Doctor draws our attention to the uncertainty of medical practice

The week before last I was talking over breakfast with a delegate on a wellness programme I was delivering with some colleagues. Somehow (I don’t remember quite how) we ended up talking about the evolution versus creationism debate. I am a believer in evolution. The delegate (let’s call him Greg) believes in creationism. Many scientists believe that evolution the only rational, tenable explanation for the myriad of life forms that exist on this planet. However, as I happily conceded to Greg, evolution is but one example of something that is difficult to prove beyond a shadow of a doubt. In other words, some doubt might remain in the minds of believers of evolution, and this is not necessarily a bad thing.

This is no different to a lot of things taken to be ‘fact’ in science and medicine. Very rarely, if ever, is anything completely clear-cut in science. And I think good doctors and scientists do need to remain open to the fact that we live and work in a world that can so often be quite uncertain.

The conversation with Greg went from my mind quite quickly after we had it, but came back to me this morning while I was reading this week’s edition of the British Medical Journal. Specifically, I was reading a piece [1] by columnist Dr Des Spence, a general practitioner based in Scotland. I don’t know Dr Spence, but regularly read his writings and always enjoy them. He’s something of an iconoclast, and does not shy away from questioning conventional medical practice. While I do not know Dr Spence, but he strikes me as a doctor with integrity, honesty and an ability to think freely. I don’t have a doctor, but if I did, I think I’d like him or her to be like Dr Spence.

Here are the opening sentences from Dr Spence’s column this week that struck a chord.

We are scientists. But the Big Book of Medical Facts is in fact just a pamphlet printed at home, with two paragraphs in a very large font. The only certainty of science is uncertainty. Medicine is often little more than an opinion, a faith system: we believe that what we do is right. This is despite history telling us that what we do now is almost certainly wrong. Our faith has invented words, rituals, elaborate costumes, and a culture of reverence and deference.

The column goes on to draw our attention to that fact that much of cardiological practice is open to question, including the fact that:

  • The risk assessments models used to guide treatment decisions have not been properly tested over time.
  • Often, doctors do not even assess risk, but merely ‘treat the numbers’ (e.g. ‘raised cholesterol’).
  • The recent doubling in the use of statins has had no effect in the real world.
  • Much of the research is conflicting.
  • Many people don’t understand probability, numbers needed to treat, or the treatment paradox (the fact that the majority of people treated will not derive benefit).
  • Illegitimate terms such as “prehypertension” have been coined.
  • That ‘cardiology jumbo jet circuit of international conferences’ exist, in which ‘pharma anointed experts’ receive undisclosed fees and research grants.
  • The research sponsored by the industry is stopped early or that the authors have potential financial conflicts of interest.

Dr Spence goes on to point out that cardiovascular disease is in decline, which means that increasing numbers of people need to be treated for one to benefit, and calls into question the wisdom of treating individuals without established disease.

In other words, Dr Spence takes issue with the supposed certainty that appears to underpin much of cardiological drug treatment. He ends with the following words:

“My objection is cardiology’s certainty, for certainty is always bad medicine.”

How refreshing, I think, to see a doctor admit to the fact there is so much that we simply don’t know.

References:

1. Spence D. Bad medicine: cardiology. BMJ 2011;342:d670

23 Responses to Doctor draws our attention to the uncertainty of medical practice

  1. Ray - Pure Spontaneity 7 February 2011 at 6:30 pm #

    I think Dr. Spence is right on. So many doctors look at BMI to classify someones obesity without considering muscle mass or prescribe statins because a certain cholesterol number pops up on a screen. Then they are also influenced to push drugs by some of the best and brightest in the pharma sales industry. But the worst part is not the doctors certainty. The worse part is your friends and family who are 100% certain that what the doctor says is the Gospel Truth. If you don’t take the doctor’s advice lockstep, you are on a path to destroy your health.

  2. Chmee 7 February 2011 at 10:22 pm #

    Interesting and thought provoking post; thank you. It reminds me that it is not so very long ago that the gold standard treatment for just about anything was ‘Bleed them, purge them, keep the bowels open, and trust in God’

    Dr Malcolm Kendrick is also similarly iconoclastic, typically very amusing and always worth reading. Though I haven’t seen a lot from him of late, more’s the pity.

    How about geting one of them to do a ‘guest post’ on the blog ?

  3. Cybertiger 11 February 2011 at 1:43 am #

    I think Des should be made GP-Commissioner-in-Chief instead of that monster Lansley

  4. Bruce 11 February 2011 at 11:26 am #

    May I take issue with your claim “The recent doubling in the use of statins has had no effect in the real world.”

    If you mean the statins have no beneficial effect, they you may have an argument with fellow doctors, but if you mean statins have had no effect on patients, then I question that you are unaware of the effect of such drugs on people. The effects are usually negative on the health of the people, because these drugs are, like all drugs, poisons. Perhaps it is time to reconsider their use at all if you are correct in saying that they are ineffective as a treatment.

  5. Hedley Spargo 11 February 2011 at 12:06 pm #

    My wife & I both highlight our mothers recalling advice from doctors of the era to ‘Smoke cigarettes – it makes for an easier birth – reduces stress’ It did that I imagine because the embryo was sedated by nicotine, and was undersize due diminished oxygen. Horrific yes, BUT… it was received wisdom at the time. They gave what they believed was best advice. To us the lesson is clear – ensure your GP (or anyone you consult) is not mentally constipated! Sadly, politicians who seem the suffer the worst cases of mental constipation take it upon themselves to make blanket decisions on medical matters, and then in Orwellian fashion punish you if you dare voice question or concern. Well done Br Briffa, we wish you were our open minded GP!

  6. Feona 11 February 2011 at 12:58 pm #

    Absolutely! I was on the consultant treadmill for a few years seeing one for high cholesterol and one for osteoporosis, In the end, I was so exasperated by their insistence that I should take statins and bisphosphonates that I refused to go to either any more. Both completely refused to take on board anything that I brought to their attention re latest research or known side effects. Their attitude was how dare I question them?

  7. John Briffa 11 February 2011 at 1:47 pm #

    Bruce
    The claim your refer to was made by Dr Spence (not me, directly), but I take your point.

  8. Liz Smith 11 February 2011 at 4:13 pm #

    I feel that the drugs companies have altered our relationships with our doctors. The amount of pressure to be taking drugs for everything with the often nasty after effects appears to take the pressure off the doctors. The number of times I hear of people who are told to keep taking their medication even tho they complain of the pain or contra indications.

    We made doctors into gods, sadly now they believe it.

  9. audrey wickham 11 February 2011 at 6:19 pm #

    This piece is timely. I am at present having a tussle with my G.P. because last week he put me on Statins. Two things make me worried about this.

    1. The instruction paper inside the box from the manufacturer says – if you are over 70 tell your doctor.

    2. If you have a thyroid condition tell your doctor.

    Both apply to me so I telephoned the surgery to remind him and now await his comment.

    I once had a GP who was amazed when I said I had difficulty with a tablet she had prescribed because it had to be taken five hours after my other medication and I kept forgetting to take it. She had no idea.

    It is possible that the shrinking of the right part of my brain was caused by a stroke. I know nothing of this occurance – the only manifestation is a slight numbness in the bottom of my leg and foot. If anything my memory is better now than it was in 2009 when
    the numbness in my leg started.

    All my blood tests except my chloresteral test were fine.My blood pressure has been normal since I recently stopped taking anti-inflammatories on the advice of a Consultant. But again I ask myself – if thirty years ago my chloresteral level was just above the line and it is still just above the line perhaps that is something peculiar to my metablolism and not to be worried about.

    I eat lots of vegetables, made my own wholemeal bread for the past 40 years and have for the past few months been on an almost protein (meat) diet.

    To counteract constipation I have been swigging a dose of olive oil every morning when I clean my teeth and my chloresteral (two lots of blood tests in two months) has remained the same.

    I eat butter and frequently fry food in either Olive Oil or Sunflower Oil. It makes not one bit of difference to my chloresteral level.

  10. Brendan 11 February 2011 at 7:13 pm #

    Hi Dr Briffa and commenters.
    Re statins:
    Just finished last module of my taught masters degree and recently had to present a powerpoint show to my clinical sciences department chiefs.
    My presentation was on the saftey and efficacy of statin use in older adults. (which was a compulsory topic, not chosen by me)
    Two of my adjudicators were statin users and throughout the presentation their jaws were dropped at some of the findings I presented on statin use.
    Having passed with an excellent result one statin user commented “an eye opening and well reserched piece of work, I think I need to speak to my doctor!”

    Indeed, the statin world should be exposed in my opinion! An independant enquiry perhaps!

  11. Dr. Gifford-Jones 11 February 2011 at 8:23 pm #

    I believe that history will show that the use of cholesterol lowering drugs and the resultant cholesterolphobia has been the greatest medical hoax ever perpetrated on mankind.

    Dr. Ken Walker (W.Gifford-Jones)

  12. helen 11 February 2011 at 10:25 pm #

    And as I have discovered through intensive research on the topic that this medical “certainty” is most prevalent in the diagnosing and treating of “mental” health. Even to the point of when people complain about the disasterous side effects of medication that they are told it is only evidence of their mental condition. With more persons on medication for depressive illnesses than there are for heart disease “problems” and the withdrawal problems faced by those on these crippling drugs maybe something should be done to expose the drug cartel influence here because people with so called mental illnesses often lose all power of self determination which is in the end a bigger problem than over prescribed statin drugs will ever be. All mental illness diagnosis is based on the interpretation, beliefs and opinions of the treating doctor and this is where the true horrors in medicine are occuring.

  13. Chris 12 February 2011 at 12:40 am #

    Dr Des Spence declares himself to be a reformed ‘Pharma Junkie’. In this I perceive he infers he was once receptive to the approaches and hsopitality of the pharma reps that is a feature of the marketing of the pharma companies of drugs to GPs and also that he implies he was influenced by the reps efforts and was by degree ‘addicted’ to prescribing. He declares his self-imposed ‘pennance’ for his former errant ways is to sign up to and campaign on behalf of ‘No Free Lunch’. He declares himself the mouthpiece of No Free Lunch-UK and was responsible for commissioning its UK website that you can link to (here).

    No Free Lunch claims to be an international network of practitioners which campaigns for greater ethics and transparency in the health industry and in particular focuses upon the undue influence the pharma industry has over healthcare delivery at point of service. Dr Spence is clearly motivated to want to bring about a change of ethics and he has the ring of an activist committed to working through legitimate and appropriate channels. He has been a witness placing evidence before a Parliamentary Select Committee.

    Dr Spence concerns are very clearly pertinent to the times in which we find ourselves. The BMJ has carried other editorials which discuss similar concerns about the prescribing habit, the costs and the contra-indications. But while Dr Spences’ concerns are very much of the time I think, lamentably, he is some way ahead of the pack. The rallying cry of the day ought to be – ‘Physician, heal thyself!’

    But the pack ought to be concerned for the present status is not tenable in the long term. No Free Lunch-UK reports the cost of prescribing is £30 million-a-day, 365 days!! While the health service in the UK, we are told, is said to be the envy of others its future is looking decidedly uncertain upon ground of cost and in particular, perhaps, upon the grounds of the cost of the drugs bill. In the fall-out of the bail-outs and the rounds of cuts the veritable socialist ideal and lustre of the NHS is beginning to look a little tarnished.

    May I empathise with Hedley, the politicians do suffer mental constipation and especially with regard to science. The last incumbent Astronomer Royal, Martin Rees, remarked in a Q&A following one of his 2010 Reith Lectures that MPs are ill equipped to understand and debate matters involving science. Complexity is impeding democracy. But worse, the electorate suffer mental constipation too. Martin Rees wonders will the 21st Century be humanitys’ last. I think his concerns are justified but perhaps not for all the same reasons.

    We’ve been duped, more or less the world over. As individuals (and as groups of individuals) we each strive to attain security via our occupations and economic activities and some of us achieve that by degree. Paradoxically however, the attributes of the dominating medium of exchange (money) determine that the efforts of individuals result in a reduction of security for society at large.

    To see where humanity has gone wrong it helps to understand food and the role certain attributes of an evolving diet have played in the evolution of our species. It helps to understand the relationship and its magnitude between diet and health, and it helps to have objective explanation on many issues of science and health. So on these counts there is no better place to hang out than Dr Briffas blog. It also helps to understand Money. Finally it helps to discern some fuzzy and successional evolutionary relationship involving each of these. This has really messed with my head. Truthfully, I envy the Gregs of this world for their faith in God and in Creation. However, if God created everything, who was around to observe and record the event?

    People who truly understand money are rare. Economist John Maynard Keynes quipped, ‘I know of only three people who really understand money. A professor at another university; one of my students; and a rather junior clerk at the Bank of England.’ Keynes meant you can be at the top of the tree, as politician, economist, or central banker, and still be ignorant of the incentives, traits and outcomes that money impresses upon individuals and society at large. I’d highly recommend the work of Bernard Lietaer, ‘The Future Of Money; Creating New Wealth, Work And A Wiser World.’ It is out of print (petition the publisher, Century) but can be tracked in the UK library service or purchased used (at a premium).

    Dr Briffa, the way you introduced this thread really struck a chord with me for two reasons, and one was that I, like Dr Spence, had reasoned by alternate route that science and religion have more in common than the mutual distrust might suggest. The topic of your post stimulated more thoughts than these. Conscious of being verbose I think it polite to post them elsewhere and place a link to them. They need a little polishing yet, but if visitors are interested perhaps they can look out for the link?

    Nearly eighty years ago Orwell wrote;

    ‘In practice nobody cares whether work is useful or useless, productive or parasictic; the sole thing demanded is that it shall be profitable. .. .. (W)hat meaning is there except ‘Get money, get it legally, and get a lot of it’?’

    Orwell omitted to mention how the accumulation of money, profit, or capital, call it what you will involves the proliferation of a corresponding amount of debt. It is how many of us, and our government have been duped into unsustainable levels of debt.

    As Rees, Lietaer and Spense sense, time is not on our side. And if humanity can be led to come to its senses and evolve solutions in the knick of time we might imagine the ghost of Churchill saying, ‘That was our finest hour’.

  14. Dale (JB) Garrett 12 February 2011 at 1:05 am #

    THANK U!

  15. Jenny Hargreaves 12 February 2011 at 3:11 pm #

    I recently visited the the doctor to ask for a Thyroid review. Two friends were chatting about their different ailments – I happened to overhear the comment: They never seem to get to the bottom of things do they?….Symptomatic of scientific uncertainty and pharmaceutical unreliability. I an interesting observation by my niece who is studying BioChemistry at Nottingham University – comment: we study effects of pharmaceutical drugs on biochemistry but no mention in the whole curriculum on the role of food and nutrients. More doctors like Dr Briffa needed in this mad house.

  16. Tony Titcombe 12 February 2011 at 6:31 pm #

    I am aged 72 and 8 years ago I was diagnosed as suffering from “diseased arteries”, my left leg had a blocked artery and in my right leg 3 years later I had a plastic artery inserted. Since my original problem I have walked an average of 10 miles, in 4 or 5 sessions, a week at about 2.5mph and my legs and health are very much better. In the last 4 years, because I had a re-occurence of my problems with pains in my leg, my doctor decided to put me on a statin. This worked well for 3 years but I found I was not sleeping, and had alot of cramp in bed. I decided to stop taking the statin in early January, he disagrred with me, but I sleep well and have very occasional cramp. However for a little comfort now I may suffer later but who knows? Is this normal for my sort of problem and age. Tony

  17. Dr. Walt Goodpastor 13 February 2011 at 1:36 am #

    I have worked with medical doctors for over 25 years in hospitals, clinics and three different medical schools.

    I will begin by pointing out that medical doctors are not true scientists, they are highly politicized authoritarian technicians. Their education in the sciences consists of a general introductory exposure to the sciences in an undergraduate pre-medical curriculum, followed by two years of highly “medicalized” coursework in biochemistry, physiology, anatomy, and microbiology. That’s it. The rest of their time in medical school involves the practical “clinical” training of taking care of patients in affiliated hospitals.

    Real scientists do independent research and publish their work in refereed academic journals.
    The great majority of medical doctors have never done any independent research nor have they ever published in a refereed journal. When they do publish, the work is too often written by ghost writers paid by drug companies or simply written by one or more of their subservients. I am quite familiar with this practice since I once worked as one of these subservient ghost writers.

    Much of what medical doctors do is based on authoritarian dogma rather than scientific method. They typically develop diagnostic lables and decide what constitutes a disease by calling a meeting and simply taking a vote. This approach has enjoyed much success as it is applied by the drug and medical equipment corporations who have long utilized medical doctors as their co-conspirators, stooges and shills to lend professional authority in support of their obscene profit seeking at the expense of the sick and suffering.

    Hence, we see the fraudulent promotion of worthless and poisonous drugs such as statins, antidepressants, and flu vaccines, as well as the promotion of useless mammagrams, prostate screenings and stomach bandings for starch and sugar addicts.

    The annual cost of this monstrous psychopathic fraud is in the hundreds of billions of dollars. And now we are told that so many people can no longer afford to pay for this criminal extortation that we must have a national health plan in order that public funds from taxes can be made available to continue it.

    All this is simply racketeering at its worst. Arrests should be made and people should be sent to prison.

  18. Dr John Barr 14 February 2011 at 8:32 am #

    Could the vast (?over)-use of statins be related to a fact related to me by a drug company rep recently. I have not checked this figure, but he said that Pfizer make $12 billion per month on Lipitor alone. I am willing to stand corrected but numbers like this would not surprise me at all. No doubt there will be much wailing and gnashing of teeth when it comes off patent soon and can be made generically. Like the doctor above posting at number 11, I feel most people do not need statins, and frequently tell my patients so.

  19. Dr. Walt Goodpastor 15 February 2011 at 1:43 am #

    Dear Dr John Barr,

    Of course, you are correct sir. There is simply NO COMPELLING EVIDENCE that statin drugs help anybody, and there is evidence that these poisons cause much harm. Nor is there any compelling evidence that cholesterol itself has any thing to do with cardiovascular disease. Cholesterol production appears to be the body’s response to injury. The hype for statins is the result of psychopathic drug company marketing

  20. Chris 16 February 2011 at 6:01 pm #

    Dr Walt Goodpastor said,

    “Cholesterol production appears to be the body’s response to injury.”

    Yes, certainly the idea that cholesterol is a direct and singular explanation for being the cause of CVD is looking a little uncertain. Particularly when the processes of inflammation are increasingly coming under the spotlight as contributing to the advance of CVD and also in the light of observations that in instances where statins may be beneficial the benefits may boil down not to their perceived cholesterol lowering properties but instead to them also having anti-inflammatory properties.

    The body is not a simple machine but a complex adaptive system. So we should be guarded against simple mechanistic associations like cholesterol and CVD (that is unless we are in pursuit of profit). Changes to the levels of lipoprotein look like a complex adaptive response to some stress or other and could constitute a defensive and/or healing process, but for the same token, it is hard to be certain.

    However, if an alteration to dietary habits can bring about such a rapid and distinct change to the oft-cited markers of ill health such as BP and cholesterol, as was the case in this for TV experiment (link), then I don’t think the case for the cholesterol hypothesis or for mass prescription of statins is so certain as we would be led to believe.

  21. Dr. Walt Goodpastor 8 March 2011 at 2:28 am #

    Dear “Pure Spontaneity” I hoped for a discussion of truth & value. But I am lead to the nowhere of simple-minded twits as in the moronic abomination “Twitter” in which all things are reduced to nothing.
    Grab onto this concept if you are ABLE BODIED OF MIND & SPIRIT: the whole goddammed thing is driven by the greed of psychopaths who feed on the flesh of the sick. It is all so sad.

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    [...] Doctor draws our attention to the uncertainty of medical practice: We are scientists. But the Big Book of Medical Facts is in fact just a pamphlet printed at home, with two paragraphs in a very large font. The only certainty of science is uncertainty. Medicine is often little more than an opinion, a faith system: we believe that what we do is right. This is despite history telling us that what we do now is almost certainly wrong. Our faith has invented words, rituals, elaborate costumes, and a culture of reverence and deference. SOURCE [...]

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