kindness, empathy, and medical outcomes -- 12/1/21
Today's selection -- from The Body by Bill Bryson. The effect of kindness and empathy on medical treatment:
"Nothing in medicine is simple, however, and there is an additional consideration that profoundly complicates results almost everywhere: overtreatment
"It hardly needs pointing out that for most of history the focus of medicine has been to make sick people better, but now increasingly doctors devote their energies to trying to head off problems before they even arise, through programs of screening and the like, and that changes the dynamics of care entirely. There is an old joke in medicine that seems especially apt here:
Q. What is the definition of a well person?
A. Someone who hasn't been examined yet
"The thinking behind a great deal of modern health care is that you cannot be too careful and you cannot have too many tests. Surely it is better, the logic runs, to check out and deal with or eliminate any potential problems, however remote, before they have a chance to turn into something bad. The drawback with this approach is what are known as false positives. Consider screening for breast cancer. Studies show that between 20 and 30 percent of women given the all clear after a breast cancer screening actually had tumors. But equally, and contrarily, screenings often catch tumors that needn't cause concern, and result in interventions that aren't actually necessary. ...
"We have reached the decidedly bizarre point in health care in which pharmaceutical companies are producing drugs that do exactly what they are designed to do but without necessarily doing any good. A case in point is the drug atenolol, a beta-blocker designed to lower blood pressure, which has been widely prescribed since 1976. A study in 2004, involving a total of twenty-four thousand patients, found that atenolol did indeed reduce blood pressure but did not reduce heart attacks or fatalities compared with giving no treatment at all. People on atenolol expired at the same rate as everyone else, but as one observer put it 'they just had better blood-pressure numbers when they died.'
"Drug companies have not always behaved in the most ethical of ways. Purdue Pharma paid $600 million in fines and penalties in 2007 for marketing the opioid OxyContin with fraudulent claims. Merck paid $950 million in fines for failing to disclose problems with its anti-inflammatory drug Vioxx, which was withdrawn from sale, but not before it had caused perhaps as many as 140,000 avoidable heart attacks. GlaxoSmithKline currently owns the record for a penalty $3 billion for a raft of transgressions. But to quote Marcia Angell again, 'These kinds of fines are just the cost of doing business.' For the most part they come nowhere near offsetting the huge profits made by the errant companies before they are hauled into court.
"Even in the best and most diligent circumstances, drug development is an inherently hit-or-miss undertaking. Laws almost everywhere require researchers to test drugs on animals before they try them out on humans, but animals don't necessarily make good surrogates. They have different metabolisms, respond differently to stimuli, contract different diseases. As a tuberculosis researcher observed years ago, 'Mice don't cough.' The point was frustratingly well illustrated on tests of drugs to fight Alzheimer's. Because mice don't get Alzheimer's naturally, they must be genetically engineered to accumulate in their brains a specific protein, beta-amyloid, associated with Alzheimer's in humans. When such doctored mice were treated with a class of drugs called BACE inhibitors, their beta-amyloid accumulations melted away, much to the excitement of researchers. But when the same drugs were tried on humans, they actually worsened the dementia in test subjects. In late 2018, three companies announced they were abandoning clinical trials of BACE inhibitors.
"Another problem of clinical trials is that test subjects are nearly always excluded if they have any other medical conditions or are on other medications because those considerations could complicate results. The idea is to get rid of what are known as confounding variables. The problem is that real life is full of confounding variables even if drug tests are not. ...
"All drugs come with a mixture of benefits and risks, and these are often not well studied. Everyone has heard that taking a low-dose aspirin daily may help prevent a heart attack. That is true, but only up to a point. According to one study of people who had taken low-dose aspirin daily for five years, 1 in 1,667 had been spared a cardiovascular problem, 1 in 2,002 had been spared a nonfatal heart attack, and 1 in 3,000 spared a nonfatal stroke, while 1 in 3,333 suffered major gastrointestinal bleeding that they would not otherwise have experienced. So for most people there is about as much chance of suffering dangerous internal bleeding from taking a daily aspirin as there is of avoiding a heart attack or stroke, but in all cases actually there is very little risk of either.
"In the summer of 2018, matters became even more confused when Peter Rothwell, professor of clinical neurology at Oxford University, and colleagues found that low-dose aspirin actually is not effective at all in reducing cardiac or cancer risk in anyone weighing 154 pounds or more -- but does still pose a risk of serious internal bleeding. Because about 80 percent of men and 50 percent of women exceed that threshold, it appears that a lot of people are getting no possible benefit from a daily aspirin while preserving all the risk. Rothwell suggested that people over 154 pounds should double the dose, perhaps by taking the pills twice a day rather than once, but that was really only an educated guess.
"[I]t is an inescapable fact that [modern medicine] is far from perfect and in ways that aren't always widely appreciated. In 2013, an international team of researchers investigated common medical practices and found 146 in which 'a current standard practice either had no benefit at all or was inferior to the practice it replaced.' A similar study in Australia found 156 common medical practices 'that are probably unsafe or ineffective.'
"The simple fact is that medical science alone cannot do it all -- but then it doesn't need to. Other factors can significantly affect outcomes, sometimes in surprising ways. Just being kind, for instance. A study in New Zealand of diabetic patients in 2016 found that the proportion suffering severe complications was 40 percent lower among patients treated by doctors rated high for compassion. As one observer put it, that is 'comparable to the benefits seen with the most intensive medical therapy for diabetes.'
"In short, everyday attributes like empathy and common sense can be just as important as the most technologically sophisticated equipment."