I find myself constantly talking people out of medical care. Well, not so much talking them out of it as trying to talk them into seriously considering the evidence in favor of (or against) a test, procedure, or drug before undertaking anything. The big problem in American medicine today is that patients believe that "more = better." They use the same logic when buying cars, when ordering dinner, when building houses. And see where that's gotten us?
In medicine, the consumer mentality has been a disaster for patient outcomes. Of course, it's been terrific for drug and device makers. Fighting against them in defense of patients is so very difficult in this country, because we allow our medical care to be run as a "consumer-provider" system. What does this profiteering approach to medicine make our doctors? Salespeople.
But good doctors aren't salespeople. Good doctors follow the dictum my husband (an internist) uses constantly to admonish his residents: "Don't just do something! Stand there." Meaning? Meaning think before your act on a patient's body. First, do no harm. (A very modern idea, huh?)
This past week, the BMJ (British Medical Journal) blog published "The New Therapeutics: Ten Commandments," a little ditty that proves the old adage that a lot of truth is said in jest. These humorous commandments, by John Yudkin, remind physicians how to think past the games that drug and device makers play with "science" to really think scientifically and ethically about patient care.
To get the jokes in the piece, you have to be a medical insider. But reading them, I realized it would be so great if American patients understood the ideas in the "Ten Commandments," too. So I asked my mate, Aron Sousa, MD, Senior Associate Dean for Academic Affairs at Michigan State University's College of Human Medicine, to help me translate into plain English Yudkin's "Ten Commandments." My translations aren't funny, but if you can understand them - and if you can somehow hold your doctor to them - you will likely live longer and better.
- "Thou shalt treat according to the level of risk rather than level of risk factor." In medicine, a risk factor is a trait that increases the likelihood of having something really bad happen to you. For example, having a high level of triglycerides is a risk factor for having a heart attack. (That means that having high triglycerides increases the likelihood you will suffer a heart attack.) But you want your doctor to try to prevent what's really bad - the heart attack - not just treat your triglyceride level. Why? Because lowering your triglyceride level with some prescription drug won't actually decrease your risk of a heart attack. Doctors need to treat what really matters to you, the patient, not what is merely measurable in you.
- "Thou shalt exercise caution when adding drugs to existing polypharmacy." It's generally a bad idea to give a patient another drug when a patient is already on a drug. Doing so increases the risk of bad interactions between the drugs. It also increases patient confusion, thereby again increasing risk. So adding one drug doesn't just introduce the risks named on the pamphlet you get with that drug, because the body is a complex machine, drug interactions are poorly understood, and humans on lots of drugs make mistakes in the use of those drugs.
- "Thou shalt consider benefits of drugs as proven only by hard endpoint studies." This is similar to the first commandment because it reminds the physician that what you really care about are "hard endpoints" - things like heart attacks and strokes, not things like levels of cholesterol and triglycerides. A particular drug might make your labs look really great, but it's not a good drug if it doesn't actually improve your health in the ways that matter (for example, reduction of risk of a major disease, or reduction of risk of death.) A drug might increase your bone density, but if it doesn't reduce your risk of fracture, who cares that your bones are denser?
- "Thou shalt not bow down to surrogate endpoints, for these are but grave images." Again, "surrogate endpoints" are things like blood pressure readings, as opposed to "hard endpoints" like heart attacks and strokes. It doesn't actually matter what your blood pressure is if your blood pressure doesn't hurt you. We use blood pressure readings as a surrogate for what we really care about. It's worth measuring, but we should not treat high blood pressure with a drug unless that particular drug is shown to achieve what we really care about: reduction of risk of heart attacks and strokes.
- "Thou shalt not worship Treatment Targets, for these are but the creations of Committees." Sometimes consensus groups come up with "treatment targets" that tell physicians what patients' lab numbers should look like. But physicians need to take individual patients' bodies, lives, and needs into account. An example: a consensus committee might issue a treatment target for glucose (blood sugar) control. They might say everyone should have low blood sugar. But imagine a patient who is an 80-year-old woman who has been falling a lot. Lowering that woman's blood sugar could increase her risk of a big bone fracture from a fall. So she should not be treated glibly according to a Treatment Target that might be perfectly reasonable for an otherwise healthy 30-year-old woman. Physicians and patients should especially beware any consensus issued by a committee of people who have had financial ties to drug and device makers.
- "Thou shalt apply a pinch of salt to Relative Risk Reductions, regardless of P values, for the population of their provenance may bear little relationship to they daily clientele." This is a complicated way of again reminding physicians what should matter: actual reduction of risk of the things their own real patients really care about and are really likely to suffer from. Relative Risk Reduction is another way drug companies often fool physicians and patients into thinking a drug is better than it really is.
- "Thou shalt honour the Numbers Needed to Treat, for therein rest the clues to patient-relevant information and to treatment costs." The phrase "numbers needed to treat" refers to how many patients a doctor needs to treat with a particular intervention in order to have one patient's outcome improve. This concept acknowledges that not every intervention benefits every patient. In fact, there's a "number needed to harm" for each drug, too, but you don't often hear about either stat from your doctor. Yet for many medical interventions, you have to treat a relatively large number of people to benefit just one, but you're introducing ALL of them to the risks of that intervention. You might think from pharmaceutical ads that a drug for heartburn will lower your risk of esophageal cancer. But the truth is that probably dozens if not hundreds of people will have to take the drug before just ONE of those people has cancer prevented by the drug, while ALL of you on the drug will bear all of the risks of the drug. Note that this commandment also refers to treatment cost, an idea that is supposed to offend us Americans. But the truth is we are already rationing healthcare in this country, and it would be better if we thought rationally about how much money it makes sense to prevent, say, one death from cancer. If we keep ignoring that calculation, we'll kill a lot more people than we save.
- "Thou shalt not see detailmen, nor covet an Educational Symposium in a luxury setting." These days, detailmen are actually often women - perky, young, blond women chosen because they still carry their cheerleader looks from high school. They are the representatives from drug and device makers who come to seduce your doctor into using their products on your body, so that profit can ensue. Drug and device makers also like to whisk your doctor off to "educational symposiums" where they are wined, dined, and sold the idea of using more of the companies' products. Profit is the only endpoint these companies really care about, so they will take all the risks they need to in order to achieve that endpoint, including treating your life as an acceptable risk. If you are at your doctor's office and you see detailmen or their paraphernalia (pens, mugs, posters, videos, etc. produced by these companies), you can assume your body is being used as an endpoint by a corporation that doesn't care what really happens to you. So ask yourself: how much does your doctor really care about you?
- "Thou shalt share decisions on treatment options with the patient in the light of estimates of the individual's likely risks and benefits." Your doctor needs to talk to you about what YOU are trying to achieve with your medical care. Then she or he needs to discuss with you the reasons and evidence for the options being offered to you. She or he really should be educating you about all the things we've covered so far: risk factor versus risk, surrogate endpoints, unknown drug interactions, etc. You can start this conversation by telling your doctor about what exactly you're trying to achieve in a given office visit. For example, you might say in a yearly exam, "I would rather live a healthy life than a longer life, so I'm only interested in tests, procedures, and interventions that are likely to give me good health, not those that will necessarily keep me alive longer but make me feel unhealthy during those years." Or at a sick visit, you might say, "I didn't come for a prescription. I came to try to figure out why I feel sick, and what I can expect in terms of healing. I only want a prescription if I really need one to get better. I would rather suffer the symptoms of this thing than take the risk of a drug that's just going to treat the symptoms and increase my risk of ‘side effects.'"
- "Honour the elderly patient, for although this is where the greatest levels of risk reside, so do the greatest hazards of many treatments." This one is self explanatory, but too often ignored.
Don't be a consumer. Be a patient patient, and teach your doctor to be a patient doctor who thinks about what you really need from her or him. Do that, and you'll give your doctor a better life, too.