There are hundreds of anecdotes and data to show that we are often taken for an expensive and life-threatening ride by the business complex of research, doctors, hospitals, medicines and medical equipment.ery in the US has the same potential for graft and corruption as casino gambling and construction rackets" wrote Lisa Van Dusen in theCanadian Medical Journal in 1997. I wanted to review this statement in today's scenario.
Just as I was sitting down to write this piece, I happened to glance at a beautiful book Bottom Line Medicine by Richard K Stanzack. The author had been a registered nurse in the US medical system and he came out after getting disgusted. The amount of research he has done to write this authentic book fascinated me as he was not privy to those documents as a nurse. That might be his advantage as we doctors are being spoon-fed by company representatives who get us the best medical literature that one could hope to get in addition to the free conferences and lectures that they provide us with.
The case of the missing data is an excellent medical satire written on the lines of Sir Arthur Connon Doyle's Silver Blaze (Penguin classic 1981) in the British Medical journal by James Le Fanu, a family physician in London. This sums up the present scenario. "Risk factor screening for major diseases such as cardiovascular disease, alcohol abuse,diabetes mellitus raised cholesterol and breast cancer, and subsequent treatment of the detected risk factors/diseases in the The Malmö Preventive Project did not reduce total mortality in the intervention group as a whole." Malmo was the famous study which follwed the trial subjects for a very long time in Europe. "Epidemiologic data, however, consistently show a continuous, positive, linear relationship of the height of both systolic and diastolic blood pressure with the incidence of stroke and heart attack. No threshold level distinguishes those who will have a cardiovascular event from those who will not. In fact, most heart attacks and many strokes occur among persons with 'normal' blood pressures," writes Michel Alderman commenting on almost all the major studies in the field.My own analysis of the 17 major studies of hypertension treatment with drugs, some of them followed up for nearly 20 years, showed how we are taken for a ride. There are three ways one can sell research results in medical interventions: relative risk reduction, absolute risk reduction and number needed to be treated to get that benefit. In the 17 hypertension drug treatment trials thus analysed the relative risk reduction was very impressive to sell but does not mean anything for the practising doctor on the ground. But that is exactly what is being shown in mainline journal articles and company literature. In the analysis reported in the BMJ of 18 June 2002, researchers claim clinical trials are reported with misleading statistics. The table below is theirs.
To give an example, if the statistically anticipated death in five years in a group of 1,000 research subjects with hypertension is 10 (how to estimate this God only knows) and if that is reduced to five by our treatment, the study would record that as 50% reduction in death by the drugs concerned! Very impressive indeed! The truth, however, is that there has been a statistical reduction of five deaths in 1,000 apparently healthy adults in five years by our treatment, which works out to an absolute death reduction of 0.05%-almost negligible. The latter is the absolute risk reduction. Similarly, the MRC study of mild to moderate hypertension showed that to "save one possible stroke in the next five years, we have to treat 850 healthy people with anti-hypertensive drugs for a period of five years with all the risks of adverse drug reactions!" The chart below shows the causes of death in MRFIT (Multiple Risk Factor Intervention trial) data which is self-explanatory. At the end of the day the balance sheet was that intervention was not worth it from our point of view and was a curse from the patients' point of view. The final death tally was not statistically significant.MRFIT data after 16 years follow up of thousands of subjects on hypertension treatment
Roger Sherwin is the Chair of epidemiology at Tulane after having been at Cambridge, Johns Hopkins, etc, who was involved with most of the major studies of interventions has this to say at the end of it all. "In other words, we found that changing the "risk factors" does not apparently change the risks. This necessarily means that the "risk factors" are not as important as was thought. Indeed, it should be concluded that the "risk factors" were no such thing, at least as far as this trial (MRFIT) is concerned.The story is similar for diabetes, cancer, and even drug interventions of AIDS! Maggie Mahar's Money Driven Medicine is another great book from where I have lifted the following lines in italics (mine) that sums up the whole book which has facts and figures with authentic cross references. "What the manifold tales, stats, and interviews illuminate is a system almost irreversibly infected by money. The story here is one of market failure, of a peculiar sector where the drive for profit demands not efficiencies and innovations, but volume and market share. That may be fine when we're talking widgets, but when it means more heart surgeries, less time with patients, more collusion with drug companies, and higher prices for less care-well, even Adam Smith would feel a little ill. But believe me, he'd think twice before summoning the ambulance."Does all this mean that doctors should close shop and go hunting? Never ever! Doctors were needed in the past; they are vital today and will be relevant for all times to come as long as there are patients. How do the two statements that I have made above go hand in hand? A recent study in the British Medical Journal showed that even in major surgical procedures it is the placebo doctor effect that was important to the extent of nearly two-thirds of the times. This brings back to memory the famous quotation from Oliver Wendell Holmes that the "two most powerful drugs that medicine ever discovered are the two kinds words of a good doctor." Good doctors are the need of the hour.Even a major event like total myocardial revascularization (like bypass surgery ) study "showed that those that had the surgery got relief from pain but also those that were told that they had a successful surgery but never had any surgery done had equally benefited from pain. Moreover, at the end of five years the sham operation group's blood supply had become normal on scanning," wrote Roger Laham, one of the researchers and the director of angiogenesis laboratory at Harvard. The study did show that the operation was more of a sham and what worked was the faith in the doctor that assured them that their operation was a success." Most of our interventions, including surgery in many areas, have not been shown to do good to our patients. How are the patients relieved of their troubles after the interventions? They were relieved because they believed in their doctors and had faith in them. They survived inspite of interventions but because of their doctors.This boils down to spirituality in medicine. Spirituality has nothing to do with religion. On the contrary, spirituality is simply sharing and caring. James F Peabody was a great doctor at the Mass General Hospital and wrote this note in 1927 that became the major motto of that hospital even to this day. He said that "patient care is caring for the patient." That is true spirituality. After all who heals the sick?A great surgeon like Michel De Bakey, who died recently at the ripe old age of 96, who could innovate major surgical feats during his life at Baylor would have accepted the fact that he could only stitch the wound but could never heal the same. The scientific proof of that statement of mine, if such a proof was ever needed, could be guessed from this question. Could any surgeon, including Michel De Bakey, make a great operation heal in a dead body? Healing occurs in a living body only. What then is the difference between the living body and that of the dead? The dead do not breathe! Breath (spires in Latin) is the root of the word spirituality according to our cave dwelling ancestors. The latter thought, in their wisdom, that there was one difference between their living brethren and the dead ones. The dead did not breathe. They surmised, very scientifically compared to our epidemiological science that breath entered the body at birth and left the body at death. They wrongly drew the wrong conclusion that breath was God and the word spirituality thus connects to God and religion.That is the conclusion of all our studies in modern medical science today. "Passion makes some of the best observations but, draws, many times, most wretched conclusions" wrote John von Neumann years ago. Our research has made some wonderful observations but we have drawn wrong conclusions from those studies. Let us change the science of medicine from the reductionist science of linearity that we discussed above to that of the future science of chaos and holism as was elegantly shown by Professor David Eddy, a former professor of cardiovascular surgery at Stanford converted to a mathematician, to get at the right holistic science for medicine in his ground-breaking research work which could be accessed by readers on www.archimedesmodel.com.By:Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS. He is also editor-in-chief of the Journal of the Science of Healing Outcomes, chairman of the State Health Society's Expert Committee, Govt of Bihar, Patna. He is former vice chancellor of Manipal University at Mangalore and former professor for Cardiology of the Middlesex Hospital Medical School, University of London. Prof Dr Hegde can be contacted at hegdebm@gmail.com
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