|By Dr. B. M. Hegde, India [ Published Date: June 9, 2006 ]|
Dr. B. M. Hegde MD, FRCP, FRCPE, FRCPG, FRCPI, FACC, FAMS, is presently the Chairman of State Health Society, Govt. of Bihar, India, Visiting Prof. Cardiology at The Middlesex Hospital Medical School - University of London, Affiliate Prof. of Human Health - Northern Colorado University, Visiting Prof. Indian Institute of Advanced Studies - Shimla, Retd. Vice Chancellor, MAHE University - Manipal. Prof Hedge regularly gives talks on AIR, Doordarshan, BBC and Zee TV, London.
We, in the medical field, try and give an impression to the public and the powers-that-be that all is well with modern medicine and the other alternate systems of medical care are all unscientific and should be shunned. How many of us have searched our hearts to see if what we are doing is "scientific" as we claim it to be? What is the basis of the science of medicine and how much of what appears in the medical textbooks and the journals is based on hard irrefutable evidence? Except an occasional daring soul trying to peer into the inside of this huge web, there have been no attempts to find the truth. It was in the year 1974 that I wrote an article entitled "Should we be drugging every patient with elevated blood pressure? This almost cost me my job! I survived by the skin of my teeth, thanks to an understanding professor in our department at that time, Late M.Keshava Pai.
Lots of water has flowed down the Nethravathi Bridge since then. I have been consistently trying to expose the myths-I was the bad boy. No one, not even the best in the world, could give the truth, but we must try to find a truth in every situation. Things keep changing in science like in any other filed. Change is life. After forty years of struggle there comes a break for me now. The best brains in the US have realized and are working hard to expose the myth now. I am giving some of their opinions below, which a discerning reader would make out is exactly what I had been writing for decades now. This week’s Business Week Magazine (25th May 2006) gives an extensive interview with some of those researchers. Leading the flock is David Eddy, the former cardiovascular surgeon at Stanford turned Duke University mathematics PhD, who has devised a new computer model called ARCHIMEDES which has shown him that most, if not all, treatments for chronic diseases like diabetes and high blood pressure do more harm than good.
Eddy showed that the conventional approach to treating diabetes did little to prevent the heart attacks and strokes. In contrast, a simple regimen of aspirin and generic drugs to lower blood pressure and cholesterol sent the rate of such incidents plunging with millions in savings. "This is as good as it gets to improve care and lower costs, which doesn't happen often in medicine,"' Eddy recalled. He feels that if we don't implement these we you might as well close up shop. For Eddy, this is one small step toward solving the thorniest riddle in medicine. "The problem is that we don't know what we are doing," he says. Even today, with a high-tech health-care system that costs the US $2 trillion a year, there is little or no evidence that many widely used treatments and procedures actually work better than various cheaper alternatives.
During his long and controversial career proving that the practice of medicine is more guesswork than science, Eddy showed that the annual chest X-ray (routine check up) was worthless, over the objections of doctors who made money off the regular visit. He proved that doctors had little clue about the success rate of procedures such as surgery for enlarged prostates. He traced one common practice -- preventing women from giving birth vaginally if they had previously had a cesarean -- to the recommendation of one lone doctor. Eddy liked to cite a figure that only 15% of what doctors did was backed by hard evidence. Others like, Stephen Schoenbaum of the Commonwealth Fund says that we are not trying to audit this. "Clearly, there is a lot in medicine we don't have definitive answers to," adds Dr. I. Steven Udvarhelyi, senior vice-president and chief medical officer at Pennsylvania's Independence Blue Cross.
Eddy has spent the past 10 years leading a team to develop the computer model that helped him crack the diabetes puzzle. Named Archimedes, this program seeks to mimic in equations the actual biology of the body, and make treatment recommendations as well as figure out what each approach costs. It is at least 10 times "better than the model we use now, which is called thinking," says Dr. Richard Kahn; chief scientific officer at the American Diabetes Assn. Eddy’s Stanford PhD thesis made front-page news in 1980 by overturning the guidelines of the time. It showed that annual chest X-rays and yearly Pap smears for women at low risk of cervical cancer were a waste of resources. It won him the most prestigious award in the field of operations research. Based on his results, the American Cancer Society changed its guidelines. Eddy ferreted out decades of research evaluating treatment of glaucoma. He found about a dozen studies that looked at outcomes with pressure-lowering medications used on millions of people. The studies actually suggested that the 100-year-old treatment was harmful, causing more cases of blindness, not fewer.
He showed that a man with enlarged prostate after surgery might be able to pass urine normally ranging from 0%-100%--the biggest guess ever! Eddy showed that bone marrow transplant for breast cancer did not work. When clinical trials were actually done, they showed that the treatment, costing from $50,000 to $150,000, didn't work. Is medicine doing any better today? In recognizing the problem, yes. But in solving it, unfortunately, no, he said. Doctors now routinely test for levels of prostate-specific antigen (PSA) to try to diagnose the disease. But there's no evidence that using the test improves survival. Then, once cancer is spotted, there's no way to know who needs treatment and who doesn't. Plus, there is a plethora of treatment choices -- four kinds of surgery, various types of implantable radioactive seeds, and competing external radiation regimens, notes Dr. Eric Klein, and head of urologic oncology at the Cleveland Clinic.
Vested Interests work in the area:
"Because there are no definitive answers, you are at the whim of where you are and who you talk to," says Dr. Gary M. Kirsh at the Urology Group in Cincinnati. Kirsh does many brachytherapies -- implanting radioactive seeds. But "if you drive one and a half hours down the road to Indianapolis, there is almost no brachytherapy," he says. Head to Loma Linda, Calif., where the first proton-beam therapy machine was installed, in 1990, and the rates of proton-beam treatment are far higher than in most other parts of the country. Go to a surgeon, and he'll probably recommend surgery. Go to a radiologist, and the chances are high of getting radiation instead. "Doctors often assume that they know what a patient wants, leading them to recommend the treatment they know best," says Dr. David E. Wennberg, president of Health Dialog Analytic Solutions.
"More troubling, many doctors hold not just a professional interest in which treatment to offer, but a financial one as well." "There is no question that the economic interests of the physician enter into the decision," says Kirsh. The bottom line: The conventional wisdom in prostate cancer -- that surgery is the gold standard and the best chance for a cure -- is unsustainable. Strangely enough, however, the choice may not matter very much. "There really isn't good evidence to suggest that one treatment is better than another," says Klein.
"When there is more than one medical option, people mistakenly think that the more aggressive procedure is the best," says Annette M. Cormier O'Connor, senior scientist in clinical epidemiology at the Ottawa Health Research Institute. The message flies in the face of America's infatuation with the latest advances. "As a nation, we always want the best, the most recent technology," explains Dr. Joe Thompson, health adviser to Arkansas Governor Mike Huckabee. "We spend a huge amount developing it, and we get a big increase in supply." New radiation machines for cancer or operating rooms for heart surgery are profit centers for hospitals.
Is Heart Surgery Worth It?
Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill and author of The Last Well Person, is urging the U.S. medical Establishment to rethink its most basic precepts of cardiovascular care. Bypass surgery in particular, he says, "should have been relegated to the archives 15 years ago." Nevertheless, the data from clinical trials are clear: Except in a minority of patients with severe disease, bypass operations don't prolong life or prevent future heart attacks. Nor does angioplasty, in which narrowed vessels are expanded and then, typically, propped open with metal tubes called stents. "People often believe that having these procedures fixes the problem, as if a plumber came in and fixed the plumbing with a new piece of pipe," explains Dr. L. David Hillis, professor of cardiology at the University of Texas Southwestern Medical School. "But it fundamentally doesn't fix the problem."
"With doctors doing about 400,000 bypass surgeries and 1 million angioplasties a year in the US- part of a heart-surgery industry worth an estimated $100 billion a year -- the question of whether these operations are overused has enormous medical and economic implications." Fisher, professor of medicine at Dartmouth Medical School, first looked at regional differences in health-care spending in the U.S., he assumed that people in areas with lower expenditures would have worse health than people in regions where spending was 1 1/2 to 2 times as high because they were failing to receive needed care. It turned out that the opposite was true. "Patients have a substantial increased risk of death if cared for in the high-cost systems," he says. Why? For one thing, additional doctor visits and testing often lead to unnecessary procedures and hospitalizations, which carry risks. "My data suggest that we are wasting 30% of health-care spending on stuff with no benefit and perhaps causing harm," says Fisher.
Once a hospital installs a shiny new catheter lab, it has a powerful incentive to refer more patients for the procedure. It's a classic case of increased supply driving demand, instead of the other way around. "Combine that with Americans' demand to be treated immediately, and it is a cauldron for overuse and inappropriate use," says Thompson. U.S. patients and insurers will spend $3.4 billion this year on drug-coated stents from suppliers Boston Scientific Corp. and Johnson & Johnson according to Citigroup. At many hospitals, cardiac units have become major profit centers. "We've shown that it is a lucrative area for hospitals," says Paul B. Ginsburg, president of the Center for Studying Health System Change. But are heart procedures always the best path for patients who currently get them? The answer today is an emphatic NO.
"The latest thinking on heart attacks may explain why not. In the traditional view, the slow accumulation of plaque inside arteries gradually narrows the vessels. Reduced blood flow causes chest pain, or angina. Eventually the arteries are blocked, bringing on heart attacks. Newer evidence, however, pins the blame not on this gradual narrowing but on unstable plaque that breaks off and causes clots. The clots are what obstruct the arteries, causing the heart attacks -- which is why so many such events are unexpected and why there is no evidence that opening chronically narrowed arteries reduces the risk of heart attack," Harvard Medical School associate professor of medicine Dr. Roger J. Laham reported on follow-up results of a randomized trial looking at laser surgery to improve blood flow. Patients who got the surgery had significantly less pain and improved heart function. But so did patients who had a sham operation -- the equivalent of a placebo. After 30 months the placebo effect was still there. Scans and other tests showed physiological gains in blood flow among only those who thought they had been operated on. This is where the patient’s mind works better than the procedure. A similar large placebo effect might explain "most of the benefits that we've seen so far with balloon angioplasty and bypass surgery," Laham says.
"What worries some doctors is that people getting the new stents might have a higher risk of clots, which then could cause heart attacks more than a month after the procedure. "Out of 100 patients who get a drug-coated stent vs. a bare-metal stent, maybe 10 will avoid a repeat procedure," says Dr. Eric J. Topol, chief of cardiology at the Cleveland Clinic Foundation. "But how many will wind up with a heart attack or death? Maybe one in 1,000? We just don't have that nailed down yet." "There is a massive amount of spending on things that really don't help patients, and even put them at greater risk. Everyone that's informed on the topic knows that too many common conditions are viewed as diseases needing treatment, and too many treatments of uncertain benefit are used too often. "What Hadler does is question the soundness of that thinking in a very profound way," says Dr. Glenn D. Pomerantz, senior vice-president for global innovation at Cigna. Hadler hopes that enlightening people about the limitations of medicine will help them worry less and stay well longer. In the end, few doctors will object to the basic prescription: Avoid drastic procedures that probably won't help and might actually do harm.
That is not the whole story about the delusions in medicine. I have extensively quoted from the Business Week to show the reader their side of the story. All these are good but the last word has not yet been written. The sentence that says that enlightening people about the limitations of medicine will help them worry less and stay well longer says it all. In Eddy’s computer model ARCHIMEDES also the most important component of the human being is not taken into consideration-the human consciousness. Time evolution in the human body depends on the total initial state. The large part of that initial state is the mind or consciousness. Just as Charaka wrote that it is more important to know the patient than the disease to manage any illness, which was verbatim quoted by Hippocrates in his Treatise, only Ayurveda has all the three components of the human system-- the phenotype, genotype and consciousness-- looked into in their classification of major genetico-constitutional types of vaata, pitta and kapha with their sub types. The holistic science of chaos and fractals goes well with the holism of Ayurveda. In the west now there is a push towards a new science called Systems Biology- a computer model that adds time, space to the existing reductionist model of biology. I feel that also is not a complete answer to the human problems. Let us continue our search to integrate the best in emergency management in modern medicine with other 90% of chronic illnesses managed with the help of the best in many complementary systems. Readers who have been keeping in touch with my views in the last 45 years would certify that all the above information had been given out by me years ago. Long live mankind on this planet!