Alternative Medical Facts
In today’s post-truth world, opinion carries more weight than evidence, and you can choose your facts to fit your beliefs. But medicine is one area where objective truth informs every decision. In fact Evidence Based Medicine has become an article of faith for doctors around the world. Right?
Well, yes and no. In medicine, as in politics, there are no truths universally acknowledged. The fact that you can get a second opinion on any diagnosis proves that there is room for interpretation. There are variations between doctors, divergence between professional bodies, and differences between healthcare systems, skewed by local traditions and economics.
But the direction of travel is towards consensus and universal agreement on best practice. Organisations like NICE and the Cochrane Collaboration put interventions to the test of systematic review and meta-analysis, to see whether they are truly effective.
All of this striving for objectivity ought to result in a streamlined approach and ultimately, improved medical outcomes. However, there is a large gap between theory and medical practice, highlighted in a recent article in The Atlantic magazine. The article described a range of widely-used medical interventions in the USA that are either unnecessary or positively harmful, according to the latest evidence.
These include the use of coronary stents in stable angina patients, which don’t prevent MI or improve survival but carry a risk of complications or death. Similarly, antihypertensive agents such as atenolol are widely prescribed even though they don’t significantly reduce heart attacks or deaths; patients just have better measurements when they die. Yet they remain the standard of care, despite being contradicted by better evidence.
Why do doctors persist with practices that are unproven? There may of course be financial incentives for carrying out unnecessary procedures, as well as a desire to reduce patient anxiety or the risk of a lawsuit. Patient pressure is a big factor, for example, in the use of antibiotics for conditions where they are known to be ineffective.
Doctors are subject to heuristics and biases, such as the ‘availability heuristic’, which favours evidence that comes easily to mind. To this we could add ‘confirmation bias’ (people are drawn to evidence that confirms their existing beliefs), and ‘anticipated regret’ (we are motivated to avoid the guilt that follows the failure to act). This is compounded by what The Atlantic article calls ‘bio-plausibility’: if there is an obvious problem such as a blocked vessel or raised blood pressure, it is intuitively logical to fix it, regardless of proof. So what passes for best practice may actually be personal belief hardened by habit.
Beyond these factors, one of the biggest barriers to the adoption of Evidence Based Medicine is that doctors simply don’t keep up with the science. A 2007 paper in JAMA found that it took 10 years for the medical community to abandon practices that had been shown to be ineffective.
Before blaming doctors, let’s consider the amount of information they have to absorb. Back in 2005, an audit of patients admitted to a hospital in a single day showed there were 3,679 pages of guidelines relevant to their care, which would take an estimated 122 hours to read. And as the reservoir of evidence builds, it takes even longer to trickle down to everyday practice. An article in the BMJ last year concluded that “the number of clinical guidelines is now both unmanageable and unfathomable.” Another article described Evidence Based Medicine as a movement in crisis. One of the chief concerns was that guidelines are disease-oriented and do not reflect the needs of individual patients, including their treatment goals and comorbidities.
The status of clinical evidence is also in jeopardy. The 21st Century Cures Act is set to lower the evidentiary standards required for new drugs and devices, and the Trump administration intends to further reduce FDA regulations to accelerate the uptake of new treatments.
But when Evidence Based Medicine is correctly implemented, it can produce big health improvements. Adoption of the BTS asthma guidelines, for instance, has led to reductions in morbidity and mortality. So what can be done to convert evidence into action?
We need to enlist patients in shared decision making. People are increasingly willing to challenge treatment choices, often armed with a second opinion from Dr Google. With better knowledge they can question whether their doctor’s recommendation is evidence based.
The pharmaceutical industry has been accused of herding prescribers towards specific brand choices that are not supported by evidence. Today, however, it is impossible to market a medicine without robust clinical proof. Every claim must be fact-based and code-compliant. We can therefore use our skills in simplifying complex data to bring doctors up to speed on the latest guidelines.
We should always place medicines in the context of best medical practice. Case studies can help to individualise treatment choices and ensure that new medicines go to the people they will benefit most. And if the treatments we promote are not compatible with the best current evidence, we should switch our marketing focus to alternatives that are.
The best antidote to fact-free medical decisions is a simple dose of truth.