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Janet Rosen
10-12-2011, 10:46 AM
The most recent Sunday NY Times Book Review reviewed "Your Medical Mind: How to Decide What is Right for You" by Jerome Groopman and Pamela Hartzband (http://www.nytimes.com/2011/10/09/books/review/your-medical-mind-by-jerome-groopman-and-pamela-hartzband-book-review.html?_r=1&ref=books)

I will be picking up a copy of this book and recommend you do also. It offers a lot of examples of how to take available information and make sense of it. It also may help explain why a health professional like I am is very cautious in recommending certain medications or surgery. A couple of examples from the book review:

"For example, the “number needed to treat” for a particular cholesterol-­lowering drug is 300. (For every 300 people taking it, only one heart attack is prevented.) The drug has a 5 percent probability of side effects, including severe muscle and joint pain and gastrointestinal distress. Thus, for every person helped, 15 people (5 percent of 300) will experience side effects and not be cured. In other words, anyone taking the drug is 15 times more likely to experience the unwanted effects of the medication than the beneficial ones. "

"According to one 2004 study, for every 48 prostate surgeries performed, only one patient benefits — the other 47 patients would have lived just as long without surgery. (Groopman and Hartzband discuss the important epidemiological concept “number needed to treat,” which applies to surgeries, prescriptions, therapies, you name it.) Moreover, the 47 who didn’t need the surgery are often left with an array of unpleasant and irreversible side effects, including incontinence, impotence and loss of sexual desire. The likelihood of one of these side effects is over 50 percent — 24 of our 47 will have at least one. This means a patient is 24 times more likely to experience the side effect than the cure."

mathewjgano
10-12-2011, 10:58 AM
Thanks, Janet! Do you think these are examples of how business demands supercede actual health needs? I don't have any direct experience with the medical field, but I have family who do and from what little I can gather, the big business surrounding health care (everything from insurance to pharmaceutical companies) exerts a bias that not only costs the companies large amounts of money, but incentivizes doctors and nurses in ways that aren't actually in the patient's best interest. Not to say things like Lipitor are bad, just that where profit is concerned (usually on the part of insurance and pharmaceutical companies), patients' needs seem to be viewed as secondary. I've been forming the opinion that the medical field should be not for profit since money seems to mitigate the quality of health care.

Janet Rosen
10-12-2011, 11:34 AM
It's partly the money but it's also partly that unless one can frame the numbers in context, it SOUNDS good.

For instance here is a typical article on health stats, found via google, and from NY Times: "Statins May Halve Heart Attack Risk (http://www.time.com/time/health/article/0,8599,1857796,00.html)."

The article says: "....tracked about 17,800 people in 26 countries. Participants included men ages 50 and older and women ages 60 and older, who had high levels of C-reactive protein (CRP) but normal cholesterol levels and no history of heart disease. Half the participants were given rosuvastatin (Crestor), and half were given a placebo daily for just under two years. The statin group reduced their CRP levels by 37%; their LDL, or bad cholesterol, levels dropped 50% to about 55 mg/dL. Among the 8,901 statin-takers, 31 suffered a heart attack and 33 suffered a stroke. When compared with the placebo group, those figures translated to a 54% lower risk of heart attack and a 48% lower risk of stroke in people taking a statin for inflammation — double the reduction of risk in patients who lower their cholesterol alone."

Your typical doctor is going to have EXACTLY the same reaction you or I will on reading this: WOW. That's great! Over 50% reduction in heart attacks! ... and he'll reach for his prescription pad. And he'll think patients who refuse statins are bull headed, stupid, "noncompliant" or just plain wrong.

I just reached for my calculator. 8901 sample divided by 31 heart attacks = 287:1 - pretty much the 300:1 cited in the book review.

So for every 287 people NOT taking statins, there are 2 heart attacks. For every 287 people ON statins, with potential side effects, there is 1 heart attack. That puts it in a different light.

The danger, or power, of anecdotal evidence of course lies in the testimony of the minority who ARE saved by the medication or treatment.

I don't think it is that any given med or surgery is bad or wrong. for any given human but that many of us, if given the information IN THIS CONTEXT, may opt for a different treatment path.

mathewjgano
10-12-2011, 01:02 PM
But don't you think they use the comparison because it looks nicer? I don't think the doctors are the ones who tend to skew or otherwise crop the data, and I might just be demonstrating a cynical view, but one of the things I took away from my education courses was the way data gets presented to imply something is more (or less) than it actually is. I imagine the research scientists plotting out the data and then the advertizing team presenting it based on how it will be best received, not on how it will be best understood. Like I said though, this probably just represents my disillusionment with large-scale business and people who want to sell something.
I'll have to check that book out. Thanks for the info!
Take care,
Matt

Janet Rosen
10-12-2011, 01:34 PM
I think it is important to distinguish between Big Pharma and those minority of physicians who greedily shill for them and the majority of doctors who frankly are in no more position time-wise or education-wise than the rest of us to evaluate the myriad news stories and research reports that pass their desks, inboxes and computers each days.

The former are indeed manipulating, massaging, witholding data to suit their desire for maximal profits at any social cost.

The latter are sincerely doing what they think is best for their patients. If they didn't have to spend an additional 2 to 5 hours every work day completing paperwork demanded by the for-profit insurance companies, they might be in more of a position to do some digging for information.

But in my experience, I have more up do date info on research affecting my conditions than any members of my health team. One example, simply the most recent: there is plentiful info online, both pro AND con, on the effect of niacin (used in high doses as a low cost and fairly benign alternative to statins) and blood sugar levels; some is the usual reprint-blindly drivel, but there is actual research and it isn't conclusive...but there is enough of a suggestion to give one pause. I have had two doctors and one nurse practitioner stare blankly at me. They simply had never heard there might be any connection.

mathewjgano
10-12-2011, 02:34 PM
I think it is important to distinguish between Big Pharma and those minority of physicians who greedily shill for them and the majority of doctors who frankly are in no more position time-wise or education-wise than the rest of us to evaluate the myriad news stories and research reports that pass their desks, inboxes and computers each days.

The former are indeed manipulating, massaging, witholding data to suit their desire for maximal profits at any social cost.

The latter are sincerely doing what they think is best for their patients. If they didn't have to spend an additional 2 to 5 hours every work day completing paperwork demanded by the for-profit insurance companies, they might be in more of a position to do some digging for information.

But in my experience, I have more up do date info on research affecting my conditions than any members of my health team. One example, simply the most recent: there is plentiful info online, both pro AND con, on the effect of niacin (used in high doses as a low cost and fairly benign alternative to statins) and blood sugar levels; some is the usual reprint-blindly drivel, but there is actual research and it isn't conclusive...but there is enough of a suggestion to give one pause. I have had two doctors and one nurse practitioner stare blankly at me. They simply had never heard there might be any connection.

Very interesting! And a little scary.
I agree it's important to point out the vast majority are not greedy and anti-social. Even with my cynicism I don't think most pharmaceutical employees are trying to hurt anyone. I think in most cases the problem arises through a form of status quo neglect...particularly if I think much past my usual knee-jerk response. In these large "people" (i.e. corporations) so much seems like it could be over-specialized...or otherwise overly compartmentalized. Recently my wife and I had to deal with our hopsital apparently not knowing how to bill our insurance company for the birth of our child. After we got the bill showing almost no coverage from insurance, we called them and they reran it. After it didn't work the second time they asked us to have our insurance company call them to clear it up. We called them and were told to call the hospital and let them know it wasn't their job. As a customer I'm still pretty upset because I've been largely unemployed for the last year and my wife is a half-time teacher on unpaid maternity leave. This was a stressor we really didn't need added, but we weren't the prime interest on the part of the isurance company, and I'm sure the rep. my wife spoke with was just following protocol. I'm just glad someone at the hospital finally figured it out because it was clear the insurance company didn't care enough to. Next year I'm changing companies, but I doubt it'll make any difference. As usual, the little guy is stuck between the powers that be...and I'm seriously considering forming a savings account for future medical costs: cut out the middle "person."
Did I just hop up on a soap box?:D
Thanks again, Janet!
p.s. I finally checked out your Zan Shin Art page: really very awesome stuff!!!

Basia Halliop
10-12-2011, 03:36 PM
It's also a philosophical question, I think. You're weighing both the probability and severity of what will happen if you do or don't take a treatment. But given the same understanding of the probabilities, two patients might still make two different choices. Some will consider the high probability of serious side effects worth it for even the tiny lowering of risk if they're talking about something like death -- they'll say if that one person in 300 who is saved is your family member, you'll consider it worth it.

I'm sure some doctors are thinking of it that way. Although others perhaps haven't thought it through clearly enough to always ask themselves the question in quite those terms.

Part of the problem, though, is that patients don't necessarily always have the background to frame the question clearly to be sure of what THEY think. In the end they're the one who will live with either taking or not taking the drug.

It's a question that requires both objectivity and subjectivity --- objectivity to really understand the question and the numbers, but also a sense of your own values to know what to do with those numbers.

Basia Halliop
10-12-2011, 03:41 PM
But in my experience, I have more up do date info on research affecting my conditions than any members of my health team. One example, simply the most recent: there is plentiful info online, both pro AND con, on the effect of niacin (used in high doses as a low cost and fairly benign alternative to statins) and blood sugar levels; some is the usual reprint-blindly drivel, but there is actual research and it isn't conclusive...but there is enough of a suggestion to give one pause. I have had two doctors and one nurse practitioner stare blankly at me. They simply had never heard there might be any connection.

Yeah, it seems to be a common story, and so much more so if your condition or treatment are a bit less common or not your doctor's specialty. But even when they are common, there's a lot of research out there to keep up with... not all do...

Janet Rosen
10-12-2011, 04:09 PM
Basia I completely agree with what you say about each individual making a different decision, and the reason I think this book is of value is that it starts getting people to think about and reframe the common "health care facts" they are given so they can make a decision based on their individual values and priorities.
As a health care professional, I always try to take time to let my clients work through these delicate issues. Being able to give them another more concise evaluation method is a wonderful thing.

Dan Rubin
10-13-2011, 01:57 PM
I just read How Doctors Think by Jerome Groopman (co-author of the book Janet is talking about). It, too, is about empowering patients, by educating them on how doctors make treatment decisions, and giving patients ways that they can help their doctors make good decisions. Groopman is an excellent writer; the book is a very easy read.

Janet Rosen
10-13-2011, 02:03 PM
Thanks for the reminder on that one, Dan - I see it for sale at our local non-chain real pharmacy but never picked it up.

Janet Rosen
10-29-2011, 07:41 PM
Here's another article, this one on today's NY Times website (http://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html?hpw), even more apropos to training as it has to do with yet another study debunking MRI as a tool for diagnosing what is causing your pain.

"Dr. James Andrews, a widely known sports medicine orthopedist in Gulf Breeze, Fla., wanted to test his suspicion that M.R.I. (http://health.nytimes.com/health/guides/test/mri/overview.html?inline=nyt-classifier)’s, the scans given to almost every injured athlete or casual exerciser, might be a bit misleading. So he scanned the shoulders of 31 perfectly healthy professional baseball pitchers.The pitchers were not injured and had no pain. But the M.R.I.’s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews (http://www.andrewscenters.com/getpage.php?name=andrews) says. "

Janet Rosen
10-29-2011, 07:43 PM
NOTHING trumps careful history and physical:
"Dr. Green and his colleagues reviewed the records of 101 patients who had shoulder pain (http://health.nytimes.com/health/guides/symptoms/shoulder-pain/overview.html?inline=nyt-classifier) lasting at least six weeks and that had not resulted from trauma, like a fall. Forty-three arrived bearing M.R.I.’s from a doctor who had seen them previously. The others did not have scans. In all cases, Dr. Green made a diagnosis on the basis of a physical exam, a history, and regular X-rays.
A year later, Dr. Green re-assessed the patients. There was no difference in the outcome of the treatment of the two groups of patients despite his knowledge of the findings on the scans. M.R.I.’s, he said, are not needed for the initial evaluation and treatment of many whose shoulder pain does not result from an actual injury to the shoulder.
Dr. DiGiovanni did a similar study with foot and ankle patients, looking back at 221 consecutive patients over a three-month period, 201 of whom did not have fractures. More than 15 percent arrived with M.R.I.’s obtained by doctors they had seen before coming to Dr. DiGiovanni. Nearly 90 percent of those scans were unnecessary and half had interpretations that either made no difference to the patient’s diagnosis or were at odds with the diagnosis"

Dan Rubin
10-30-2011, 04:08 PM
This information about MRIs is related to what Groopman writes about in How Doctors Think (which, to be more accurate, is about how doctors arrive at diagnoses, not treatments). I can readily accept that MRIs are often unnecessary to arrive at a proper diagnosis, but it's disturbing to learn that an MRI can lead to an incorrect diagnosis.

This is the kind of knowledge that can make for a better patient; not one who argues with the doctor, but one who can ask questions that will cause the doctor to think about how he/she arrived at the diagnosis, which is Groopman's goal. I've bookmarked the article for future reference.

kewms
10-30-2011, 10:01 PM
This information about MRIs is related to what Groopman writes about in How Doctors Think (which, to be more accurate, is about how doctors arrive at diagnoses, not treatments). I can readily accept that MRIs are often unnecessary to arrive at a proper diagnosis, but it's disturbing to learn that an MRI can lead to an incorrect diagnosis.

The problem is that there isn't a clear understanding of the difference between "normal," "abnormal," and "dysfunctional." Consider the example (from the article) of major league pitchers with shoulder abnormalities. Yes, clearly they had shoulder structures that were different from the average person. But they had no pain and were successfully functioning at a high level. They were abnormal, but not dysfunctional.

(Or consider the related issue of cancer screening. It turns out that many "abnormalities" that show up in cancer screens are fairly benign: if ignored, they either won't grow at all or will grow so slowly that something else will kill the patient first. The cells being studied are abnormal, but not dysfunctional. )

And so when some kind of dysfunction does occur, there isn't a clear way to decide *which* of the observed abnormalities (if any) is responsible for it.

Katherine

Basia Halliop
10-31-2011, 11:20 AM
quote: "Yes, clearly they had shoulder structures that were different from the average person. But they had no pain and were successfully functioning at a high level. They were abnormal, but not dysfunctional."

That actually raises an interesting question for me. What kind of baseline comparison group exists for things like, in this case, MRIs of a specific joint? Are there enough MRIs of a big enough range of healthy people of different ages, genders, activity levels, etc to even know what IS 'normal'?

They're kind of expensive, so I wonder how often they're ordered for random people with no apparent problem or reason for concern. Unless maybe in a research study?

Basia Halliop
10-31-2011, 11:38 AM
BTW, I got out that book from the library this weekend and agree that it was very good.

I would warn though that it doesn't really answer questions so much as asking them :). Mainly it's a lot of case studies of different people making decisions about medical care in their own or family members' lives, how they decided what treatments to take or not, what happened, and how they ended up feeling about their decisions.

One chapter I found particularly interesting and difficult was about end of life care and living wills. They really highlighted how inadequate the idea of living wills was, because of how subtle the decisions can be (e.g. what about temporary life support? what if someone's generally declining but the specific problem might be treatable? how invasive is invasive? etc), how rapidly they sometimes have to be made (not always time to understand what's going on) and because of how huge a percentage of people feel differently once they're actually in the situation than they thought they'd feel.

Janet Rosen
10-31-2011, 02:27 PM
Yep, its really about creating a blueprint for "critical thinking" and conversation.

Abasan
11-05-2011, 10:02 AM
There should be a like button here somewhere...