February 08, 2008

The Muddled World Of Medicine

Researchers yesterday halted a portion of a long term study of diabetes treatment which, as it turns out, disemboweled a key bit of dogma in treating type 2 diabetes. One of the central conceits of diabetes care is that patients should lower their blood sugar level as low as possible, even to normal levels, in order to protect their hearts. That sure sounds like it should make sense. But patients who followed that strategy died of heart problems at a greater rate than patients who didn't.

The finding certainly upsets one of the central tenets of health care, and there's been a lot of that going on the last few years. The theory that hormone replacement therapy was good for post-menopausal women went down in flames; so did the belief that being skinny assured us of long lives; and that low-fat diets were a form cancer prevention; and that low cholesterol always protected against heart disease; and that anti-depressants were anti-suicide technology in a pill; and that second generation anti-psychotics had no side-effects in long term use. All of that has either been called into doubt or struck down.

Next thing, we'll learn that smoking cigarettes is actually good for you.

Strangely, I'm sure that there are thousands of doctors going into their offices today certain that all of the above theories are true and advising their patients to abide by their precepts, probably because they believe it works for their particular set of patients or because they are out of touch with the evidence base.

For the last 30 years in our culture, we've been doing medical research on a scale never seen in human history and doctors have been making sweeping pronouncements about how individuals should live and how society should order human behavior. We've got food bans, smoking bans and depression screenings in schools, and yet none of that seems to be having the effect on human health that the proponents of various theories claimed they had evidence of. That's just weird.

So what happened? How did medicine become so muddled? I don't even have a theory. Do you?

Note: As with other of today's posts, after 8.30 a.m. PST I won't be able to approve comments again until late this evening as I am on the road today. But comment anyway and thanks for your patience.

Posted by Philip Dawdy at February 8, 2008 12:05 AM
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Comments

A theory for why medicine is meddled?

Mine says that medicine got misdirected for economic reasons. Pharmaceutical medicine is a major part of the problem. It is great business, but like all business, it requires continuous growth.

After initial successes, any alternative to pharmaceutical intervention was scrapped as "bad for business" and labeled bad medicine or quackery. Research was directed ONLY towards finding those causes for illness that are amenable to pharmaceutical intervention.

This has been going on for close to a hundred years, started in the US by Rockefeller and his medical schools. The result: Good business for pharma but bad medicine.

It is almost impossible today to do basic research in health that is not financed by pharma and therefore directed towards ends that will forward the business model.

The model has blinded us to the greater part of possible health interventions, leaving us with a very poor understanding of disease processes and tools that don't work in the majority of cases.

Posted by: Sepp at February 8, 2008 01:32 AM

Your comment about smoking cigarettes reminded me of this exchange from Woody Allen's Sleeper, "
Dr. Melik: This morning for breakfast he requested something called "wheat germ, organic honey and tiger's milk."
Dr. Aragon: [chuckling] Oh, yes. Those are the charmed substances that some years ago were thought to contain life-preserving properties.
Dr. Melik: You mean there was no deep fat? No steak or cream pies or... hot fudge?
Dr. Aragon: Those were thought to be unhealthy... precisely the opposite of what we now know to be true.
Dr. Melik: Incredible. "

Posted by: Sally at February 8, 2008 03:16 AM

I think medicine got muddled in part when investigators started using computers to analyze data. They could plug in any variable against a population and quickly come up with association data--which were then reported to the public, and often led to interventions based on what affected the association variable. Results that varied widely were accepted as part of the deal, because the goal was to lower "overall risk"--the thing that was "identified" in the first place. Treatment needs to go back to an orientation on single patients and cause-effect.

Posted by: Joan McClusky at February 8, 2008 07:01 AM

that's an excellent point, joan.

Posted by: Philip Dawdy at February 8, 2008 08:37 AM

Actually, for some gastrointestinal conditions (in my understanding Crohn's and Celiac's are two of them), smoking helps reduce the constipating effects and alleviate symptoms / blockages, and is considered by some doctors to be less risky than allowing the condition to progress unchecked. Since the long-term prognosis for those conditions isn't especially good, some of the side effects of smoking outweigh the health risks when compared to the disease.

Posted by: Puckett at February 8, 2008 10:47 AM

The sad truth is medicine most often makes you more sick and encourages you to give up responsibility for your own well being. A truly profound book on this topic is Ivan Illich's Limits to Medicine. I urge everyone to read it.

Posted by: Sara at February 8, 2008 11:43 AM

Take a look at history - medicine has always been muddled. Even in modern times, the process of figuring out best how to treat ailing human beings has always been two steps forward, one step back. The problem here is not that medicine has changed. It's that too many people - including doctors, patients, and the public - buy into the archetypal modern myth that scientific progress necessarily follows a smooth, linear path. In reality, nothing could be further from the truth.

Posted by: Garth at February 8, 2008 02:07 PM

Re: the diabetes study--because of the care they received, the annual death rate for both groups in the study was far below patients in the general population at similarly high risk.

Posted by: M at February 8, 2008 06:25 PM

it's great that doctors are re-examining current theories of disease. mabey, somewhere, a pendulum is changing direction. . . (cue overture)

Posted by: jenna at February 8, 2008 10:21 PM

This is a great round up of health related topics Philip.

Though Sara-- I'm pretty sure there are some life-saving medications out there.

Just enough chemo to kill the cancer not the patient; has saved many breast cancer survivors for instance.

Yeah, the side effects can be deadly, hair falls out, you come to a near death, but there is the % rate of survivors at least in that category, who may even be bipolar or depressed or SZ and be alive to tell about it.

Posted by: Stephany at February 9, 2008 06:51 PM
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