All Things Flow, Nothing Abides

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. 

From heart surgery to prostate care, the medical industry knows little about which common treatments really work. The signs are not very encouraging. David Eddy, a former professor of cardiovascular surgery at the Stanford, who left his job and got his PhD in mathematics from Duke’s university, has been struggling to get to the bottom of this uncertainty, without much success though. He has developed a computer model “Archimedes” that has given him an insight into our failings in this field. No body seemed to bother about my pleadings in the last forty years that doctors have been barking up the wrong tree and were taking patients up the garden path to the mirage of omnipotent treatment strategies. David’s strategy using complicated computer models which common doctors don’t understand seems to have woken up this slumbering dinosaur, the medical profession, at least in the west to a certain extent.

With a groundbreaking computer simulation, Eddy showed that the conventional approach to treating diabetes, cholesterol, high blood pressure etc. did little to prevent the heart attacks and strokes that are the predicted complications. The same thing probably holds good in the field of hypertension in an asymptomatic individual. Eddy calculated that simple generic drugs to lower blood pressure with simple aspirin could send the rate of complications plunging down. He felt that if we doctors don’t pay heed, we might have to close shop soon. Eddy’s first half is very scientific and true but the second half is based on future predictions that never could come true in a dynamic human system as shown below. The message seems to be filtering through in the US. Kaiser Permanente, the largest HMO in the US, is trying to follow Eddy’s advice in a million patients.

Where has Eddy gone wrong so far?  Not in correcting the past but in predicting the future. For Eddy, this is one small step toward solving the thorniest riddle in medicine — a dark secret he has spent his career exposing. “The problem is that we don’t know what we are doing,” he says. Even today, with a high-tech medical-care system that costs the nation $2 trillion a year (in the US alone), there is little or no evidence that many widely used treatments and procedures actually work better than various cheaper alternatives,” feels David. This judgment pertains to a shocking number of conditions or diseases, from cardiovascular woes to back pain to prostate cancer. During his long and controversial career proving that the practice of medicine is more guesswork than science, Eddy has repeatedly punctured cherished physician myths. He showed, for instance, that the annual chest X-ray screening 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.

A great many doctors and medical care quality experts have come to endorse Eddy’s views. While there has been progress in recent years, we are still to know more than 80% of what we practice is only a myth. Clearly, there is a lot in medicine we don’t have definitive answers to. My recent book, What Doctors don’t get to study in the Medical School, deals with all these and much more. This book had very a few good reviews abroad and in some Indian quarters. Following a really damning review in one of India’s “top” medical journals, all the copies were sold in just one month necessitating two reprints in four months. This book was recently released in London by the former editor of the British Medical Journal, Richard Smith, who said that this is not a textbook but a “Holy Text” of medicine. The book has been well received both in the UK and the USA with a British publisher coming forward to publish it in the west.

David Eddy feels that the limitation is the human mind. Without extensive information on the outcomes of treatments, it’s fiendishly difficult to know the best approach for care. The human brain, Eddy explains, needs help to make sense of patients who have combinations of diseases, and of the complex probabilities involved in each. To provide that assistance, Eddy has spent the past 10 years leading a team to develop the computer model that helped him crack the diabetes puzzle. Dubbed 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.

Eddy in the medical school soon became troubled. He began to ask if there was actual evidence to support what doctors were doing. The answer, he was surprised to hear, was no. This was referred to in the British Medical Journal in 1983. Doctors decided whether or not to put a patient in intensive care or use a combination of drugs based on their best judgment and on rules and traditions handed down over the years, as opposed to real scientific proof. These rules and judgments weren’t necessarily right. He concluded that medicine was making decisions with an entirely different method from what we would call rational. Dr. William H. Herman, director of the Michigan Diabetes Research & Training Center, has a competing computer model that clashes with Eddy’s. Nonetheless, he says, “Dr. Eddy is one of my heroes. He’s sort of the father of health economics — and he might be right.”  The predictions of success invariably ranged from 0% to 100%, with no clear pattern. “All the doctors were trying to estimate the same thing — and they all gave different numbers,” he says. “I’ve spent 25 years proving that what we lovingly call clinical judgment is woefully outmatched by the complexities of medicine. Go to one doctor, and get one answer. Go to another, and get a different one. Or think about expert testimony. You don’t have to hire an expert to lie. You can just find one who truly believes the number you want, adds Eddy.
Medicine is doing somewhat better in recognizing the problem, but in solving it, unfortunately, no.  Doctors now routinely test for levels of prostate-specific antigen (PSA) to try to diagnose prostate cancer. But there’s no evidence that using the test improves survival. Some experts believe that as many cancers would be detected through random biopsies. 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. How is a poor patient supposed to decide among those? Most of the time, patients don’t even know the options.

Because there are no definitive answers, you are at the whim of where you are and who you talk to. Take cancer for example. If you 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. It is really troubling to know that many doctors hold not just a professional interest in which treatment to offer, but a financial one as well.  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 is no evidence to suggest that one treatment is better than another.

As a proud people, westerners always want the best, the most recent technology. We, in India, ape them anyway, thanks to Centuries of dominance. They 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, for instance. 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.  The US spends 2 1/2 times as much as any other country per person on medical care. Yet middle-aged Americans are in far worse health than their British counterparts, who spend less than half as much and practice less intensive medicine, according to a new study. The investment in health care in the U.S. is just not paying off. Recent audits have shown the US to be last but one in the ranking of fourteen industrialized countries! The head of health care at one of America’s largest corporations puts it more bluntly: “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 it, but it is such a scary thing to discuss that people are not willing to talk about it openly.”

Of course, there are areas of medicine, from antibiotics and vaccines to early detection of certain tumors, where the benefits are certain to a great extent, although some of them are questionable with newer evidence. The antibiotic resistance is a time bomb which could burst any moment. A lot of things we absolutely believe at the moment based on our intuition are ultimately absolutely wrong. Large randomized studies did not deliver the goods as expected because we have been treating the human body as bio-medical electromechanical machine like a car engine. Human body is much more complicated and follows totally different rules of the game. We need to think afresh. So it’s no surprise that up to one-third of clinical studies lead to conclusions that are later overturned, according to a recent paper in JAMA. Even when common treatments are proved to be dubious, physicians don’t rush to change their practice. They may still firmly believe in the treatment — or in the money it brings in. With proof about medical outcomes lacking, one possible solution is educating patients about the uncertainties. “The popular version of evidence-based medicine is about proving things,” “but it is really about transparency — being clear about what we know and don’t know. I wrote the following letter to the editor in the BMJ this week.

Medical science, or for that matter, any other science, can never be certain of the future unless the total knowledge of the initial state of the organism is known. In this particular case, where the sub-arachnoid haemorrhage must have been very severe, there is no way the doctors in charge could have predicted a happy outcome, although it is certainly possible to have such happy ending to the sordid drama. These are exceptions which go to prove the rule. Doctors have been predicting the unpredictable all through. Human body has two attractors, the chaotic dynamic attractor called health and the static attractor called death, in phase space. Disease is a state where the patient falls outside the healthy chaotic attractor. In the majority of situations s/he gets attracted back to the “healthy chaos”. Rarely, though, s/he can never ever be brought back to the healthy attractor despite all the hi-tech stuff that we boast of!

I can visualise the misunderstanding in the minds of the lay people, who have been brought up to believe that we doctors are omnipotent in the face of serious illnesses, but it is surprising that the medical profession is not aware of our inability to predict the future of the human organism under any circumstance with certainty. Uncertainty is the only certainty in human health and disease.  If one has been in practice for a considerable time, one would have noticed that even in trivial illnesses, where one could be sure of a positive outcome, the patient surprisingly could even meet his maker! Isaac Newton’s laws of deterministic predictability do tell us that to predict the future of the Universe one should know the position of each and every single particle in this world, which is impossible. Weather predictions rarely come true, necessitating Edward Lawrence to propose the new hypothesis of the “butterfly effect”.

Even with the help of the gamma ray microscope one finds it impossible to say what happens to a particular electron after one stops looking at it. One does not even know what the electron does when one is not looking at it! Erwin Schr?dinger’s cat hypothesis is a good proof of the above truth. The human body is much more complex than all those, especially under disease conditions. Let us educate the public that doctors are not capable of predicting the future in any disease set up and, therefore, doctors should have faith and hope even in the most desperate situations. If this is understood then the question of lawyers coming into the picture does not arise. Empathetic transparent communication and good record keeping are the best insurance against malpractice suits.

Author: Dr. B. M. Hegde- India