Trust me, I’m a Doctor

Doctors are highly venerated in our society. Even their coats, shining white, conjure associations of health, cleanliness, and truth. But the coat, along with the sleek veneer of the hospital itself, is a mirage, obfuscating an unfortunate reality – that many times, a trip to the doctor’s office may do more harm than good.

Let’s start with the coats themselves. The loose white coats of doctors are sanctuaries for bacteria. Even worse, because these coats receive so much exposure to the various chemicals floating around a hospital, those bacteria are heavily resistant to drugs. But as symbolic as it would be for doctors to ditch the whites, the issues with the institution of medicine are not simply one layer deep; they stretch both through medical history and across medical disciplines

Medicine has long been an inexact science, riddled with remedies that were not simply ineffective, but actually deleterious. We can skip over the misguided therapies of the pre-industrial age, when leeching, bleeding, and shock therapy were fixtures on the therapeutic scene. But even in relatively modern times, there are several instances of frightening medical practices.

In 1935, Portuguese neurologist Antonio Egas Moniz performed the first ever lobotomy, sparking a decades-long trend during which the practice served as a popular “cure” for mental illness. But evidence against the procedure was mounting; Moniz won the Nobel Prize in medicine 1949, but in 1950, lobotomy was outlawed in the Soviet Union. Unfortunately, in other countries, including the U.S. where over 40,000 lobotomies were performed, the practice persisted for years longer.

In oncology, breast cancer was long treated by radical mastectomy, a procedure in which the breast, underlying chest muscle, and lymph nodes are all removed in an effort to excise every last remnant of a tumor, to prevent any possibility of relapse. Unfortunately, it didn’t work – the surgery led to no improvements in outcomes compared to more modest procedures. It did, however, leave patients horribly disfigured. Nevertheless, radical mastectomies were the default treatment for breast cancer for over a hundred years, until it was generally abandoned in 1975.

Perhaps most horrifying, though, are instances of drugs harboring dangerous, unknown side effects. Thalidomide was first commercialized in 1959 to treat many of the symptoms of morning sickness. It was widely hailed as a “wonder drug”, but was soon banned after it was linked to severe birth defects in the children of women taking the drug. Over 10,000 children were born with Thalidomide-related disabilities worldwide, with several of these children missing some or all of their limbs. In the 1990s, estrogen pills were recommended to postmenopausal women to lower risk of heart disease. It wasn’t until 2002 that a careful trial established that estrogen pills don’t decrease the risk of heart disease, and may in fact increase it. Darvon & Darvocet was a pain reliever that killed over 2000 people from 1981 to 1999. The list goes on, too lengthy to feature in full.

Of course, this shouldn’t be surprising, given the perverse alignment of incentives between the pharmaceutical and medical industries. Drug manufacturers frequently sponsor doctors, paying for them to fly out to conferences and to trial drugs, and this sponsorship predictably impact doctors’ behaviors. The correlation between the sponsorship doctors receive and the amount of related medications they prescribe suggests that the drug market is not entirely a meritocracy; patients are likely not being prescribed the drug that is most suited to their symptoms.

Pharmaceutical companies are also highly involved in the drug approvals process itself, often funding the studies that test a drug’s fitness for public use. These studies are far from unbiased: tests funded by pharmaceutical companies whose drugs are being tested, are much more likely to find those drugs safe and effective, even when controlling for study design. Furthermore, pharmaceutical companies often employ former FDA employees in a potentially dangerous relationship. The cumulative result is several drugs of low or no effectiveness being pushed into the market, and then pushed onto doctors to prescribe.

But pharmaceutical companies are not alone at fault; doctors must face some of the blame. Medical technology that can now detect smaller and smaller issues, along with the push toward early detection, is leading to unnecessary testing, financial and emotional stress in patients undergoing said testing, and even many cases of entirely unnecessary operations. But there’s another, more nefarious, force at play – conflicts of interest among physicians. As stated earlier, doctors can receive significant funding from drug manufacturers, and this funding affects their behavior. Additionally, doctors often have stakes in medical device companies – and these companies sell their products to the hospitals in which these doctors work in or preside over – another questionable relationship. Some surgeons even own surgery and advanced imaging centers, incenting them to suggest more and costlier treatments. In fact, patients were referred to an MRI scan 7 times more frequently in physician-owned institutions than non-physician owned institutions. The very payment model used by most institutions, fee-for-service, encourages doctors to perform more tests and provide reactive care, rather than focusing on patient outcomes.

These problems are large and complex, and they won’t be fixed overnight. Some are unavoidable: limits of on knowledge will always exist, as will limits on the resources realistically available to test drugs. But there are issues that can be addressed.

Science writer John Horgan has a few recommendations: “First, the fee-for-service model should be replaced with a different compensation scheme—perhaps one that gives physicians a flat salary with bonuses for improved patient outcomes. The Mayo Clinic and other hospitals that have adopted this practice deliver better care at lower cost. Second, malpractice laws should be revised so that doctors don’t prescribe tests simply to avoid lawsuits. Third, we need better evaluations of the efficacy of all medical tests.” Fourth, consumers should try to educate themselves about the risks and benefits of tests.”

You may have read this piece and become discouraged. Perhaps your trust in the medical system was slightly shaken. That was never my intent. Modern medicine has saved countless lives and is still by far our best tool to improve our health and wellness. But even our most venerable institutions are not above scrutiny – how else will they improve, and evolve? My intent, rather, was to aid Horgan in his fourth recommendation – to help us become more responsible consumers, patients, and citizens (and perhaps future doctors). So that the next time you visit the doctor’s office, you can be aware of the risks, ask the right questions, and, collaborate with your doctor to reach the best outcome possible.

Bibliography:

White Coats as a Vehicle for Bacterial Dissemination – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3471503/

The doctor’s white coat: A valuable tradition of a dangerously dirty habit? – http://www.georgiahealthnews.com/2016/10/doctors-white-coat-valuable-tradition-dangerously-dirty-habit/

12 Crazy Historical Medical Practices That Did More Harm Than Good – http://www.huffingtonpost.com/nathan-belofsky/crazy-historical-medical-_b_3516415.html

The Surprising History of Lobotomy – http://psychcentral.com/blog/archives/2011/03/21/the-surprising-history-of-the-lobotomy/

History of mastectomy before and after Halsted – https://www.ncbi.nlm.nih.gov/pubmed/19623880

The history of breast cancer surgery: Halsted’s radical mastectomy and beyond – http://www.amsj.org/archives/3019

Evolution of cancer treatments: Surgery – http://www.cancer.org/cancer/cancerbasics/thehistoryofcancer/the-history-of-cancer-cancer-treatment-surgery

Thalidomide – http://www.sciencemuseum.org.uk/broughttolife/themes/controversies/thalidomide

Thalidomide: The Canadian Tragedy – http://www.thalidomide.ca/the-canadian-tragedy/

Estrogen & Hormones – http://my.clevelandclinic.org/services/heart/prevention/risk-factors/estrogen-hormones

35 FDA Approved Prescription Drugs Later Pulled from the Market – http://prescriptiondrugs.procon.org/view.resource.php?resourceID=005528

Pharmaceutical industry sponsorship and research outcome and quality: systematic review – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC156458/

Industry sponsorship and research outcome – http://onlinelibrary.wiley.com/doi/10.1002/14651858.MR000033.pub2/abstract

Drug-Company Payments Mirror Doctors’ Brand-Name Prescribing – http://www.npr.org/sections/health-shots/2016/03/17/470679452/drug-company-payments-mirror-doctors-brand-name-prescribing

Is the FDA Too Cozy With Drug Companies – http://time.com/4510025/fda-drug-companies-pharmaceutical-industry-medical-reviewers/

Cancer drugs, survival, and ethics – http://www.bmj.com/content/355/bmj.i5792

TMI in Medicine: the Problem of Overdiagnosis – http://health.usnews.com/health-news/patient-advice/articles/2015/08/20/tmi-in-medicine-the-problem-of-overdiagnosis

What Can Patients Do In The Face of Physician Conflict of Interest? – http://healthaffairs.org/blog/2015/04/10/what-can-patients-do-in-the-face-of-physician-conflict-of-interest/

Higher Use of Advanced Imaging Services by Providers Who Self-Refer, Costing Medicare Millions – http://www.gao.gov/assets/650/648989.pdf

How Can We Curb the Medical-Testing Epidemic? – https://blogs.scientificamerican.com/cross-check/how-can-we-curb-the-medical-testing-epidemic/

Experimenting with a new format for sources that features fewer in-text hyperlinks. Would be great to hear thoughts on this, and the post above, in the comments!

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2 thoughts on “Trust me, I’m a Doctor

  1. empirebusiness

    I’m curious if you have any thoughts about how to remedy this “perverse alignment of incentives between the pharmaceutical and medical industries.” Pulling from one of the articles you cited, there are potential benefits to the close relationship between pharma companies and physicians, namely that it allows physicians to stay up to date with the specifics of new therapies by directly involving them in the operations of these companies.

    While I agree that there exists the potential for purely self-interested physicians to take advantage of this relationship for financial gain to the detriment of the patient, I am not convinced of your conclusion that “patients are likely not being prescribed the drug that is most suited to their symptoms.” Perhaps your conclusion is truthful in some cases, but it does not follow from your argument, mostly because it is often the case that both brand-name drugs and generics are “suited” for the patient and are even bioequivalent, and simply differ in price. This would lead to the conclusion that the notorious perversion of incentives leads to questions of price suitability, not symptom suitability. One might argue that lower drug prices would increase patient adherence, and consequently increase positive outcomes. Again though, it is my understanding that the issue is price suitability, not symptom suitability (as you argued).

    Your transition between the paragraph about Thalidomide and “perverse alignments” implies that these disasters were a result of physicians who were blinded, by pharma money, to the deleterious effects of various drugs, or even that they prescribed harmful drugs willfully. Is it possible that this was not the case? Medicine is an evolving field, and often times we learn things through trial and error. Ideally, we would have infallible systems in place to filter out therapies that can have disastrous outcomes, but even such filtering processes are evolving, and are thus not perfect.

    Reply

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