Flutterby™! : evidence based medicine 2006-05-23 00:02:03.199079+00

evidence based medicine

2006-05-23 00:02:03.199079+00 by Dan Lyke 8 comments

In some of the literature I was digging through for information on training, now that I'm diving into this bicycling thing slightly obsessively, I ran across a couple of references that fructose was a precursor to blood triglicerides that became low-density lipoproteins (one such article in Science Daily, PubMed if you want to dig deeper) that led to... well... all the issues we normally associate with [gasp] "high cholesterol". In fact, in my amateur poking around, it looked to me like the usually fingered culprits, saturated fats, had little or nothing to do with the stuff that causes such problems, which lead to various indications that claims about the "glycemic index" of sugars probably lead to some almost exactly backwards decisions related to diabetes as well.

I've also had some experience with people playing with SSRIs (Flutterby mentions here and here, at least), and the results of those have indicated to me that for the most part such treatments are a matter of "hey, try this, see if it works".

So when people wonder at the rise of alternative medicine and the various health related scams (and boy I've seen some doozies), well... The reality is that a good portion of the medical establishment seems to be pretty darned full of hooey, and doing things that, while they may lead to higher profits, appear to be counterproductive for patients.

Yeah, I'm underinformed and taking easy shots, but the point is... it looks like most doctors are too: Business Week looks at Dr. David Eddy and his push for "evidence based medicine"

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 dollars it brings in. And doctors whose oxen get gored sometimes fight back. In 1993, the federal government's Agency for Health Care Policy & Research convened a panel to develop guidelines for back surgery. Fearing that the recommendations would cast doubt on what the doctors were doing, a prominent back surgeon protested to Congress, and lawmakers slashed funding for the agency.

Well, yeah, and before the "Food Pyramid" we had the "Four Food ~~Lobbies~~Groups".

Oh, and an article on the politicization of the health effects of kimchee.

#Comment Re: made: 2006-05-23 00:40:17.072532+00 by: meuon [edit history]

I also like the idea of: Evidence based religion and evidence based ________. Well, just about everything.

#Comment Re: Science Daily Article made: 2006-05-23 02:32:18.437955+00 by: m

I can not speak to the actual veracity of the "High Blood Triglycerides Are Independent Risk Factor For Stroke" pub 2001, but I did some work in the late '70s on comparing the then accepted lipoprotein analytic techniques of ultracentrifugation vs electrophoresis. Elevated stroke risks have been long expected for individuals who exhibited high levels of Triglycerides.

I have seen a number of errors in Science Daily. These are extracts from a variety of sources, and are not a completely reliable. Another statement in the brief that was clearly wrong was "Triglyceride levels are measured by a standard cholesterol blood test." I can guarantee that triglycerides are measured by a triglyceride test, not a standard cholesterol test.

As far as glycemic indexs go, its been a long time since I have had any involvement with this. But glycemic indexs are often counter-intuitive, and must be measured separately. For example, bread alone has a lower glycemic index than bread eaten with cheese. The opposite would be expected. What would happen if olives were added to that mix? Pimentos? Basil?

But, for all of the intricacies of diet, metabolic defects and the complex sequels of diabetes, most diabetics who follow their physician's regimen live a fairly normal life. This is an incredible achievement in the less than 90 years after Banting and Best discovered insulin. Is it perfect? Obviously not. But it is well understood enough to dramatically improve the quality and length of life of those afflicted with this disease. Diabetes has been known since antiquity, when tests for urine sugars were done by tasting.

Another word of caution. Individual papers can be interesting. But recent studies have indicated that more than half of all published papers in medicine are simply wrong (of course, these info reliability studies are probably wrong too). There are many reasons for this, and it is not necessarily because the people conducting the work are incompetent (though that may be a factor at times). The studies are complex, and subject to a wide variety of conflating issues that cloud results and causes. It often takes many, often conflicting, studies to come to a true understanding. Yes! Read. Learn. Knowledge is wonderful. But don't take what you learn too seriously. It is the achievement of many to integrate the knowledge into something truly useful.

Hell, if medicine was simple, then anybody could do it. You pay your Doctor, not for his ability to read a paper, but for his ability to evaluate it, and integrate it into his total knowledge. And no, I am not an MD, and generally am not particularly fond or trusting of them as a group.

In the far simpler issues of lab tests, I once published a brief paper on a minor improvement to a cholesterol test. Of the hundred or so labs from Japan to Israel that corresponded with me, half were able to reproduce my improved results. The other half couldn't. It would have been nice to further determine the cause for that difference, but fate took me elsewhere.

I don't think you pay a doctor for his ability, but rather his liability... MDs do what they do because it's what's least-likely to get them sued. They can practice because they've jumped through the requisite hoops to do so without getting sued just for saying "take two aspirin and call me in the morning".

For the best possible tests - listen to your own body. Chances are it works differently than most others anyhow. And knowing Dan, there's a high likelihood that his body puts him in the "outlier" range in most clinical tests.

Disclaimer: I'm involved with a CDH/evidence based medicine initiatives in Texas.

Once of the things that interesting about some of the new consumer directed healthcare initiatives is that they're deeply grounded in evidence based medicine and standardized reporting. So far, CDH products have been very successful and CDH participants consume a lot more healthcare services. As a result, there's some great efficacy and side effect data available for the first time for various treatments across a much larger population over a (potentially) much longer time frame. It's really fascinating stuff.

#Comment Re: made: 2006-05-23 09:42:57.442035+00 by: topspin [edit history]

So far, CDH products have been very successful and CDH participants consume a lot more healthcare services.

I tend to equate "success" and "consume a lot more healthcare services" as polar opposites. True, healthcare services could mean lifestyle changing programs, but it more often means meds, scans, procedures, etc.

As a healthcare worker I've tried to maintain the idea that NOT seeing my patients as often is a measure of the success of the services I offer. It's easy, in this culture, to view intense relationships with patients as vital and certainly there's good reason for closely monitoring some conditions and regular exams/screenings will detect underlying issues for treatment. However, and perhaps I'm merely cynical, the people devising and marketing CBH can't be entirely altruistic and blind to the fact "CDH participants consume a lot more healthcare services" and that increased consumption is lucrative for the industry.

Healthcare is huge business and it markets itself like any other business to increase revenue. In the past several years, Madison Avenue has gotten bolder and bolder with the "Ask your Doctor if <insert latest and greatest new drug> is right for you" campaigns. The marketing on the white coat side has shifted to "We're going to be promoting this heavily to the public and you need to be ready" as much as or more than it is about whatever gains may be acheived by new meds.

It's easy to envision good things resulting from consumers helping direct their healthcare and getting more involved in their health, but we need to realize that no matter what decent medical info we provide, the "dark side" of the healthcare industry will ALSO assure the consumers receive powerful "medical evidence" during American Idol commercials from the same people who convince them they need a new car every 4 years, a new plasma tv when their old tv is fine, etc.

Actually, what I mean is that the data says that CDH consumers access preventive care and disease management services more, which is definently a good thing.

There's a study kicking around somewhere that makes the connection between CDH and real personal health management. I'll try and dig it up.

m, all good points, and I didn't back up the "fructose causes your LDL to go up" as well as I felt it last time I was poking through the literature, but the rest of your points I think support my general feeling: I've got friends on Lipitor and the like who are (if they're not just saying "the drug will take care of it for me") cutting back on butter but not on the high fructose corn syrup.

Here in Marin I've seen an awful lot of the MLM supplements and alternative medicine market, and part of me says "how can people fall for that", but the other part looks to the evidence for many of the recommendations of traditional medicine and says "well, both sets of claims are about as plausible".

One of the reasons I wasn't surprised to see that Kaiser Permanente was mentioned in the same breath as David Eddy is that they've got a really tight feedback loop between what the doctors recommend and what it costs 'em. And I think this is the advantage of something that's set up as "health maintenance" rather than insurance. I've been really pleased (like, even more than when I had Pixar's amazingly comprehensive covers everything with almost no out of pocket insurance) with the service I've gotten through them.

And Topspin makes the good point that it's tough to be both an informed consumer who can effectively second-guess a doctor, and yet be immune to the "ask your doctor about" syndrome. You can know more about health maintenance than your doctor, and yet the need for that research leads to a lot of ignorant consumers.

I know my answer to this problem. I have run across some really lousy Mds on both professional and personal levels. I even got taken in by a cardiologist who convinced me that I had a silent cardiac event. It seemed to be backed up by a variety of exams until I ended up on the wrong side of the table in a catherization lab. I got the reports, I looked at the EKG, which did have some questionable abnormalities, the thallium stress test was abnormal. I checked this guy out through physicians I had a personal relationship with and trusted. Still, I got taken. I would have ascribed to a modern day Ulysses syndrome, but then I found out the cardiologist had a history of gross over diagnosis.

I have seen some truly fine Mds badly screw up their own medical choices. Including one who I had worked with for 30 years, and whose husband was the head of medicine at one of the larger university hospitals in the country.

Like just about everything else in life, you can do the research, you can wrestle with it, make your best guess, and then take your chances. You may or may not do better than if you had thrown a dart at a list of all possible regimens. It doesn't matter whether its picking a college, selecting a job, mate, house or investments. You make your choice on the basis of what you personally, intellectually and emotionally can. Be it chance, intensive selection, or something different.

But for most, some level of autonomy in the decision process is needed. I have rules about how I make serious decisions. I follow them as best I can. While I may go back and critique a decision for learning purposes, I try not to wallow in the failures. I can't guarantee the correctness of any decision I make, only that I have gone about making it in a way that I am comfortable with.