Recently, sitting next to me at a family friend’s wedding, was a middle-aged Indian male, a retired investment banker. He had an axe to grind with doctors. He said, “You doctors don’t know what you’re talking about. One doctor says check your PSA, and another doctor says don’t bother. Can’t you doctors make up your minds?”
He was an aggressive chap, faux aggression really; a tardive alpha male, who’d looked like he’d been hen-pecked most of his life. He had just eaten four pieces of rasmalai, and was storming the fifth. Rasmalai is a sugar-rich Indian desert that’s monstrously tasty and devilishly diabetogenic. I retorted, “Uncle, PSA testing won’t save you if you keep scoffing the rasmalai.☺”
He wasn’t related to me, but Indians call random Indians, “uncle.” “Uncle” had a capacious midriff sculpted by years of disciplined over eating rasmalai and laddu. He had a point, though. Despite our profession’s call for shared decision making (SDM), he, amongst others, wanted doctors to unequivocally tell him what to do. He couldn’t appreciate the controversy of screening for prostate cancer for what it was – uncertainty over true effect size. The controversy reaffirmed his belief that doctors were incompetent.
“Uncle” isn’t alone in taking unkindly to medical controversy. A recent study in the BMJ showed that the controversy over statins, and negative media reports about statins, may have persuaded thousands to stop statins, and might lead to several premature deaths and MIs.
The findings are hardly implausible. Many patients are on the fence with primary, and even secondary, prevention. Adherence is exquisitely sensitive, or elastic if you wish to be clever, to many factors, including media skepticism. It is hard motivating yourself to take pills for an ailment you don’t have, and might not get. Adherence to screening is precarious as well and is affected by a meagre copayment, which is why the Affordable Care Act mandates that insurers cover screening at zero cost sharing.
The study led to a discussion about the culpability of the media, and responsible reporting of medical facts. Edward J. Schloss, an electrophysiologist, tweeted cheekily “mainstream media is now the third leading cause of death in America.” Some questioned the numbers. Some wondered whether the benefits-harm ratio of statins is really as high as we think. Many implicitly believe that evidence based medicine will reduce medicalization and healthcare costs – a premise which lacks evidence.
It is through a sleight of hand that in our age of unprecedented rationalism arguments of kind (value) masquerade as arguments of degree (precise numbers). Arguments of degree are interminable – you can argue about true effect size, statistical methods and biases, till the cows come home without resolution. Arguments of kind need courage. The question people seemed unwilling to answer is what if the numbers are true? What if thousands really will die because they stopped statins because of the negative reporting. What next? What should be done, differently?
If number needed to treat with statins for primary prevention to save one person from death/ MI is 100, and 200,000 people stop statins because of negative media coverage of statins, this means 2000 people will die prematurely or have heart attacks. Does the media have blood on their hands? Given the frivolity with which causality is insinuated these days, ironically by the mainstream media, it’s hard not to conclude that the media is culpable. Such a conclusion would, however, be a mistake. It would imply that the media, and by extension medical journals, can never discuss any medical controversy, lest that discussion leads to treatment non adherence leading to a bad outcome. It would imply that scientific inquiry can kill.
I once wrote about overdiagnosis in screening mammography. A prominent radiologist wrote to me that my “academic inquisitiveness could kill women.” His moral confusion about causality, a confusion for which I have nothing but utter disdain, was understandable. If health and longevity are goods of infinite value to be guaranteed to citizens, it follows that any possibility that people are devoid of these goods, should be stamped. The logical conclusion is that what is discussed in medical journals, what is questioned by scientists, what is reported by the media, be subject to a high level of scrutiny. This requires a regulatory state of a scale one struggles to comprehend, a central control which even Stalin and Mao might have looked upon enviously. Theists, not scientists, reach the truth by censorship and certainty.
Nevertheless, I feel for doctors who prescribe pills for primary and secondary prevention. The non-judgmentalism which comes with acknowledging uncertainty in medical treatment won’t encourage patients to take their medication. A friend, who is a GP in London, tells his patients, who are mostly first generation Indians and Pakistanis, that if they wish to cuddle their grandchildren, they must take their statin, aspirin and anti-hypertensives. His world is far removed from the indulgence of SDM – a practice which seems bizarre to eastern cultures. His patients love him. They confess to him when they’ve forgotten to take their pills, and expect to be scolded by him, and when he tells them off, they say in a loving tone, “I’m sorry beta (son).” You’ll never learn about such patients in medical school, where the fervor for SDM has become religious, and where patient-centeredness is really Anglo-centric-patient-centeredness.
There’s confusion over statins because statins are an easy target. I, too, have ridiculed statins. But their prescription isn’t unscientific. If you believe the treatment effect of statins is too small – and I do – have the courage to say so, rather than deny that their effect is real or cloud the effect with statistical sophistry. In a similar vein, if you believe that the prescription of statins isn’t worth the public purse, say so, rather than bleat on about the harms of statins, or muddy the issue with patient preferences and shared decision making.
I’m encountering a new species, Gladius Medicus Skepticus, who claim to be about the evidence, the whole evidence, and nothing but the evidence. Their mantra, when skeptical about expensive treatment, is that it’s about harms, not costs, which makes them conveniently patient-centered and non-judgmental. Harping on about harms is a nifty way of dodging the more difficult question about costs. But some harms this genus is concerned about are parody. One such harm is anxiety from false positives in screening. It is disingenuous to be worried about anxiety from false positives. Much of public health works by scaring people nearly to their death about their imminent death – think about the macabre warnings about smoking. After being told that they may die a miserable death from lung cancer, do you really think smokers, for example, are worried about anxiety from false positive screening CTs to find that lung cancer we’ve been scaring them about?
In the case of statins, over stating harms, such as muscle pain, can backfire cosmically. Pharma will make newer, grotesquely more expensive, phenotypes (let’s call them Safer Statins) with fewer side effects. Since costs aren’t an issue, only harms are, and as statins are beneficial in some but harmful in others, and because healthcare is a right, and there’s no moral distinction between anticipatory medicine and medicine to deal with existing problems, it follows that people are entitled to Safer Statins and Even Safer Statins. If they’re not entitled, on what basis are they not entitled?
Healthcare will bring civilization to its knees. Not because it’ll break the bank – there’s a school of thought which says that healthcare may become the primary driver of the economy. But because health, as a good of limitless value and a human right, is big government writ large.
Have a happy Independence Day.
I think we have to consider quality of life as well as length of life. If we’re going to give 1/100 patients a few more years of life but they’re miserable what’s the point? And, if patients had to pay out of pocket for these meds, how many think they would continue taking them?
I guess you get the most qaly improvement in the U.S. by perinatal care, especially of poor mothers. But, I’m not sure, maybe public health stuff–improvement in water quality, sewage treatment, housing, vaccines–is still the most efficient saver of lives. It used to be.
But, like you say, Bobby, are we to find the most effective way to go and then blindly go?….pour all our resources into perinatal care? …or malaria or TB or dysentary in the wider world?
Dentist friends tell me that there is not the slightest possibility that we will ever have enough dentists to take care off all the US needs.
Conclusion: We have to live imperfectly.
I think Hadler has the best review of research on statins….and it isn’t very favorable….even before some of the more recent studies on statins impact on type 2 diabetes and memory.
“because health, as a good of limitless value and a human right, is big government writ large.”
Hardly “news.” See Elhauge, 1994 “Allocating health care morally.”
“Moral absolutism has powerfully emotive appeal. Easy as it may be to reject in the abstract, moral absolutism remains difficult to reject in practice. Indeed, the persistent power of absolutist beliefs in the face of unending escalation of health care costs is the most striking moral phenomenon of health law policy in the past quarter-century.
Nonetheless, moral absolutism is wholly untenable as a societal system of resource allocation. Most knowledgeable observers believe we could today easily spend 100% of our GNP on health care without running out of services that would provide some positive health benefit to some patient. Surely, the most committed moralist must concede that, if these observers are empirically correct, some health care must be denied even though it has a beneficial effect. Otherwise, the extreme a moral vision would require that we fund health care even if that means starving ourselves to death. And once the moralist makes this concession, she acknowledges that at some point trade-offs must be made and that thus the moral principle is not in fact absolute. The moral question then becomes aware, rather than whether, trade-offs are appropriate.” [“Allocating Health Care Morally,” p. 1459]
PS, oh, yeah, Happy Independence Day…
What do you think we should do with life-style diseases? Alcohol, drugs, smoking, hang-gliding, base-jumping, working as a commercial fishermam, living alone (social connections are critical).
I have decided we should ignore all these and treat everyone the same–as if they were non-risk seekers.,,but I am not sure.