This post may get a little heavy on theory and scientific jargon. Possibly one of the reasons why there are often so many disagreements between patients and physicians.
Introduction
I was having dinner yesterday evening with some friends. At the table there were a group of doctors, a computer scientist, a technical consultant and a health economist.
Discussion quickly turned to inconsistencies in healthcare between different countries and also amongst different physicians. I am going to present my thoughts on giving any form of treatment to patients in this post and why it’s a good thing if your doctor tells you to go away and take paracetamol (aka Tylenol for all you Americans out there).
If current guidelines would permit and if medical committees would allow, I would be happy to give even less treatments to my patients than I do today.
Positive (Naive) Treatments
We have all heard anecdotes such as the following;
“I saw Dr X and she didn’t know anything! She just told me to take Paracetamol!”
“Dr Y didn’t recommend a x-ray! I know that Dr Z would have if I saw her!”
We are living in an interesting time. We have an abundance of information*. Medical technology and the choice of medications has increased into their hundreds in the last few decades. There has also been an explosion in the number of procedures to choose from.
I want people – both clinicians and patients – to stop and consider whether this is a good thing. Is it good that more and more people are on more and more medications? Is it a good thing that so many people are having CT scans (and thus being exposed to so much radiation), invasive investigations and procedures?
Most of the public and indeed it seems, most of my patients seem to think so. I say this in view of how often they are pushing me to give them antibiotics or send them for brain scans.
My argument is that although “positive evidence” exists for giving treatments, the antonym (“negative evidence”) doesn’t or is much harder to come by. To compound the issue medical councils and regulators do not even recognise/are cognisant of such things.
What I mean by this is that most scientific/medical evidence study what effects an intervention has on patients with regards to a very specific outcome. For example if a given drug is thought to lower the chances of getting bowel cancer, then the study will look at if the incidence in the cohort of people taking that drug is lower in comparison to a control group. However it completely disregards unforeseen effects of the medication. For example does the drug cause certain other types of cancer? Does it cause bone degeneration? Does it cause more heart disease? The evidence doesn’t exist and pharmaceutical companies and physicians are unlikely to go looking for such findings as the scientific community in general, are so biased towards finding positive results and therefore more interventionism.
It is true that more evidence causes doctors to prescribe more and carry out more interventions than is needed. The absence of evidence is not the same as evidence of absence.
Let us take the example of tonsillectomies.
In the 1930s tonsillectomies were very common. The thresholds for operating on children were much lower than it is today. There was a study carried out on just shy of 400 children in New York during this period. In the study they took the children to a doctor and asked whether these children needed to have a tonsillectomy. 174 of them were recommended to have the operation. The remaining children were then taken to another doctor and 99 of them were advised to have a tonsillectomy. They took the remaining children to another doctor and another 52 were recommended to have an operation.
Consider that there is a 2-4% morbidity rate today (not back in the 1930s when rates were much much higher) and that 1 out of 15,000 children will die from the procedure or as a complication of the operation.
Obviously more children are alive today, simply by carrying out less treatments. If the morbidity and mortality statistics were available in the 1930’s it is likely that less operations would have been performed. More-so, I think the number of parents giving consent for such procedures would have fallen also.
I think it is easy to see why tonsillectomies are much less common nowadays. No one would argue that we should go back to doing more of these operations today. Can a similar thing be said about other treatments patients are given today?
Iatrogenics
Iatrogenics are the illnesses caused by physicians. For example, if a patient is subject to certain procedures, such as radiotherapy or they have an adverse reaction to a medication they are said to have suffered from an Iatrogen**.
Although doctors are somewhat aware of iatrogens, medicine is still very naive when it comes to possible risks of different treatments – due to absence of evidence.
It would be foolish to think that doctors know what harmful effects there will be in the future for patients if they are given treatment today.
Medicine is littered with examples of absence of evidence (not evidence of absence!). A famous example is that of Thalidomide. Thalidomide was used during pregnancy as an anti-emetic. It seemed like an obvious treatment to an obvious problem back when it was widely used. Thalidomide helps pregnant women overcome nausea and eases their pain, therefore it is a good thing that they receive treatment it was thought. Only after years did it become apparent that Thalidomide was teratogenic and as a result caused deformities in the foetus.
You see, lack of evidence (of harm), is not the same as absence of evidence (of harm).
Thalidomide is an interesting case study as the malformations caused by the drug were so obvious yet it took so many years for scientists to link thalidomide to the harm it caused. It is very hard to extrapolate and find causality in such a complex world.
Think of all the treatments, medications and procedures we carry out today. I wonder what side effects people are suffering from. It is impossible to say right now, but I can guarantee that there are plenty out there.
The Medical System
This is the crux of the problem. There may be short-term benefits with certain treatments. However, with a lot of medications and treatments there is often very little or no evidence that such therapies are actually helping patients (for example, some studies have shown that water is just effective for treating depression as antidepressants are). Not only this, but there is absence of evidence of the risks of treatments.
The reason people continue to get treatments from their physicians is because of presence of some information which could mean that some benefit may be gained by the patient.
This leaves doctors in a very difficult position. We are continually forced by medical guidelines to carry out more and more investigations and treatments. On the other hand, patients are also becoming more and more pushy demanding treatments they have heard of from the media or their friends or family. The problem is that if no treatment is given and something goes wrong then the doctor is held liable for the “mistake” of not treating. Doing something – any kind of treatment – seems to be recognised, but doing nothing is currently indefensible.
The case of Michael Jackson immediately springs to mind. Conrad Murray was sentenced to four years of prison due to Involuntary Manslaughter. However, would not treating Michael Jackson have been defensible in court? This is the very real scenario that all practicing doctors face.
No one seems to have an understanding of the real risks of modern day medicine.
What I am suggesting in this blog post is that doctors, patients and medical guidelines are all blind to the harms of the medicine we practice today. The side effects of the overuse of antibiotics, antidepressants unnecessary operations etc will not become fully apparent until many more years have passed.
Now, having realised that medical treatments today may be much more likely to harm you than you initially thought, would you still like that course of broad-spectrum antibiotics? How about a nice MRI scan of your back so you can be considered for a spinal fusion and laminectomy?
Any takers?
Thalidomide…
Ps. A good question to ask your doctor is: “What would you do if you were in my position?”, instead of “What do you recommend I do?”. You will be shocked to see the difference in recommendations as your doctor is much more aware of Iatrogenics (although they are probably greatly under estimating them).
*Interestingly this abundance of so much information will add to more and more un-informed treatments and long term morbidity. As mentioned there isn’t enough data at all on negative information – only on positive intervention and medication. “Big data” is all the rage in the tech scene right now, but actually this is a disaster in the making as more people will be diagnosed with dubious pathologies and have excessive treatments for such conditions.
** As an aside – it is interesting to note that medicine is pretty much the only field in the world where there is a study of iatrogenics and where iatrogenics are talked about. If you speak with economists, politicians etc then you will not find a single person who is aware of what an iatrogen is or how to assess for them. It’s just not in the common discourse.
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