Friday, July 10, 2009

Not Superman, not demi-gods, just people...

First off, let me apologize for this post. This is a subject very near and dear to my heart. I've been trying to put this post together for several days, and it keeps evading me. I finally just sat down and wrote it. It's not very good, and it jumps all over the place. Perhaps after a few days, I will attempt to re-write it into something more coherent. Until then...

I've been reading several books lately (the latest is Overtreated, others I've read include Better: A Surgeon's Notes on Performance, Complications: A Surgeon's Notes on an Imperfect Science, and How Doctors Think). They have led me to a topic very important: medicine (human and animal) and its limitations. Ever since I started actually being a veterinarian, I have been undergoing a slow and painful awakening to my misconceptions about medicine. Growing up, I invested fully in the idea that doctors are semi-gods, capable of bringing disease to its knees and helping us all. I viewed medical technology and medical research as hallowed institutions - ones not subject to market forces and the whims of the pharmaceutical industry.

Then I became a doctor myself.

Now, I see medicine for what it truly is: a wonderful but limited ART form. Medicine has created many wonder drugs and done many amazing things, BUT medicine does not cure all. Medications are not the panacea for every disease (not what the pharmaceutical companies would have you believe).

Medical journals - once the bastion of ivory tower research - have now become largely written by researchers that are funded by pharmaceutical companies. One recent estimate put the number of researchers WITH CONFLICTING FINANCIAL INTERESTS doing research and writing literature for the Journal of the American Medical Association at 80-90%! Yes, you read that right. The great majority of the medical literature that doctors rely on to make medical judgments is funded by pharmaceutical companies that want to sell a drug. Veterinary literature is NO better.

On another, completely separate subject: how many of you think that every drug we use in life has undergone rigorous, controlled, randomized, blinded clinical studies before being put on the market? How many believe that these drugs are safe because the FDA says they are? Further, who believes that they all work as they are supposed to and that each new drug is a huge advance on an older drug that does the same thing?

If you answered yes to any of those questions, check out a brief rundown of the Vioxx debacle. I realize this is a Wiki article, but this information is verifiable through the AMA. I have read several of the studies myself.

How many of you believe that if your doctor recommended high dose chemotherapy followed by bone marrow transplant for breast cancer than it must work? That this treatment would only be recommended after extensive and rigorous studies?

If you answered yes: read this brief blurb about high dose chemo and autologous bone marrow transplants. Since that blurb was published by the NCI (in 2001) - this type of chemotherapy has been discredited as being no more successful for treating breast cancer than standard chemo. It was a horrible experience in the early days - with women being isolated for up to 3 weeks while they waited for their bone marrow to recover. During this time, they were sicker than you or I could probably ever imagine. Many women died from the treatment (although this can be true of any chemotherapy).

Other examples? There are a million...but it would take pages and pages to write them all.

Ahh. To delve into this topic with any amount of clarity and determination would take hours and hours.

My message: doctors and veterinarians are humans. We are subject to the same bias as the regular public. We are ordinary people who may or may not be able to read the published literature regularly and with a very studious eye. We are not gods, and medicine doesn't fix everything. Whenever your doctor or veterinarian recommends something - TALK to them about it, ask questions, do research, and figure out for yourself (with the help of professionals) whether that recommendation is a tried and true diagnostic/therapy.

Be an informed patient/owner. Know the medications you or your pet receive. Make sure your doctor/veterinarian is aware of them.

Remember: medicine is only as good as human beings themselves can be. We're all fallible, we all make mistakes, and most importantly: MORE medicine does NOT equal good medicine. Sometimes more is just more.

As a doctor, I am rapidly learning to view treatments and diagnostics with a discriminating eye. I try to keep up on the literature, to read it with discernment (although it's difficult to read 10 article, pick them apart, then go look up the researchers and find out WHO funded them). It is something I take very seriously. Just because a new technology or new drug or new test is available doesn't mean I should or need to use it on a patient. Just because I CAN order a CT scan on a patient with suspected cranial bleeding doesn't mean I SHOULD - especially if the owner is not interested in pursuing a craniotomy.

Just one more thing that makes being a doctor such a damned challenge!

If you take nothing else from this post, take these 2 things: the pharmaceutical companies are spending millions of dollars supporting doctors that in turn do research and publish articles in respected medical journals (JAMA, JAVMA, New England Journal, JAVIM). And second: often more medicine isn't better medicine, it's just MORE.

(As a sidenote: while Overtreated is riveting reading, full of spectacular examples, it is a poorly referenced book that seems rather sensational. It does - however - point out some ideas that are important to think about in regards to the sky-rocketing cost of human medical insurance/medical care and the medicalization of the American people.)


Anonymous said...

What is true for the field of medicine is also true for every area of "higher learning" and research. Motivations either from drug companies (without which there would be a lot less money for research!) or expectations of the university or company who employ you drive much of what is published. Add to that being politically correct in your ideas (which may not get published if you are not) and personal egos of the "learned" and who knows what else entering in and you realize how very little man really knows. This was the most important thing I learned from doing research. Be informed, be critical, be discerning, use some common sense, and be as truthful as flawed man can be. Prayer helps a lot also. Man is not God; he never has been, and he never will be. God alone is Truth. Mom 2

Anonymous said...

By the way, I sent Papa an article a couple of years ago that included documents from drug companies in the 1950s that indicated they were plotting a strategy to sell drugs since they knew that since antibiotics had become so pervasive, they were worried it was going to lead to their (drug companies') demise. Their overall strategy was to convince otherwise healthy people to take medicines. They have been extremely successful; a vast majority of the U.S. population takes at least one drug regularly. As part of this strategy, you can see that in the last few years the level considered as average for cholesterol, blood pressure, blood sugar, etc. has been lowered so that more people would "need" to go on prevention meds such as cholesterol or BP drugs. It's all part of the same strategy. As for the demi-Gods view of docs...over the years I have taught many future and a few current MDs and have not been impressed with the group as a whole...they tend to be highly driven individuals, but are not the smartest of students overall. And they really don't get statistics and probabilities. In the book, Fooled By Randomness, a test was conducted of MD's understanding of probabilities associated with certain treatments and less than 10% made the right choices. And that was at TOP med centers like Mayo, Johns Hopkins, etc.! So I believe greatly in figuring out most of this stuff for myself, with some pretty strict drugs (except antibiotics if absolutely necessary) and no invasive procedures (except critical to save life). Dr. Paul says whatever you do avoid being hospitalized unless it's a life and death choice. Regular exercise and a sensible diet take care of most things, but people would rather pop a pill than exercise the self discipline it takes! -M.