{"id":58787,"date":"2015-08-05T22:29:44","date_gmt":"2015-08-06T02:29:44","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=58787"},"modified":"2015-08-06T00:06:41","modified_gmt":"2015-08-06T04:06:41","slug":"mysteries","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/08\/05\/mysteries\/","title":{"rendered":"mysteries…"},"content":{"rendered":"\n

I’ve always liked a good mystery. Nancy Drew<\/em> was my favorite book·mobile selection, until I discovered The Complete Sherlock Holmes<\/em> [my parents finally bought it for me because I would”t return it to the library]. Math problems were like mysteries to me – looking for the hidden answer. Little wonder I was a medical researcher who ended up a psychoanalyst. My own analyst had a field day with all of this – what secrets was I in search of? I learned some interesting things about that, but there was no cure. I still scroll the Netflix roster periodically for some new British Mystery series [before re·watching either the British or Swedish Wallander]. And it’s little wonder I ended up in medical research, then migrated to psychoanalysis.<\/p>\n

In former times, Internists were called Diagnosticians<\/em>, unraveling those who·dun·it<\/em> cases that make it to the T.V. shows like House<\/em>. But by the time I came along, those cases went to specialists, and office practice began to focus on health care management and preventive medicine, sending the mysteries<\/em> on to the higher ups. And even the specialists see the same mysteries repeatedly. I still spend a week every summer with a group of doctors I worked with as an Internist forty years ago. In an oft-told story, one night, one of the guys [Gastroenterologist] and I were reminiscing, and he said, "You know, nowadays when I see a new case, I know in minutes what they’ve got and what’s going to happen. I still ask all the questions, do all the tests, but I’m rarely wrong." His music was mastery<\/font><\/em>. I said, "I never know for a very long time." My music was mystery<\/font><\/em>. <\/p>\n

So there was one part of the evolved role of the General Internist I was assigned to be in a three year tour in the Air Force that I didn’t much like – the focus of health maintenance and preventive medicine. It’s not that I didn’t think it was a good idea for doctors to talk about smoking, obesity, even the perils of being a couch potato. It’s not even that I found it boring, which it was. It was something where I felt like I was treating "proxies" or "surrogates" that I couldn’t really evaluate myself. What I’m talking about are things like how tightly to regulate glucose control in Diabetes; what level of Blood Pressure elevation constituted Hypertension requiring treatment; what was a High Cholesterol level in need of dietary adjustment or medication; when is alcohol consumption something to talk about; and so on and so on. Those may have been mysteries, but I couldn’t solve them. The literature was long on conclusions and short on solid data. A lot of it felt like the opinions of armchair scientists, and didn’t give me much conviction in my dealings with patients – particularly treating hypertension. I just didn’t like treating lab values and physical findings like Blood Pressure. I felt more at home with whole diseases.<\/p>\n

Flash forward: In the waning days of my academic career, our new chairman, a disciple of the neoKraepelinian changes in psychiatry, and I had a recurrent discussion. He was a devotee of evidence-based medicine in psychiatry, the beginning search for biomarkers, and the brain science approach that has flowered since those salad days. I claimed that psychiatry was the repository of ambiguity in medicine, each case being its own unique mystery, and things that got "cleared up" would leave psychiatry and become part of general medicine like Syphilis when Penicillin arrived. These were good·hearted discussions, though they became the substrate for my ultimate exodus to the world of practice. And because I had left Internal Medicine, I never made my peace with my questions about treating these surrogates·of·future·health<\/font><\/em>. So some of what goes on in modern medicine brings up those old questions about preventive treatment.<\/p>\n

In the 70s, the congenital hyperlipidemias had just become characterized, and there was no question that they needed treating. These patients had heart attacks and strokes starting in their thirties unless you did something. But what about mild elevations of serum lipids without those underlying diseases? Nowadays, it’s an obsession. I live in an elderly community where everyone is on a Statin, and can wax eloquent on their lab values. I declined the offer when my perfectly normal values exceeded the newer recommendations. So I guess I’m not a believer after all. I wonder what I would do if I had an asymptomatic positive Hepatitis C lab test in my hand. Would I spring for a $90,000 Solvadi®<\/font> treatment, or leave that money in the bank for my kids’ futures? And I thought about that reading Roy Poses’ really interesting post on Healthcare Renewal<\/font> about the new "breakthrough" cholesterol lowering treatment, Praluent®<\/font>, that costs over $1000\/month [see Praluent, the Next Expensive "Game Changer," Blockbuster," "New Hope," – But Not Yet Shown to Benefit Patients<\/a>]. After a detailed vetting of the Clinical Trials, Dr. Poses concludes with:<\/div>\n
\n
All the enthusiasm about this drug may be premature, and does not appear to be evidence-based.  That clinical research sponsored by organizations that sell health care goods and services may be manipulated to make the sponsors’ products look better than they really are is now an old story.  We have seen multiple instances in which drugs and devices turned out to be less efficacious and\/or more dangerous than originally advertised.  Excess enthusiasm about such new innovations may drive up costs, and worse, hurt patients.  Physicians, other health care professionals, and those concerned about health policy ought to be much more skeptical about every new instance of a purportedly wondrous innovation.  <\/p>\n

Evidence-based medicine rigorously applied suggests that individual health care and health policy decisions should be driven by the best available evidence, mostly from clinical research, about the benefits and harms of tests, treatments, programs, and so on, in the context of what outcomes matter to patients.  The skepticism EBM should engender could lead to health care that is more about patients and their outcomes, and less about ideology, hype, and hucksterism.<\/p>\n

How high must our health care costs go, and how many unproven treatments must eventually be exposed as such before we learn that lesson?<\/p><\/div>\n<\/blockquote>\n

Sounds good to me. In the face of many medical mysteries, premature closure is the greatest danger of all. We even have a name for it. We call it Watchful Waiting<\/font><\/em>. Hercule Poirot is at his best when he remains vexed and doesn’t jump to conclusions…<\/div>\n
<\/div>\n","protected":false},"excerpt":{"rendered":"

I’ve always liked a good mystery. Nancy Drew was my favorite book·mobile selection, until I discovered The Complete Sherlock Holmes [my parents finally bought it for me because I would”t return it to the library]. Math problems were like mysteries to me – looking for the hidden answer. Little wonder I was a medical researcher […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-58787","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58787","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=58787"}],"version-history":[{"count":7,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58787\/revisions"}],"predecessor-version":[{"id":58794,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58787\/revisions\/58794"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=58787"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=58787"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=58787"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}