I just had to throw out this post from SD_Mikey:
Hi Robb,
Ever hear of comparative-effectiveness research (link below)? Seems to fit in nicely with some of the intolerance (pun intended) that MDs have against prescribing a gluten-free diet to people who have the sundry health issues that plague the modern American.
http://science.slashdot.org/article.pl?
This COULD be a very juicy place to drive the skinny end of the wedge into the mainstream medical establishment. How? What are THEY using a premise for advocating this proceedure vs that proceedure? Currently it’s some kind of consensus built from past experience, influence from drug companies and just inertia. How about making Evolutionary Medicine the framework for study development and policy implementation? I’m all about free markets, but at some point the economics of situations cut through the bull-shit. Advocating failed nutritional approaches and state managed health care is not going to fix things. Economic incentives for living in accordance with our genetics will.
Yeah, this is interesting, except that it is really more scary than interesting. I’m a doctor, let me just get that out of the way, but one that tries to apply science to my practice. I say “try” because, in the consumer-driven, litigious society in which we live, science doesn’t always triumph over human emotions and clinging to previous beliefs or even so called “common sense”.
The alternative medicine groups have pointed out, after being persecuted by mainstream medicine for not being evidence-based, that somewhere around 90% of the therapies, interventions or tests mainstream doctors recommend are not evidence-based and in fact simply handed down from mentors. Of course, this isn’t always bad, and may actually work well most of the time…I mean, come on…do we have to study absolutely everything? That’s ridiculous! But is it? I think it would be great to study everything. But is it practical?
A few years ago I read a study summary that seemed to strongly suggest that using sterile gloves did NOT decrease the rate of infection compared to using non-sterile gloves for suture repair of lacerations. So, really, there is pretty good evidence that I can just use a non-sterile glove to sew up your uncomplicated laceration and it won’t get infected. But if you’re that patient do you want the sterilized glove all nice and wrapped up in its cute package? Or do you want the gloves that have been laying out on the counter in their box, knowing a pair of snot-nosed kids were just in that room coughing all over the place? I mean, the science shows you’d probably be okay with either, but what would you want? Which will triumph? Science, or human emotion and “inertia”?
In this same category are things like mammograms and fecal occult blood tests. A study on mammograms done in 2006 showed no decrease in breast cancer mortality when beginning screening at age 40 and continued for 10 years. A 2005 review of three trials of fecal occult blood tests showed no decrease in mortality. So, even though it makes ‘sense’ to do these screenings, the data doesn’t really show that people’s lives are saved in the end. Does it mean we should stop? I don’t know. Experts are arguing as we speak.
In regard to this article about vaginal cuff pap smears, when done for benign causes is indeed, probably kinda useless. However, to be fair, a 2000 study that recommended against screening for women with previous hysterectomies, still showed a 3% rate of dysplasia in the paps of vaginal cuffs. As you know dysplasia is sometimes indicative of premalignant changes, sometimes not. From this we can extrapolate that by not screening post- hysterectomy women we will probably miss about 3 in 100 ladies with some dysplasia, and potentially someone will get cancer and maybe they will die. Not such a bad deal, unless its YOUR grandma that this happens to.
And if this does happen to some poor sap doctor and your family sues the shit out of him and CNN gets a hold of it and your crying family gets a million dollar settlement, what do you think then happens to pap smear screening rates for these women that “don’t need it”? They skyrocket. What about the doctor’s livelihood and his family? Its shit.
By the way, for many years, courts have upheld standards of practice NOT expert or consensus panel recommendations. So if this doctor does indeed go by the science (and this type of thing has happened) the judge or jury will most likely find that since MOST doctors would still screen these women with pap smears, that the doctor has been negligent and violated standard of care. So when it comes down to it, who gives a shit what these twerp scientists recommend?! If some court is gonna cut your balls off because most of the other douche bag docs in your state still do this stupid type of screening and you actually followed the science but someone died…. you get screwed!!! Just do a google for standard of care and consensus panel recommendations, there’s tons of stories of doctors getting the shit end of the stick for doing exactly are you are suggesting….trying to be the good science guy and ending up losing their career.
The media lets everyone know about this and you suddenly have a lot of what you call “inertia.” It isn’t surprising. I call it justified fear and people protecting their careers and livelihoods, this is indeed emotion/tradition and decidedly not science, but until the courts start using science as their guides you probably won’t see many doctors doing it either. Although we are trying. And to be fair some courts are trying too, and there has been progress, but there is a long way to go, my friend. So don’t blame us doctors…write your congressman/woman/person. When courts start CONSISTENTLY using the recommendations of these panels to defend doctors who are following their guidelines then you can bet your ass that we’ll start using the guidelines. Otherwise your good little science doctors are gonna keep getting thrown to the wolves and your grandma’s are gonna keep getting pap smears. That’s called self preservation and it is VERY evolutionary.
So think about it….really think about it…..you are a doctor. Granny is here in your exam room and wants her pap smear just like she gets every 2 years or whatever. You have the knowledge that probably she doesn’t need it and you start to explain this to her and immediately you see her defenses start coming up, she starts looking confused and worried that you aren’t going to help her keep away “the cancer”, you then think about the fact that in reality she could very potentially have a dysplasia, that it would be rare but it could happen, and you may indeed save her life or at least help her in some way. On the other hand you think about how if she does have dysplasia and you don’t do the pap, she gets cancer and she dies and then her family sues you because you denied her standard of care. Then your kids get to come visit you at your new job, which is not being a doctor anymore. It will only take a few seconds on Google to find that these types of cases happen all too often. So then what do YOU do, doctor? Tell the poor old lady, “too bad, studies don’t show it’s of any benefit?” No, dude, you’d do the freaking pap. Trust me, that’s what you will do. When you are sitting in the room faced with a confused, hurt patient that could potentially spell lawsuit and financial ruin versus doing a stupid $50 pap… you will do the pap. Unless she’s on board with evidence based medicine, but believe me not all patients are capable of understanding EBM, and many frankly don’t care.
You are right that alot of interventions are recommended due to consensus built from past experience and to be fair this consensus is sometimes dead right, but sometimes wrong.
The relationship doctors have with drug companies is complicated; I consciously try to evaluate and be skeptical of what drug reps say, but if I don’t give them time and listen, then they don’t give me samples, and my patients that have trouble affording meds, won’t get those samples that will likely help them very much financially, so what do you do? kick out the drug reps and tell your patients “too bad, no more samples!?” Mind you, some people do NOT have an extra $10 a month for a medication, this is the reality for some.
And inertia, ahhhh yes, indeed doctors are guilty of this, but more so patients. The truth is, most docs do read this stuff, we are required to do CME, and we usually keep abreast of what’s going on to a large extent, but do YOU. Does your mom? your wife? your friends? Probably not. So when a doc comes in with only a short time to visit, 3 other patients waiting and finds the patient he is talking to isn’t interested in hearing his newly gained knowledge from a recent study showing that little Timmy doesn’t need antibiotics but just ibuprofen, and the mom starts saying “but, what? you mean he doesn’t need antibiotics? his daddy took antibiotics and he’s all better now!” After about the 1000th time of hearing this it gets pretty old, and your back to the dilemma as stated above. Potential bad outcome and lawsuit (aka financial ruin) vs. taking 30 seconds to write the antibiotic which will probably not be harmful, but if it is will likely only be diarrhea but could be death from an unknown allergy. In this case, a lot of times, you actually gotta stick up for the kid, it gets old going through the same speech and fighting parents but in reality it is the best for the patient, even though the parents think they know what’s best. But to be honest, sometimes you lose and you write the prescription. And science/evidence based medicine loses too. It happens for lots of reasons, time, energy, uncertain of diagnosis and potential benefit, in the end, it is usually far, far more complicated than just doing what studies suggest.
There is an inherent incongruity in most dynamics between consumer-minded patients and professional-minded doctors. Most patients have begun to think that doctors are like Burger King, and they are paying to get it “their way, right away.” However, many doctors are of the notion that patients are actually paying for their professional opinion and recommendations, the benefit of many years of education and training. I’ve seen some estimates that the vast majority of patients don’t need to see their doctors for coughs, sore throat etc (some of the most common reasons to see doctors). But do you know what happens when you tell a patient that in fact, they can probably just get some OTC meds and they will be better in a few days without any prescription meds?(—and this is indeed what evidence shows). Well, I’ll tell ya, it usually isn’t very pleasant, usually they get huffy or act like you are doing them wrong somehow, when in reality you are doing the absolute best thing you know how. You are telling them the truth and not giving them unnecessary meds….do they thank you for it? Sometimes. Sometimes people are very understanding, but not always. At times they call you names and threaten you, because you are trying to do the honest, best thing.
Anyway being a doc is hard and its a whole lot more ART than it is science. The guys at Burger King just hand out whoppers, even if the customer is morbidly obese, struggling to breath and should probably be avoiding all food for the next 3 months, but they do it anyway. For doctors its different, often times a patient wants something they don’t need. And as a professional its your job to tell them they don’t need it, especially if it may harm them. But what if it won’t harm them? Like a pap smear? A patient wants something and they think you should give it to them, but you have to decide, and don’t forget, if you don’t give them what they want and they have a bad outcome, they’re likely to sue you and this may have dire consequences. This is called practicing defensive medicine, it is unfortunate, it is costly, it is very common, and it is sadly, the reality. Once again, write your representatives, get tort reforms in your state, punish frivolous lawsuits and pressure courts to protect doctors who practice evidence based medicine, and slowly, over some time, these things will change. But not until society stops persecuting the people that try to help them. I mean, the pact was broken a long time ago. Really, what did you expect would happen? I’m not saying doctors deserve total immunity from consequences… far from it. But what I am suggesting is that $10 million lawsuits will never bring back a lost loved one, but that lawsuit will greatly affect the rest of the patients in our society that still have to see all the medical providers that are acutely aware of what just happened in the big media-covered lawsuit. People don’t realize that they are paying for all those huge lawsuit settlements, one unnecessary pap smear at a time. You get it?
So, anyway, I’m a crossfitter and eat paleo, and honestly I get a little tired of some of the fairly frequent doctor maligning in our little communities. If some of you haven’t noticed yet, there ARE doctors that are crossfitters and do eat paleo and zone, and believe these things are healthy and good. Not everybody with an MD behind his name is a low intensity treadmill/carb loading recommending douche bag, ya know? So if anyone cares, when you make little statements like “intolerance that MDs have against prescribing…” it might be better to say “intolerance that SOME MD’s have…” because there is definitely a presence of doctors in our communities and we aren’t the enemy, but your allies.
I think most of the time docs get a well-deserved bad wrap because so many of them are socially inept, or have other character traits like dysfunctional narcissism or arrogance and don’t really communicate well with people. And I totally understand people wanting to give docs some shit for acting like that. But just remember, not all doctors are against you; and we are here, sprinting, doing thrusters and pull ups, and eating 5 cups of spinach and a hundred freakin’ walnuts just like some of you.
I guess really to lump all doctors in as believing something just because they are an MD is, to my thinking, prejudice. And really its offensive. I guess nobody likes to be labeled and put in a little box, especially people that are absolutely not in that box. And its even worse if you stereotype somebody based on their occupation, I mean what the crap? Is that occupationism? (I know its not professionalism).
You speak of Evolutionary Medicine. I’ve also done some studying about evolutionary psychology and its fascinating, anyway here’s something to think about…Is the job of caring for strangers constantly throughout the day in harmony with our evolutionary nature???
I mean, I don’t think eating bread really is, and I don’t really think sitting behind a computer desk all day is very much in line with our genetic predispositions. So what about being constantly bombarded by the emotionality and personal problems of other people (strangers who you are not related to or have any personal connection with)?
I think that our ancestors would have helped a stranger in acute danger, say of like drowning or hanging off a cliff. And they probably would have nursed a sick relative or tribe member back to health through an extended illness. But the psychological and emotional effects of being invested in the health problems of complete strangers for long periods of time is probably something none of us are really evolved to do. Brief encounters with illness and death and then moving on to getting food, or build shelter or something else is probably very natural. But the medical field is a form of specialization, and a unique one. And I’m not talking about empathy, I’ve read about the evidence for empathy development and mirror neurons and all that crap. My point is that if it goes against our evolution to be taking care of sick people all day then it may be understandable that some doctors are less than perfect when it comes to social interactions. Same goes for receptionists, nurses, computer people, and anyone that does the same type of unnatural repetitive crap all day. Of course, not everyone develops weird social skills because of this, but for some it could be a factor.
And I totally agree that advocating failed nutrition approaches will not fix things. The USDA was recently taking recommendations from the public for their new daily food intake recommendations which they are or will be making soon. I hope some of you got to chime in on that. I read some of the recs by other public contributors, and it didn’t seem like there is much hope for paleo/zone/low carb diets, or grass fed beef and free range chicken/eggs. But I guess we’ll see.
Nathan-
Thank you for the long, thoughtful post. You are o9f course right, much of the blame gets laid on Doc’s little personal accountability is maintained by anyone. It is worth mentioning….the above study is in preparation for health care rationing. We have removed market forces from the equation (3rd party payers) and are now looking to give free health care to everyone. Ironically, this does not work very well, so we then need some kind of rationing system to divy up the services.
Nathan, your post was great. I’m one of those that blame doctors and I’m a student naturopath too so we blame you guys a lot more!! After, reading your post I understand the many situations you are faced with daily and will not be so biased against all doctors.
I am currently studying Evidence-Based Practice and had to do an assignment on the strengths and weaknesses of EBP in regards to Complementary and Alternative Medicine. I had no idea that you may still be sued even if you can show that you were practicing the evidence. You were not following standard of care and consensus panel recommendations.
Sue-
This si something that was a serious oversight on my part to omit. Standard Of Care is what protects Doc’s…all docs, ND, MD, DC. If someone deviates from SOC they are hanging their ass on the line. This often times for patients who are not compliant with treatment and generally a pain to deal with. Interestingly, I found the medical community at the University of Washington MUCH more open to tinkering and new ideas than the Naturopathic community at Bastyr. At Bastyr, they assumed they knew it all!
Robb
You are absolutely right! The economy of third party payers is indeed much of the problem. It’s kind of insane actually. You might not BELIEVE some of the ridiculous shit that YOU and I have paid for with our tax dollars. Doctor visits that I have personally had to perform, on complaints that even half-conscious 10 year-olds would consider retarded. Some people do not have even a modicum of common health knowledge, and you and I and every other working person pays for their doctor (or worse, ER) visits for things like common headaches, sniffles, typical bruises or abrasions, or sometimes even…MOSQUITO BITES! Yes, this has actually occurred. Not infected mosquito bites, not unknown bites that needed diagnosing, but a plain old mosquito bite, an hour or so old that ‘just hadn’t gone down yet.’ I had to bite my tongue from asking if they were in fact, pulling a joke on me. And I have no problem with people that have even a little bit of a legitimate question or possible concern, I’m happy to educate and assist people with this type stuff. But some of it is just ridiculous. The medical system is often abused by all types of people for all types of reasons. I honestly think some people go to the doctor when they’re bored, which is fine, just don’t use our tax dollars for it.
I think the above example is part of the reason that universal or even somewhat extended healthcare seems to have failed miserably everywhere its been tried in the U.S. (Tennessee, and Hawaii are great examples, heck I think Hawaii’s state funded health insurance program for children quickly went past budget and the experiment ended in just 7 months). Honestly, should we all have to pay for the health care of people who do not know how to properly care for a typical mosquito bite? No, I don’t think we should, it seems extremely wasteful to me, and frankly, more than a little stupid…especially considering most mosquito bites require no special care at all.
I didn’t know that was a study preparing for health care rationing. That’s interesting, but what’s even more interesting is that the collective consciousness of societies can and does change. Look at the diamond engagement ring ‘tradition’ for instance, entirely and intentionally created by a marketer for a (the) diamond company. It was genius actually.
I guess my point is that all hope is not lost, and if we can, for example, get women who don’t have a cervix to stop thinking they need paps to screen for cervical cancer and doctors who do them to not feel fear of legal retaliation for not performing said needless paps then we can indeed save money and use medical resources in places where they would be more effective.
But changing the minds of millions takes massive effort, either through time (aka repetition) or perhaps exposure (mass media messages from say…Oprah). That type stuff can and does change the societal collective mindset, and that would indeed be the type of change we need.
Your site is helping with some of this positive change and that’s something to be proud of. It is a great thing to help people improve their health and quality of life and as the initial post alluded to, you can do this much more effectively with nutrition than with medication.
This is a wonderful dialog! Thanks Nathan, Sue, and Robb.
Here is another link to add fuel to the fire. It’s about still using treatments that don’t work.
http://well.blogs.nytimes.com/2009/04/02/the-ideology-of-health-care/