March 6, 2009
Dr. Steven Horvitz- Reading between the Lines:
Bringing you healthcare information you can trust!
Medical Studies- We can't live with them, and We can't live without them?
I graduated from medical school in 1991 and completed my family practice training in 1994. At that time, I was just embarking on my medical career. I was still idealistic. I believed what I was taught in school to be 100% the truth. Part of our training involves keeping up with all the newest and latest treatments of disease. We were taught to believe in peer reviewed placebo controlled medical studies. These studies shaped the way I practiced my new profession.
Fast forward to March 2009. I am 15 years older, and no longer in the early part of my career. I have come to realize that my hairline will continue to recede, and I have also become more realistic about the diagnosis and treatment of disease. With these realizations, I have become more realistic about what it means to be a family physician. Being a family physician means treating each patient as an individual, and to treat these individuals as you would treat your own family member. Please note I am assuming that we all love our family members. If you do not, please insert your favorite pet or your best friend wherever you see the words "family member".
So what does this have to do with medical studies?
As mentioned earlier, by practicing for 15+ years, I realize that medical care is far from idealistic. There is a tremendous amount of bias, especially as it involves medical studies and guidelines. My problem is with how medical studies are performed, who funds the studies, how they find their conclusions, how they promote their results and how they are used for propaganda and profit. One of the biggest offenders are the pharmaceutical companies. They have a tremendous knack for transforming mediocre medical studies into billion dollar drug sales. The two biggest culprits are the statin cholesterol medications and the bisphosphonate osteoporosis medications. Both of these medication classes have been marketed as the best thing since sliced bread. As a low carb proponent, you know how I feel about sliced bread. But if you truly look at the study statistics, you will find the conclusions and recommendations to be heavily biased.
Example: a statin cholesterol medication is advertised to lower your cholesterol by 30-50%. And then they tell us that further studies show a 20% relative decrease in heart disease. Wow!!! I should run and start taking that pill. But if you look closely at the numbers you find out that the 20% relative decrease is a marketing ploy. So I look at it differently. The number that I like to look at is what is called the NNT, or the number needed to treat. It goes like this. If 11 people have strep throat, and I give an antibiotic to all 11, 10 people will be cured and 1 will not. The NNT is 10/11, or a 91% success rate. Pretty good!!! Now, let us look at statins. A Business Week article examined the NNT for a poplular statin drug Lipitor. The NNT of Lipitor to prevent a cardiac event was 1/100 or a 1% success rate. You need to treat 100 people with Lipitor to prevent 1 cardiac event. Wonderful for the one individual, but what about the other 99.
So as I grew older and balder, there is hope. Not for my hairline but the tremendous amount of bias in medical studies that is finally getting some press. A recent article in JAMA, the Journal of the American Medical Association, (2.25.09. vol 301. No.8), wrote about guidelines that cardiologists propose as evidence based, is actually based on weak evidence. I even read in other blogs how these guidelines have been used to increase the need for cardiologists. How is that for self-referral??
So in my practice, I trust less of what the so-called experts propose, and more on common sense, and personal professional experience. I still use guidelines, but not as the holy grail of medical care and treatment. As many of the standards of care that I used 10 years ago, are now obsolete, or even dangerous, I am not close-minded to believe that the treatments proposed today by the "experts" will still be around ten years from now. Instead, I look for the causes and triggers of disease. I look for treatments that work with the bodies normal activities and not against it. I treat each patient as an individual, and I do not use population based medical studies as the determining factor in treatment. I consider these studies as options, but I always try to understand how this treatment will affect the individual sitting across from me. I look for bias in all studies, and all marketing that comes before me. The only way to be true as a doctor is to be true to your patients. And that means not drinking the medical study kool-aid that others in my profession drink. Besides, I prefer water. It tastes better, has no artificial ingredients, and has been around forever.
I will end with one of my favorite quotes:
"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
Steven Horvitz, D.O.
Board Certified Family Medicine
Founder of The Institute for Medical Wellness