Listening to philosophy tapes certainly gives me a different perspective on medicine. Currently I am listening to Will to Power: The Philosophy of Friedrich Nietzsche. This morning on the way to working out and then to work I was lietening in particular to: Lecture 11: Nietzsche on Truth and Interpretation. This lecture expands on the quote you see on the right of this blog: There are no facts, only interpretations. - Nietzsche .

As the lecturer expands on this discussion, I started to understand why yesterday's rant created such interest (8 comments by this morning). As I personally rate my rants, the number of comments provides me a good indicator of their effectiveness in stimulating thinking and interest.

Reading the comments, and then rereading Sydney's column, I realize that I am working from a different context. Nietzsche would argue (or at least the lecturer is arguing for him) that we only have interpretation in our attempts at truth. All interpretations depend on the context in which one views the data.

Our friend and frequent poster Bernie lives in a different contextual framework than I do. Thus, he views the same data but interprets it differently.

Now unlike many politically correctness advocates today, Nietzsche does not assume that all viewpoints have equal value (of course, he is judging from his own context). I believe that the bio-medical model is the superior model for judging medical data. (Bernie might disagree - but then I should not speak for Bernie).

As I read Sydney's column, she alludes to an important point. We must take all new data and put those data into our underlying context. What do we already know? Can we reconcile these new data with previous data?

I believe that the best way to interpret new data uses the principles of evidence based medicine. One should not discount previous knowledge or expert opinion (I am a Bayesian, and therefore adjust my probabilities based on prior information).

However, we should not ignore new data just because it does not fit current expert opinion. When the major study examining anti-arrhythmic therapy after MI came out - we all changed our context and practice - FINAL REPORT FROM THE CAST STUDY . The study results were unexpected and counter to expert opinion. The study had such compelling results that it overcame previous expert opinion and changed expert opinion.

As one studies the precepts of evidence based medicine, one first learns the hierarchy of research designs. The randomized double blind controlled clinical trial is the epitome of research. Epidemiologic studies represent an excellent method for generating hypotheses.

Perhaps my disagreement over Sydney's column involve shades of interpretation. I know many physicians who teach and practice evidence based medicine. They strive to interpret data in the context of previous knowledge and the quality of the new data.

I agree that often the popular press does not hold the same high standard. Autism and MMR attracts headlines, and headlines sell papers. Even if most medical reporters understand the evidence and avoid the article, some other reporter will see this as a quick easy controversial piece to publish.

So I would probably have written a similar article, but shaded it differently. In my mind we must remain skeptical of all new data and wait for the accumulation of supporting data prior to changing our contextual model. As a physician and scientist this seems natural. Perhaps Sydney's underlying message is that patients should remain just as skeptical.

Medpundit (Sydney Smith) and I often disagree on issues. We have communicated and agree that our public disagreements (on our respective blogs) advance thinking. Only when we have polite yet spirited debate can our readers be stimulated to think carefully about issues.

In this spirit I wish to disagree with her latest Tech Central column - Medical "Truths"

And medical science has continued to march on, or so we like to think. Discriminating doctors of the early twenty-first century, unlike the doctors of the early twentieth, pride themselves on practicing "evidence based medicine." Unless there's a paper and statistics to back up a theory, we don't put it into practice. We like to think of medicine as a hard science, as dependent on the observable and quantifiable as chemistry, or some branches of physics. But, the truth is, in many respects medical science has devolved into a science as soft as economics or sociology.

Sydney does a nice job in this article of creating a straw man argument. She reasons that when she can show examples of incorrect analyses, that we can discard all analyses. She argues (I believe) that evidence-based medicine is futile because the studies are so often flawed.

There's nothing wrong with putting forth a hypothesis. That's what science is about, coming up with and disproving hypotheses. But not all hypotheses are created equal, and this one was based on particularly shoddy science -- a very small study, and the confusion of association with causation. Yet, for some reason The Lancet found it worthy of publication, well aware of the potentially devastating effects its poorly thought out conclusions could have on public health. At the time of publication, the article was accompanied by a prescient guest editorial from an official at the CDC that warned that "passion would conquer reason and the facts" if the study's conclusions were taken at face value by the media and the public. And that is just what happened. Blessed with the imprimatur of a world renowned medical journal, and a subject enticing to the media, the lead researcher was treated to a press conference at which he suggested that parents should avoid the MMR vaccine. MMR vaccine rates in Great Britain, where the story got much play, plummeted, and the incidence of measles rose. Within two years of the study's publication, there was a measles outbreak in Dublin that killed two children and hospitalized hundreds more.

She makes an interesting point about the article which supposedly linked MMR and autism. However, I believe that she targets the wrong group with her criticism. Certainly the Lancet editors made a mistake here. However, I am not aware of physician groups who endorsed this study as "evidence based medicine". Rather, "advocacy" groups of parents made this study a reason to avoid MMR. Most experts disagreed with the study at the time of publication.

Sydney finishes with:

These are but two of the most recent and glaring examples of just how soft medical science has become, or perhaps remained. There's no shortage of marginal hypotheses that appear in the medical literature and are passed on to the lay press as solid fact. That's why one day hormone replacement therapy is good for you and the next it's bad. Why one day fish is a health food, and the next it's a toxin. We may have better technology, better drugs, and a better understanding of many disease processes than our forefathers did a hundred years ago, but we're no more sophisticated than they were in sifting the bad science from the good.

Wow! This sentence insults the entire field of evidence based medicine and medical research. What a powerful sentence! But the sentence is incorrect and an example of hyperbole.

Those of us who try to practice evidence based medicine (and we freely admit when the evidence is not satisfactory to use) work hard to carefully evaluate the data. We rarely change our practice on a single study, unless it is a large, carefully done randomized controlled trial. One great web site for evidenced based medicine: Bandolier. The Cochrance collaboration provides outstanding reviews (requires a subscription).

The advances in medical treatment over the past 25 years are incredible. 25 years ago we had no way to modify lifespan in CHF. Now we can greatly increase life expectancy for those patients. Similar stories exist in diabetes mellitus, coronary artery disease and many cancers.

One should never regard a single study as the answer to our questions. However, as data accumulate we often can provide better care to our patients. We need more critical inquiry concerning published articles. We must put each new piece of information into context. If we do not do that, then we resemble ostriches.

We have made much progress both in scientific inquiry and the careful criticism of published articles. Medicine progresses not in a straight line, but rather through fits and starts, in a jagged line. But it does progress, and our patients benefit regularly from that progress.

Now this represents an interesting problem. Justices Hear Arguments About H.M.O. Malpractice Lawsuits

With the debate over patients' rights stalled in Congress, the issue moved to the Supreme Court on Tuesday in an argument about whether patients can invoke state law to sue managed-care companies for medical malpractice when treatment recommended by their doctor is withheld.

The federal law that governs the health insurance that millions of people receive through their workplace does not authorize such lawsuits. The question for the court is whether that law, the Employee Retirement Income Security Act of 1974, or Erisa, pre-empts the growing number of state laws that do.

The ability of patients to sue health maintenance organizations for damages for the denial of needed care is one of the most contentious issues in the health care debate, and this case has drawn intense interest from the industry and consumers alike.

Two managed-care companies, Aetna Health Inc. and Cigna HealthCare of Texas, are appealing a federal appellate decision that permitted patients' lawsuits to proceed under the Texas Healthcare Liability Act. President Bush was governor of Texas when the measure became law in 1997, without his signature, and he embraced the law during his last presidential campaign.

Now, however, the Bush administration is supporting the managed-care companies in arguing that the Texas law and others like it are invalid. Nine other states — Arizona, California, Georgia, Maine, New Jersey, North Carolina, Oklahoma, Washington and West Virginia — have enacted similar laws. These laws threaten to upset the "very careful balance" that Congress struck in the federal law, James A. Feldman, an assistant solicitor general, told the court.

As I consider this problem I do feel some conflict. I dislike legal solutions to these problems, but ... many managed care companies put physicians and patients into undesirable situations. While I understand the law, I disagree with the reasoning underlying the law. Thus, I must strongly disagree with the Bush administration on this issue.

Whenever I consider such a conflict, I try to consider first principles. In this case, patient care should trump everything. If that assumption is true (and I understand that some would debate that assumption), then it follows that managed care companies should not restrict necessary care.

First, I will start with an absurd hypothetical. A patient comes to the office with severe pneumonia. You calculate a pneumonia severity score - Improving Treatment Decisions for Patients with Community-Acquired Pneumonia - and determine that the patient needs hospital admission. The managed care company refuses admission and thus you try treating the patient as an outpatient. The patient dies. Who gets sued? Can the managed care company make this decision for financial reasons?

Now that example clearly rates as aburd, however, I have heard similar anecdotal stories over the years. What are the boundaries of medical decision making without liability for a managed care insurer?

I do not understand how I can be held liable for a decision for which I have incomplete responsibility. Thus, at least at the extremes, the insurer who refuses care must take some responsibility (and thus liability). I cannot understand any law which would prohibit this responsibility.

We will follow this decision with great interest.

Juan Davila, one of the two patients whose suits led to the Supreme Court case, was prescribed Vioxx by his doctor for arthritis but was required under his Aetna health plan to try two less expensive medications first. One of those drugs caused severe gastrointestinal bleeding that sent him to the emergency room.

The other patient, Ruby Calad, was hospitalized for a hysterectomy and other abdominal surgery under a Cigna HealthCare plan that authorized a one-day stay for those procedures. Though her surgeon recommended a longer stay, Cigna's hospital-discharge nurse refused to authorize it. Ms. Calad suffered complications at home and had to make an emergency return to the hospital several days later. The two cases, consolidated for the argument, are Aetna Health Inc. v. Davila, No. 02-1845, and Cigna HealthCare of Texas v. Calad, No. 03-83.

George P. Young, the patients' lawyer, said the inability of people like his clients to recover damages under federal law had necessitated the state's action. " What Texas has done is to fill a vacuum and say we are going to set out a professional medical standard of care when H.M.O.'s make medical necessity decisions," Mr. Young told the court.

He said that under the companies' position "they would be free to say we're going to use the medical-necessity standard of a witch doctor or whatever we decide it is."

The data continue to support moderate alcohol as cardioprotective. Study: Drinking May Help Heart Patients

In the study, men with high blood pressure who reported having about one or two drinks a day were 44 percent less likely to die of cardiovascular causes such as heart attacks than men with hypertension who rarely or never drank.

Alcohol is known to increase levels of good cholesterol and can thin the blood, warding off artery-clogging clots that can cause heart attacks.

A drink or two a day has been linked with reduced cardiovascular risks in healthy men and women. But many doctors are wary about alcohol use among people with hypertension because heavy drinking can increase blood pressure. For that reason, the American Heart Association generally advises patients with high blood pressure to avoid alcohol.

The latest findings suggest that moderate alcohol consumption offers the same benefits to hypertensive patients as it does to healthy people. But the researchers said the findings need to be confirmed in other large-scale studies.

They and other experts advised people with high blood pressure to remain wary about drinking.

"In light of major clinical and public health problems associated with heavy drinking, recommendations regarding alcohol use must be made on an individual basis," said the authors, led by Dr. J. Michael Gaziano, a researcher at Brigham and Women's Hospital and the Veterans Affairs hospital in Boston.

The findings appear in Monday's Archives of Internal Medicine.

Each study continues the general support for a drink or two each day. Clearly alcohol has a dose response curve. No alcohol or too much alcohol can harm us in different ways.

I continue to favor moderate alcohol unless the patient has a known alcohol problem.

What is malpractice? What are the costs of malpractice cases? Why does the legal system frustrate physicians so much?

One physician's malpractice battle: Dr. Diakos on trial

Despite the "win," Dr. Diakos said she didn't feel like celebrating. "I'm glad it's over," she said a few days after the trial. "But this was not a cost-free case for us."

The insurance company had to pay to defend the suit and Dr. Diakos lost about a week's worth of office time, using vacation days for the deposition and trial.

And she was clearly innocent.

Congress to look at Medicare pay formula

Physicians pushing for Medicare payment reform are hoping that Congress makes good on its intentions.

As lawmakers worked to finalize legislation laying out a fiscal year 2005 budget blueprint, the Senate Budget Committee attached a provision expressing the Senate's intent for Congress and the administration to correct "major flaws" in the formula used to determine Medicare payments for physician services. At press time, the Senate had not yet voted on the budget measure.

This intention is a "no brainer". Everyone knows that the current formula has major flaws. We need to fix the formula, not the payments.

Under the current payment formula, when spending for physician services exceeds an annual target, called the sustainable growth rate, future payments must be reduced to make up for the excess spending.

Physician groups, including the American Medical Association, argue that doctors have been held responsible for increases stemming from higher drug costs and new coverage mandates, despite having no control over this spending.

I certainly hope that Congress can pass a small bill to address this problem. But knowing Congress, they cannot think about one seemingly small problem at a time. Their effectiveness would increase if they did.

New Studies Cast Doubt on Artery-Opening Operations.

This important article does a very nice job of explaining our evolving understanding of CAD. Let me try to summarize the concepts - then go read the article.

CAD has two components, first the deposition of lipid laden atherosclerotic plaques. We used to think that these plaques were static, and grew over time. As they grew into the lumen, they eventually obstructed arteries leading to symptoms. However, several observations over the past 10-20 years have changed that thinking.

We now believe that plaques exist in a dynamic endothelium. Acute coronary syndromes occur when plaques rupture and release platelet aggregating factors. These PAFs attract first platelets - leading to the eventual development of clots - which cause acute vessel obstruction presenting as acute coronary syndromes.

This current theory (with much convincing data) stresses inflammation leading to plaque instability and the coagulation system.

We know that in acute coronary syndromes, opening the vessel helps in the short run. We also know that medication treatment remains very important. "Fixing the obstruction" does not cure the underlying disease.

We now have increasing evidence that patients with stable CAD need not have obstructions "fixed" with surgery or stents. Rather we should stress aggressive medical management with platelet inhibitors (esp aspirin), beta blockers, ACE inhibitors and statins.

This theory, which follows from available data, treats CAD as a dynamic disease which we can modify at the endothelial level.

Now for a few quotes from this well researched article:

But the new model of heart disease shows that the vast majority of heart attacks do not originate with obstructions that narrow arteries.

Instead, recent and continuing studies show that a more powerful way to prevent heart attacks in patients at high risk is to adhere rigorously to what can seem like boring old advice — giving up smoking, for example, and taking drugs to get blood pressure under control, drive cholesterol levels down and prevent blood clotting.

Researchers estimate that just one of those tactics, lowering cholesterol to what guidelines suggest, can reduce the risk of heart attack by a third but is followed by only 20 percent of heart patients.

"It's amazing and it's completely backwards in terms of prioritization," said Dr. David Brown, an interventional cardiologist at Beth Israel Medical Center in New York.

Heart experts say they understand why the disconnect occurred: they, too, at first found it hard to believe what research was telling them. For years, they were wedded to the wrong model of heart disease.

"There has been a culture in cardiology that the narrowings were the problem and that if you fix them the patient does better," said Dr. David Waters, a cardiologist at the University of California at San Francisco.

The old idea was this: Coronary disease is akin to sludge building up in a pipe. Plaque accumulates slowly, over decades, and once it is there it is pretty much there for good. Every year, the narrowing grows more severe until one day no blood can get through and the patient has a heart attack. Bypass surgery or angioplasty — opening arteries by pushing plaque back with a tiny balloon and then, often, holding it there with a stent — can open up a narrowed artery before it closes completely. And so, it was assumed, heart attacks could be averted.

But, researchers say, most heart attacks do not occur because an artery is narrowed by plaque. Instead, they say, heart attacks occur when an area of plaque bursts, a clot forms over the area and blood flow is abruptly blocked. In 75 to 80 percent of cases, the plaque that erupts was not obstructing an artery and would not be stented or bypassed. The dangerous plaque is soft and fragile, produces no symptoms and would not be seen as an obstruction to blood flow.

So for all those at risk for CAD and heart attack, we should follow a fundamental health prescription. Do not smoke. Keep our weight reasonable and exercise. Address hypercholesterolemia, especially with either a family history or diabetes mellitus. Treat hypertension.