Bad Medicine
The truth of it is that there is no evidence better than a skilled physician who understands the patient more than the numbers...
Thoughts on this fantastic Atlantic article, "When Evidence Says No, But Doctors Say Yes"
We overtreat, overtest and harm with our good intent (isn't that the case too often in life?).
An example:
Although shown to not improve, and in fact degrade a patient's outcomes, coronary stents (little tubes places in the artery) are still recommended and performed on far too many patients that do not need them.
"Stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all."
There are many more situations where actions we think work, are actually showing to not be beneficial.
Which begs the question - what defines if a treatment is "working"?
What are we looking for? - Better lab numbers, Better statistics or Better lives lived?
I don't think we've come to a consensus on that, which further muddies our understanding of effective treatment.
A few more examples through long term studies from the above article -
1. Intensive Blood Pressure Lowering Meds in Diabetics, Or intensive Blood Sugar Lowering for that matter - doesn't improve outcomes - but we push for it anyway.
2. Antibiotics in Lyme disease - not shown to be effective, but it's the standard course for the doctors who treat it.
3. Special sponges to prevent infection in colorectal surgery - cause more infections, still used.
4. Meniscal surgery - puts people at risk for osteoarthritis, but it seems to work for pain from a placebo perspective.
There are at least 5 more examples within the article.
Should we stop all these treatments and procedures? Not exactly.
Just because the evidence shows these aren't effective doesn't mean it didn't or wouldn't work for you. It just means that large scale evidence, though helpful, is difficult to put into practice on an individual scale.
Likely, these human flaws in judgement are because medical doctors live daily with the outcome of not performing a surgical treatment, or worsening a condition that they had the tools to treat, or sadly, wanting to avoid poor reviews or litigation (aka Defensive Medicine).
Deciding to forego treatment can be immediately devastating for the patient who needed it, whereas an unneeded treatment, seems harmless. The urge to be diligent and over treat overrides the better medicine of evaluating the person in front of us and making the decision that seems appropriate for them.
(Although this article tends to suggest it's more about financial incentives and lack of continued learning on the physician's part, I tend to give a little more credit to the doctor who is trying to be good:)
Large Scale Evidence gives context, but doesn't give answers.
As a doctor, if I allow evidence to override my critical thinking, my capacity for perceptive reasoning and my patient's consent & understanding, I am slowly becoming a robot.
But if I ignore evidence and let all options have equal weight or worse let my "favourite" options win - in the face of difficult decisions with high stakes - I am being negligent.
Pushing for evidence-based-only treatments disregards the skill of a physician and encourages medical schools to train in algorithms rather than train intelligent, thoughtful physicians who are good listeners and detectives.
Algorithmic thinking ends us up with a farm team that doesn't know how to perform on the big range with real people.
Pushing for treatments and medicines to be accepted as useful without proper evidence is opening the gates for massive unbridled corporate influence and large scale experimentation.
Being "intuitive" with what will work without the context of evidence being at the forefront is playing God.
Being logical seems logical, but it is vulnerable to our biases.
This whole thing is an impossible situation.
As a physician it is overwhelming to try and balance all the information being published everyday, some of it is shoddy science, some of it will be overturned within 10 years, and some will change the entire practice. It's damn near impossible to remove bias in quick interactions that require decisions. It is difficult to ignore memories of patients that have suffered when we chose against a treatment. It challenges the ego and the bank book to reject offering treatment when a patient really wants it and expects us to deliver.
Do you know what I think works?
Actually listening to a patient. Stepping off the pedestal of evidence or logic or intuition.
The cure to Bad Medicine is Good Medicine. Good Medicine comes from the patient's story combined with my capacity to watch my biases in treatment, or at the very least be explicit that they are clouding my visual field.
Something else that works? Changing the financial incentives in treatment.
Nissen [Cleveland Clinic Chairman of Cardiology] thinks removing financial incentives can also help change behavior. “I have a dozen or so cardiologists, and they get the exact same salary whether they put in a stent or don’t,” Nissen says, “and I think that’s made a difference and kept our rates of unnecessary procedures low.”
One other effort that works, and I mean, really works?
"...Something that does powerfully and assuredly bolster life expectancy: sustained public-health initiatives."
What do these include? Diet, Lifestyle, Movement, Mental Health & Medical Literacy.
Oh hey, that's what I do - on an individual level.
That's what long term medical relationships do. That's what a membership-based model does.
We need Evidence in Medicine, and we need Critical Thinkers in Medicine. We need to rethink Incentives in Medicine. We need to Listen More, Speak Less and Lead Better, in Medicine.
And we all need to remember this:
"Medical research is, by nature, an incremental quest for knowledge; initially exploring avenues that quickly become dead ends are a feature, not a bug, in the process."
We don't need to be angry that we don't have "the answer" we just need to be cognizant that nobody's "right".
Great article, worth a read if you've got the time to explore the links within as well.