The antioxidant myth

A recent Scientific American article challenges the myth of antioxidants being associated with ageing. This is not the first time SciAm has covered this topic (here, here and here). The article challenges current perceived wisdom, not only regarding the effectiveness of anti-oxidants but of the underlying theory that oxidative damage causes ageing.  The current evidence tells us that antioxidant supplementation is not only ineffective, it is harmful. The sorry story of antioxidants should really be one of my “Lessons from History” blogs, except that it has not yet been relegated to history. But the story still provides lessons.

Ethical double standards

Ethics committees (IRBs in the US) are now firmly entrenched in the research environment such that clinical research can only be performed with their approval. Clinical practice, however, is not subject to such approval, yet in many cases the risk of harm (individually and to society) from clinical practice is greater. Are researchers being held to a higher standard than clinicians? Has our concentration on ethical standards for clinical research led to an ethical blind spot for clinical practice?

Don’t just do something, stand there

This reversal of a commonly used phrase is a plea. A plea against the bias that leans doctors towards diagnosing and treating, even when the scientific evidence may not support it. Sure, it is expected that a doctor will diagnose and treat you, but sometimes there is no diagnosis or effective treatment, and pursuing either may be harmful. When in doubt, your doctor will continue to run tests until something comes up, and will continue to treat you for as long as you return with symptoms. Sometimes, not pursuing a diagnosis and not treating a patient are reasonable options. Sometimes they are the best option.

Book review: Limits to Medicine

Title: Limits to Medicine. Medical Nemesis: The Expropriation of Health (1975)

Author: Ivan Illich

Publisher: Marion Boyars

Ivan Illich was a philosopher and historian who published several books in the 1970s targeting areas like medicine, transport, education and energy use. His thesis was that modern, western, industrialisation and in particular the institutionalization of specialised knowledge by the professions has far-reaching negative consequences. His 1975 book Limits to Medicine. Medical Nemesis: The Expropriation of Health made his case against modern, institutionalised medicine. He felt that more expensive and specialised medicine was more likely to be harmful and less effective, and that important aspects of the life experience such as birth, mating, suffering, aging and dying were being medicalized. His points were interesting and controversial in their time, and the following 40-odd years of growth in specialised industrial medicine has made many of them prescient.

Lessons from history #5: Bone marrow transplant for breast cancer

In the 1990s, giving patients with breast cancer massive doses of chemotherapy or radiotherapy followed by a bone marrow “rescue” was thought to improve survival and even cure the disease. It was complex, expensive and risky, which only raised the perceived effectiveness. The treatment spread, and insurance companies had to fall in line to cover the treatment due to legal, government and public pressure. The randomised trials that were eventually done showed that it was no more effective than standard treatment. Here is the story and the lessons that can be learned.

Evidence based medicine vs the Golden Rule

I am a big fan of evidence based medicine (EBM). Not the cookbook type (“do it this way or else”), but the idea that medicine is a science and therefore should be approached scientifically. We should use the principles of logic and rational thinking to reduce the errors that result from our often irrational, subjective “human” way of making decisions. Sometimes, however, we try to use EBM to justify something that doesn’t need scientific support – something that should be the default, and only changed if there is evidence against it. Something like the Golden Rule.

What's the deal with those bad hip replacements?

Most people are aware that a year or two ago there were some new hip replacements that were recalled. The story behind it has all the ingredients to suit this blog: overestimation of benefit, underestimation of harm, regulation failure, and conflict of interest up the wazoo. The ‘deal’ as it were, was a bad one for patients, a bad one for the company (in the end), but a great one for the surgeons, as it became the gift that keeps giving.

Book review: Overdiagnosed

Title: Overdiagnosed. Making people sick in the pursuit of health (2011)

Author: H. Gilbert Welch (with Lisa Schwartz and Steven Woloshin)

Publisher: Beacon Press, Boston

Overdiagnosed is an attempt to change the conventional wisdom - the prevailing paradigm - that early diagnosis is always a good thing and therefore that the best test is the one that finds the most disease. He shows us the downside of our attempt to make sure that nobody misses out on any potential benefit by failing to be diagnosed. He shows us that the dogma of early diagnosis is maintained by overestimated benefits and a general disregard of the harms.

How you die vs If you die

Which is more important: how you die, or if you die? Research in medicine often uses mortality (death) as an important outcome. Death (from any cause, so called ‘all-cause’ mortality) is easy to measure, it is not subject to misclassification, and it is the most important outcome for many conditions and treatments. Many researchers, however, favour ‘disease-specific’ mortality (only counting the deaths from the disease being studied) rather than all-cause mortality. The argument is that this measurement is more sensitive to changes in treatments that specifically target that condition (as there is less ‘noise’ from deaths from other causes). For example, it makes sense to measure deaths from heart disease if you are testing the effect of a treatment for heart disease. However, the use of disease-specific mortality can be misleading, it is arguably less important, and it results in an overestimation of the benefits and underestimation of the harms from many interventions.

Book review: Bad Pharma

Title: Bad Pharma. How drug companies mislead doctors and harm patients (2012)
Author: Ben Goldacre
Publisher: Fourth Estate, London

Ben Goldacre, a UK based doctor, has become a popular medical and science writer. His previous book Bad Science was a big hit, he has popular web and Twitter profiles, and he is a regular public speaker and newspaper contributor. His new book, Bad Pharma, specifically targets the problems with medicines. It does not restrict itself to the pharmaceutical industry (although drug companies are the main target), the book also details problems with government regulators, patient advocate organisations, doctors, medical colleges, governments, journals, universities, academics and even ethics committees. Fortunately, the book also offers solutions.

Limits to medicalization?

The character Syndrome from The Incredibles pictured a world where everybody had super powers: “because when everyone is super, no one will be”. If more than 50% of the population have depression, then what is ‘normal’? What if it was 75% of the population? Are we witnessing a gradual approach to a situation where we will reach the Last Well Person? Is a well person simply a patient who has not been completely worked up?

Stop the medication train, the elderly want to get off

Overmedication (“polypharmacy”) in the elderly is a problem. The debate about the appropriateness of individual medications is one thing, but when you are taking 5 or more different medications multiple times per day, the physical act of simply taking the medication is a problem, let alone the adverse effects and interactions of all these medications. So what happens when you stop taking them? You feel better, that’s what happens.

Lessons from history #4: RSI

Repetitive Strain (or ‘Stress’) Injury (RSI) is a syndrome of arm / hand pain associated with certain activities. It is not a disease. It is not an injury, there is no physical evidence of stress or strain, and it bears little correlation with repetitive use. It is a social construct, influenced more by psychosocial factors than mechanical factors, and has no clear biological basis. Its history shows us how ‘unstable’ such labels are. Yet despite being easy to refute, labels like these persist. They persist because they serve a purpose and appear to fill a gap in our knowledge, and they are more socially acceptable and easy to understand than the truth. They are examples of medicalization.

Opioids: the real opium of the masses

Opioids are strong pain killing drugs that mimic the body’s own chemicals. Examples of prescription opioids include heroin (which metabolises to morphine and was banned after 1925), morphine, oxycodone and hydrocodone. As pain killers for acute pain, opioids work. However, over longer periods they become less effective, have more adverse effects, and can lead to tolerance, dependence, addiction, increased pain, and death. Here are some facts about long-term opioid use.

Treating the numbers, not the patient

What’s your blood count? Blood pressure? Bone density? PSA? If it is abnormal, odds are that you will want it to be normal. In doing so, you are making the same leap of faith that your doctor is making when he commences treatment: that treating the numbers will improve your health. Like much of what we do, treating the numbers is often naïve, and sometimes harmful, no matter how well intentioned. Read these short examples and tell me if you still want your numbers normalised.

Book review: Overtreated

Title: Overtreated: why too much medicine is making us sicker and poorer (2009)

Author: Shannon Brownlee

Publisher: Bloomsbury

There appears to be many books on the topic of overtreatment, overdiagnosis, medicalization, medical error and what’s wrong with modern medicine in general. This book covers all of those topics, but focuses on the simple theme that more medicine does not lead to better health. Instead, it leads to higher costs and worse health.

The Uncertainty Principle: from Heisenberg to Hawthorne

I know that Heisenberg’s Uncertainty Principle refers specifically to physics (in that you cannot simultaneously measure the momentum and position of an electron),¹ and I know that its interpretation has been generalised to the point where some take it to mean that nothing is certain, but at the crux of the Uncertainty Principle is the concept that you change things by measuring them. Specifically, that you will change the very thing that you are trying to measure, simply by measuring it, and you have to admit, that’s pretty cool. The Uncertainty Principle can be fun in popular culture² but in medical research, it causes problems.

Deciding versus consenting

The consent process in medicine is serious stuff. Consent forms are fine-tuned every few years to get them just right, and often a negligence suit can hang on the consent form and consent process. Less emphasis is placed on the decision process that led to the patient signing a consent form in the first place. It turns out that the more information a patient receives, the less likely they are to ‘sign up’ for the procedure.

Book review: Stabbed in the Back

Title: Stabbed in the Back. Confronting Back Pain in an Overtreated Society (2009)

Author: Nortin M Hadler

Publisher: University of North Carolina Press

Nortin Hadler has written widely on the problems with modern medicine (overtreatment, overdiagnosis, medicalization) but he is also someone who is doing something about it, and his ideas on healthcare reform are novel, well informed, feasible and reasonable. For these though, you should read Worried Sick: A Prescription for Health in an Overtreated America. This book covers back pain; from historical, cultural, physical, social, occupational and psychological perspectives.

Health – it’s all relative

Why does Japan have the highest life expectancy and one of the best health systems, yet less than 50% of the population consider their health to be good or very good (one of the lowest scores in OECD countries)? What is health; is it the absence of a negative (disease, pain) or is it a positive concept?

Health can be measured and quantified objectively (with things like life expectancy, body mass index and blood sugar levels) or subjectively, by asking people how healthy they think they are. Objective measures provide hard data that can be useful, but they do not tell us much about how the patient perceives their own health. For this we use terms like Health-Related Quality of Life, a concept closer to things like life-satisfaction, happiness and subjective well being. It is argued that this (subjective measure) is the most important measure of health.

It turns out that self-rated health is surprisingly constant over time (despite changes in objective health), because reporting of health is relative.