also think we should not put our heads in the sand and not accept that we may be dead wrong on things. I really hesitate to believe anything that rings of conspiracy (those big bad evil pharma companies running everything and making me practice bad medicine so they can make more money). There probably is some of that going on, but for white to be black and black to be white because of a conspiracy - that is hard to believe.
September 14th, 2007 at 5:45 pm
Clearly, primary care physicians cannot be experts of all the conditions we treat. We cannot pore over each individual article, looking for selection bias, poor randomization, or financial ties. Heck, it’s hard enough to keep up with the major policy statements for the major diseases. And so we have to trust our experts, just as our patients trust us.
Sometimes I see a patient who accuses me of being in cahoots with ‘the man’, whomever that means to them: the government, the pharmaceuticals, the insurance companies.
Tho it’s unintentional, to some degree I think we all are.
But aside from keeping an open mind, and watching for new information and trends, there is little else to do.
I had a patient once who was taking some natural supplement that I had a problem with. I talked about the fact that it wasn’t FDA regulated, so we were unsure of it’s safety profile. He said, “Yeah, like Vioxx.”
Not much to say to that one.
And thanks, Dr. Rob, now I have a headache too.
September 15th, 2007 at 9:59 pm
I live in fear that I’ll miss out on the one piece of news that shifts the way I practice medicine from the best practices to the worst.
In all we do, keeping up with the 400 drugs out each month (hyperbole perhaps)and 400 drugs found to cause harm each month (hyperbole definitely)is very difficult.
Thank God for Journal Watch and the like. I don’t have time to be a scientist and a practicing physician.
I just want someone to tell me what to do.
September 16th, 2007 at 11:19 pm
This highlights one of the essential truisms about the practice of medicine: while we want to adhere to data, obtained by good science, that isn’t nor ever will be nor can be the whole deal. Humans, sick ones especially, simply don’t behave in purely predictable ways: those other modalites on which you call are exactly what we need to be good docs. And it’s why strict “best practice” algorithms will never suffice.