Wednesday, March 07, 2007

Evidence-based Medicine and Skepticism

Yesterday was the kind of cold day that makes it seem like a good idea just to stay home. Although I did shovel the sidewalk and go to the library with Bill, I spent the rest of the afternoon catching up on magazines in the overflow basket.

Here's one I just can't get out of my mind. Time magazine, in an article headlined Are Doctors Just Playing Hunches? writes:

Increasingly, doctors seeking to provide their patients with the best possible care are exploring what is known as evidence-based medicine--a hard, cold, empirical look at what works, what doesn't and how to distinguish between the two...

...Whatever the merits of evidence-based medicine, it got off to a rocky start. When Guyatt began championing it back in the 1990s, he called it "scientific medicine," but he learned quickly that if you want to start a revolution, it helps to pick the right slogan. Many of his colleagues were outraged by the implied insult to their expertise. So he quickly went with "evidence-based," and tempers cooled.

Let's set aside for the moment what medicine might have been before Canadian Dr Gordon Guyatt began using the terms "scientific medicine" and "evidence-based medicine." One aspect of evidence-based medicine demonstrates that many widely accepted medical tests lead to unnecessary biopsies, false positives and incorrect, often damaging, treatments. [Some of my friends will be rolling their eyes by now - I've been saying this for years and they think I'm just nuts to resist every available test.]

There are lots of things doctors do very well. I don't hesitate to go to a doctor when I have an infection that I think will benefit from antibiotics. I can recognize critical injuries that require a doctor's attention. But our expectations of doctors' abilities to diagnose and treat chronic ailments is hugely overblown.

Most of her life my mother was thought to have tuberculosis. She was treated variously for asthma, emphysema and chronic respiratory disease. Did some of those treatments help her? Maybe. Did some of them hurt her? Definitely. In the years that she took prednisone, for example, she was never told of its affect on bone density 'til after she broke her hip. In the last weeks of her life in the hospital, visitors were expected to wear masks because of the risk of tuberculosis. I never did 'cause who, in the last days of their life, wants to see their loved ones wearing masks. Autopsy results never found any evidence of tuberculosis.

I can't even describe the regimen my father got into with blood pressure drugs, cholesterol drugs, blood thinners, memory drugs and prostate drugs except to say that he was never able to manage to take the right drugs at the right times.

My daughter had jaundice in the first few days of her life. It's the inability of an immature liver to filter dead red blood cells. I had it when I was born, too. The hospital wanted to keep her when they discharged me. With a firm, "I'm not leaving here without her!" I asked my wonderful general practitioner what he'd do. And, bless his heart, he told me frankly that he'd take her home. It's because of liability issues that he and the hospital have to try to keep her. Once in a while a baby dies of causes possibly related to the jaundice. But the hospital's treatment was an ultraviolet light and daily blood tests. So, I put a plant light over her playpen and took her to the hospital daily for the blood tests. Can't say for sure if either of these things helped. But the jaundice went away, as it normally does, and she's just fine.

So, I'll remain a skeptic. I'll go on searching for a doctor who will talk to me as if he/she recognizes that I understand complete sentences. In fact, I can understand a lot of medical explanations. And I can make evidence-based decisions. And that the risks of some treatments are sometimes just as great as the risks of illness.

[ed. 3/8/07. Thanks to Belinda for this link to a CNN story describing the failure of lung cancer screening. It does not escape my notice that she probably sent the link not so much to support my argument, as to encourage me to quit smoking.]

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