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Wednesday, March 4, 2009

alternative and personal medicines

After my post the other day, on the subject of resistance to personal medicine from doctors, there were a few interesting comments, which I figured merited their own entry.

The first comment, from Will, implied that I think all MD's are idiots - which is far from the truth. I've met idiot doctors before (such as the one that told me a collapsed lung was psychosomatic), and some very bright doctors (such as the one that asked me about 10 questions, listened to my chest, told me I had a collapsed lung and then sent me back to the hospital right away.) Like all professions, there are good ones, and there are bad ones. However, like all professions, the exceptional doctors, by definition, are few and far between.

And, as a scientist, I can appreciate why that is: doctors are to the human body as mechanics are to our cars, and a car is a relatively simple piece of machinery, when compared with the human body. Even more frightening, a lot of the human body is simply a "black box" in the sense that we know what we put in, and we know what comes out, but we rarely understand all of the intricacies of the processes that are occuring. So when it comes to my car, if I had one, I'd trust a guy named Garry who doesn't have a high school education to be able to figure out what went wrong and fix it, but when it comes to my body, I expect the person doing the fixing to have about 10 years of higher-education.

But what is that higher-education? It's not necessarily a biochemistry degree, or even a molecular biology degree - it's typically a higher level overview of how the body works: anatomy, histology, immunology, and the various other "organ-level" subjects. We don't expect the average physician to be able to describe how transcription factors, polymerases, gyrases, ligases or any of the host of other molecular tools work, or what their effect is on the human body. Thus, physicians are handcuffed by their high level view of the complex systems upon which they use.

And, of course, that leads us to the major issue. Dealing with complex systems at a high level can only be done by applying rule based solutions. For instance, if you see a broken leg, you splint it. You don't need to know about osteoblasts and osteoclasts and how they work to rebuild bone. We don't look at the molecular signals that they need, or what to do to encourage them, you just expect the doctor to apply the rule. If something goes wrong and the bone doesn't heal, then (and only then) your doctor starts looking for another rule to apply. That's not a bad thing, really - but that's how we have come to expect modern medicine to work.

The article I linked to in my earlier post wasn't about doctors being idiots or stupid, it was about doctors being influenced in their rules and the application of those rules in ways that aren't productive. When doctors are influenced by other doctors around them (group mentality) to do unnecessary or unproductive treatments, despite the lack of evidence to show the treatment works, that's not a good thing. When doctors use rule based medicine that's outdated, that's also not a good thing.

While I don't have independent stats on it, the article certainly made it seem like those are common occurrences - and that makes it appear that modern science isn't doing a very good job on matching diseases with treatments. When that starts to sink in to a patient's mind, they start looking for alternatives, which leads you to alternative medicines. In my mind, alternative medicines are any form of treatment for which there is no scientific evidence that it works. If you could show me in a properly controlled trial that waving a crystal pyramid over aching joints actually did better than placebo, I'd have no problem considering it a real medical treatment.

So what does alternative medicine have to offer? Hope and faith. Having nothing to believe in is a scary concept, and when science based rules let you down, there's alternative medicine, waiting to lure you in like a cult. Of course, I don't mean to say that alternative medicines have nothing to contribute - but the vast majority of them (in my humble opinion) are complete garbage, made up by people who want to make a living on someone else's misery and doubt.

Of course, our current medical practices aren't much better, in many cases. (See this example for Lipitor's Number Needed To Treat. It's worth a quick read.)

And that's what brings us to personal medicine. Like the rule based approach, personal medicine isn't a huge change, but it does introduce a new layer.

The advantage of he new layer is twofold: The first is that rules that were based on "bad practice" should slowly melt away, and the second is that the number needed to treat should be drastically reduced, since treatments will now be indicated for conditions that can be more closely matched with the cause (not the symptoms.)

And, best of all, it still lets the doctors operate in a rule based environment. The shift may not be as big, after all - it just means retraining all of our MDs. In some countries, that education will be mandated by the organizations that pay them, and the transition will go quickly. Only in the places where no one monitors how treatments are done will the switch be slow.

So really, I think the time is ripe to update the rules, don't you?



Blogger Will said...

Great response, and I think I agree wholeheartedly with pretty much everything. I should revise my earlier comment, I think I was too condescending of practicing physicians. I do want to say that there is a culture among some physicians against so called "evidence based medicine". This is a sort of inexplicable reaction, but I think it comes mostly from putting an excessive weight on their own experience over a large scale trial. And many doctors (the French majors in my last comment, sorry French majors) are simply not informed about the complexities of interpreting such studies. These are certainly not all doctors, but at very least a significant minority. This is a real problem for medicine moving forward, but not an intractable one.

March 6, 2009 8:50:00 AM PST  
Anonymous Henk said...

I totally agree that personalizing medicine is a great idea. However, I find the article in Newsweek to be very polarizing and blaming all faults in medicine on the doctors. All doctors seem to be conspiring with pharma and only in for the money.
I believe that most doctors want the best for their patients. However, patients are demanding certain procedures or treatments. Going home without a pill means the doctor didn't do his job. And if he didn't do the tests etc, we will just sue him.
If we could truly personalize medicine right now, doctors would embrace it. But we're not there (yet). In some cases where there are tests available that guide treatment, doctors use those tests. Much more research needs to be done however. Also no test works 100% and if you have a patient with a test saying that the treatment probably won't work, but there are no other treatment options, you still might give the treatment.
Effectiveness studies are great, but quite often are not conclusive and only look at groups of people and not individuals. So no personalisation of medicine there.
As for the Lipitor case, it is probably overprescribed, but how can we determine who is that 250th patient that will benefit? And a NNT of 250 might sound like much, but if you're treating 1 million patients, this is already 4000 patients who benefit. Furthermore, this NNT is after 3 years. A longer followup might give more benefit. Certainly, more exercise, eating healthy, not smoking will do much more, but it is easier to give a pill than to change people's lifestyle.
Anyway, bottomline: doctors don't hate science. More good science needs to be done to help doctors guide treatment!
Btw: I'm a MD, now doing research in pharmacogenomics.

March 7, 2009 8:04:00 PM PST  
Blogger Steve Murphy MD said...

Great Post Will,
I think we will get there. But I still dislike that Begley wants to blame doctors, who as a profession are getting screwed.....the money they receive for their care keeps going down, while their overhead to stay in business keeps going up. And the Insurers who are paying doctors less, are charging patients more, putting that profit into CEO salary and risky investments.......

The real problem is that we don't value physicians' care anymore and with the media out there to ping us, is there any question why?

So as a doctor we have to fight through science that is most often hyped by a researcher and then apply it.....Luckily I mave a biology degree with a concentration in Genetics.....and some time spent in a medical genetics fellowship and residency.....but most doctors do not.....

How do we fix that? Well, for starters we need doctors who know basic science, to teach the clinical utility of that basic science in 1st and 2nd years of med school. Unlike the PhDs who try to figure out what clinical utility is.....

We also need to reinforce basic science during the clinical years.....rather than this huge humanism in medicine push which went on in the beginning of 2000, we need to focus on science......

Lastly, a study in 2005 from Hopkins showed that medical students knew way more genetics entering medical school than when they left.....Average grade difference: entering 80-100%
Leaving 0-40%

It starts in medical school. We need to make it more atractive to the best and brightest....I think we should pay medical students.....similar to the way PhD education is administered in the U.S.


March 9, 2009 7:05:00 AM PDT  
Blogger Anthony Fejes said...

Hi Steve,

Thanks for your comment - I'm a big fan of your blog, and read it relatively frequently.

I agree with some of your points, although I find myself disagreeing with many others. Perhaps that's because I come from the PhD-track background, while you come from the MD-track background.

I definitely agree that Begley is putting far too much "hate" on the MDs, which is undeserved, but she does bring up some good points.

I think there's plenty of blame to go around for the inefficiency in the system, and some of it is the fault of the MDs. Regardless of the hype put out by the pharmaceutical companies, it is the job of the MD to decide what is best for the patient. I believe this means it is the job of the MD to not prescibe drugs when confronted by a patient who just wants a pill. Likewise, they shouldn't be doing unnecessary surgery and they should be putting their own wallets ahead of the health of the patient. Unfortunately, the world isn't a perfect place. We don't value physicians' care anymore because much of it has slipped in quality. The media helps shape that opinion, but on the whole, I think it's the MDs who have given us the image that the media is happy to trumpet to anyone who'll listen.

I'm not sure what your comment is referring to "Unlike the PhDs who try to figure out what clinical utlity is..." is supposed to mean. Are you suggesting that PhDs shouldn't be able to comment on what goes on in the clinic? I think oversight and continuous improvement are good things, and sometimes it's necessary for it to come from outside the field. It seems to me that if all change had to come from MDs, we'd be much further back from where we are now.

Besides, there are few physicians who have a great background in understanding the basic science. I know that there are a handful, but that's hardly the majority of practicing physicians. Why, then, should PhDs, who work on the basic science on a daily basis be prevented from commenting on the clinical utility of a drug? If Begley was right, MDs certainly aren't applying the scientific method (or even basic epidemiolgy) to their treatment regiments. Scientists and statisticians are better equiped to figure out clinical utility than the doctors are themselves.

Honestly, I'm all for improvement, regardless of it's source. A friend of mine recently called the resistance to change from the MDs a "god complex", where doctors just reject any outside help because they don't like anything that challenges their power in the clinic. I'm not sure that that's really the case, but I'd hate to hear that it was.

Finally, the last point I want to address in a comment is my strong disagreement with the point that med students should be paid like PhDs while learning. There's such a huge difference in what a med student does and a graduate student is supposed to be doing, in addition to the massive disparity in earning potential for a doctor vs a PhD. If med students were doing something that contributed to their field in their years before becoming interns, there might be value in that, but really, they're like undergrads: we expect them to memorize textbooks, do disections and other labs, and absorb like sponges. We don't expect them to publish, to further their supervisor's research or even to TA classes.

And once a med student is into their residency, they become paid employees. In contrast grad student toil long hours, research obscure points and work their butts off just to get their names on papers in the hope that that will help them get their own lab, where they'll be lucky to be in the same tax bracket as the most poorly paid of physicians. (Industrial PhDs are slightly different, but rarely make >$200,000, in my limited experience.)

So yes, while we both agree that doctors need to learn more science, and that we all want better health care, I don't think your points are particularly enlightening, otherwise.

March 9, 2009 1:29:00 PM PDT  

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