Freakology

by rcentor on April 10, 2007

I love the book Freakonomics. Their blog is quite entertaining. But this time they miss the point – Which Medical Practice Will Be Discredited Next?

This recent New York Times article tells of the compelling study which found that coronary stenting is typically no more effective than heart drugs, even though it is far more invasive — and, to be sure, profitable for the medical personnel involved.

Indeed, another article in the same issue of BMJ suggests that stenting is less common in Europe than in the U.S. mainly because “there have not been the same financial incentives to carry out some stenting.”

So here is the problem. I am not just picking on Freakonomics, but rather anyone who tries to understand part of medicine and extrapolates to all of medicine. Angioplasty is clearly indicated for acute coronary syndromes. This treatment does decrease subsequent coronary events. What the COURAGE study showed was that angioplasty is not superior to intensive medication management of STABLE coronary artery disease. The study design addressed a specific indication for angioplasty, it does not extrapolate to the majority of PCI (percutaneous coronary interventions).

Medicine is very complex. One of the problems that I have with our current guidelines is that they rarely pertain to my patients. We spend long years in medical school and residency learning the subtleties of medicine. During our careers we continue to refine our understanding of medical decision making.

Levitt and Dubner have actually made a classic interpretive mistake. I am actually somewhat surprised that they would miss the main point here.

I assume that they consider coronary artery disease is one large disease entity. Actually we know that stable and unstable coronary artery disease have different biologies. They are related, but require different management strategies and urgencies.

The bean counters want to create simple rules for medical decision making. They then will measure our adherence to those rules. The bean counters are wrong. They need to care for patients to understand the number of decisions we make on each patient at each visit. They cannot develop formulas for the interactions between diseases and medications. They do not really understand the concept of severity of disease. Some asthma is life-threatening, while other asthma is easily controlled. Some hypertensive patients require one medication, other patients require a complex 4 drug cocktail. Some patients live with HIV infection for years without developing AIDS.

While we need to understand the evidence and use the evidence to inform our decision making, we can never have the necessary evidence to make even a majority of our decisions. We do the best we can. Our increasing life expectancy suggests we are generally doing the right things.

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{ 7 comments… read them below or add one }

dr. caligari April 11, 2007 at 7:53 am

To put it mildly, you’re nuts. Of course medicine is complex–so is economics. However, both should be based upon empirically demonstrable truths. Your “oh-it’s-so-complex- impossible-to-reduce-to-rules” attitude about medicine shows you are more of a quack than a scientist. If you believe that we “can never have the necessary evidence to make even a majority of our decisions,” then you concede you have no idea what you’re doing most of the time.

You justify your ignorance with the INCORRECT claims that there is “increasing life expectancy” No there is increasing AVERAGE life expectancy. But, is that attributable to doctors? Show me the proof. I would argue that the kudos belong to the pharmaceutical companies, public sanitation, and improving diets, life-styles.

Oh–but you don’t believe in evidence–so I guess we can’t have a discussion.

You’re why medicine remains a medieval cottage industry

Val Jones April 11, 2007 at 12:32 pm

I am a strong proponent of evidence-based medicine, but I do think that Dr. Centor makes a good point – clinical trials test outcomes, safety, and efficacy under very controlled conditions. When we prove that a certain medication works under specific circumstances, we can’t know if it also works for patients with other comorbidities or over longer periods of time, etc. That’s why we keep coming up with new data that sheds light on medication use in new, real life scenarios (like antiarrhytmic use, cox II inhibitors, Zelnorm, etc.) We should keep testing, keep studying, keep collecting data… but realize that right now a lot of what we do is based on standards of care and the best plausible practices given complex realities that don’t always bear a 1:1 relationshiop to the research. That doesn’t make us quacks – it just means that we’re doing the best we can, continually improving as more information becomes available.

dr. caligari April 11, 2007 at 8:36 pm

Ahh, but when a healthcare consumer speaks to a doctor, the doctor rarely assumes the “geesh, I’m just doing my best–I’m just a stupid, a-scientific hick” attitude. To the contrary, all too often, the doctor assumes the role of oracle uttering the truth. When the health care consumers asks, is that an evidenced based protocal? or what’s your authority for that claim? doctors rarely react well.

Rather, they claim that their a-scientific hunches and practices should receive deference. Why?

Runawaydoc April 12, 2007 at 5:15 am

And, you, Dr. Caligari, seem to epitomize the rigidity of evidence-based medicine which, if left up to you, would destroy the practice of medicine completely. I believe what db was stating was that there has to me some middle ground, some compromising bewteen what the data shows and what is actually happening in the real world of caring for patients. If I understand your position, if you are counselling a patient with an LDL of 180 that he should begin a statin drug, and that patient tells you he really just does not want to take medicines, you would throw your hand up and cry “so be it…have a heart attack or stroke!! There is nothing else I can do for you!!” Dealing with human beings who are capable of making their own decisions, right or wrong, who are capable of changing the variables at will, or who may resist aknowledging the evidence just because they don’t like you telling them what to do, will never allow sole evidence-based medicine to flourish. There is still an art to medicine…something it sounds like you never learned.

Andrew Brown April 12, 2007 at 4:36 pm

Thank you for this interesting information. So often when we read things in the papers we realise there may be some other angle that we have not been told.
And I entirely agree that guidelines are good servants but bad masters. If an art is a science with more than five variables then medicine is surely still an art.
But here in the UK we GPs (family physicians) are being brought more firmly under the Guideline Grip. A significant portion of our income now depends on our annual Quality & Outcomes Framework score, which derives from computerised proof that we have adhered to certain guidelines. There are a number of problems with this. Sometimes the guidelines are out of date and wrong – thus we are compelled to change antihypertensive medication to ACEi when the patient has CKD, even if they don’t have proteinuria. I believe that this is now thought unnecessary. A lot of effort is required to assiduously record all information, including exemptions where patients fall outside the guidelines. And it focusses our minds on what can be measured, giving us less time to think about the things that cannot. As Einstein pointed out, not everything that counts can be measured.

dcs April 13, 2007 at 3:54 pm

I hope if dr caligari ever has a compex, life threatening emergency that his/her physician is not a guideline bound hack!

Chris (Dr) January 8, 2010 at 9:55 pm

I am going to go out on a limb here … and say … if your job is in the field of research or a science affected my research … then yes … NO ONE knows what they are doing – really. 100% doesn't exist in real life.

Only Dr's must assume a role of teacher of the knowledge we have … if later on down the road this knowledge changes … then we can't hold Dr's responsible for giving out wrong advice.

We all work within a framework and guidelines – unfortunately sometimes these rules get the better of us if we let them wash over our professions.

Isn't the argument or discussion here just a means of venting anger at something we can't really quantify or touch … shoudn't we people be standing up and saying enough is enough this is wrong!
or…
I didn't sign up to do this? I'm going to start my own Colloidal Silver company and education service so that these types of illness never occour in the first place?

My conclusion, people like to fight … every individual knows best.
why not flip these two points upside down and act accordingly to change this ugly fact.
 

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