On May 13th, 2015, Dr. David Sackett died. If you haven’t heard of him, I'm not surprised: many pioneers are unrecognized or soon forgotten, especially those associated with ideas and foundational thinking rather than cures or objects. Nonetheless, according to the website of McMaster University, David Sackett was widely regarded as the father of evidence-based medicine.
Evidence-based medicine is the idea that how we treat patients, how aggressively we pursue certain courses of medical action, and how we rank the use of specific drugs and techniques ought to be based on science and not on feeling or arcane knowledge. Evidence-based medicine is what caused us to abandon wide scale blood-letting and routine trephination (the practice of drilling holes in people’s skulls) in medical treatment: science says that these things don’t work, or at least not for most people in most circumstances.
We want to believe that we, as enlightened 21st century people, have moved past ill-informed or superstitious practices. When we see things which are obviously based on superstition and the remnants of animism and spiritism (like sacrificing chickens in hotel atriums and anointing the doorways of patient rooms with the resulting blood), we look askance at the practitioners, and then call the police.
But I propose that we are not really as enlightened as we suppose we are. For instance, we think nothing of Wayne Gretzky’s insistence on tucking one side of his jersey into his pants. We do not blink at playoff beards or lucky ties. And we rarely question whether a certain medical treatment has been scientifically proven efficacious in the situations when it’s prescribed.
Yet, it is a fact that some standard treatments are known to be ineffective but are still pursued on a regular basis.
You don’t believe me. Let me give you two examples.
We’ll start with something relatively benign: antibiotics. Antibiotics have been the salvation of many people and contributed to a great reduction in overall mortality. That’s because they are the cure for bacterial infections that often led to sepsis and death in the past. But antibiotics are not the cure for all that ails us. According to the website of the Mayo Clinic, antibiotics are highly overprescribed. They are prescribed for sore throats of all kinds, for colds, for influenza, and for stomach problems. However, unless you have bacterial pneumonia, tuberculosis, or strep throat—a disease caused by a bacterium called Streptococcus pyogenes—taking antibiotics is at best ineffective. At worst, it actually promotes antibiotic-resistant strains of bacteria.
So, if antibiotics are not effective for treating many of the ailments they are prescribed for, why are they prescribed? There are many reasons, but a prime one is patient expectation and satisfaction. Most often, patients go to a doctor to get problems fixed. They expect the doctor to do something to make them better. But many times the doctor can do nothing to help; patients must simply wait and get better on their own. However, that is often unsatisfactory to the patient, who becomes insistent that the doctor “do something”. So, the doctor does something: she prescribes antibiotics. Knowing that what the patient really needs is just good nutrition, rest, and time to get better, the doctor prescribes a week of antibiotics and, voilà, after that week the patient is better—no thanks to the doctor or to the antibiotics. And so the cycle continues, with the illusory efficacy of the treatment being seen as evidence of its success, and the patient’s reliance on antibiotics increasing. And, to make things easier on her end, the doctor begins to prescribe antibiotics as a matter of course, even if the patient does not ask, simply because it is expected and because the doctor can avoid long talks to explain the fact that there is little that can be done beyond nutrition, hydration, rest, and patience.
That makes doctors look bad, doesn’t it? Well, it’s not intended to. It’s simply to illustrate that, like many other people, doctors want to avoid confrontation, to have people feel satisfied with their services, and to take the path of least resistance. After all, patients can otherwise simply move on down the road to find a doctor who will give them what they expect.
Even though evidence gained through double-blind scientific study shows that this course of action is not recommended and can ultimately be dangerous, we (doctors and patients both) insist on it. That is not evidence-based medicine; it is convenience and wishful thinking.
So, let’s say that, using the above example, I have convinced you of our unscientific practice of medicine. Let’s move on to something much more emotionally charged, with seemingly much more at stake: chemotherapy. We know from clinical double-blind trials that chemotherapy works; that is, chemotherapy treatments have been shown to kill cancer cells and to shrink tumours. That is science and is reproducible both in the lab and in actual patients. But, we also know from clinical double-blind trials that chemotherapy does not work; that is, there are many circumstances under which chemotherapy is simply ineffective to remove or stop cancer. That is also science. And, to make matters just that much more complicated, we know that chemotherapy sometimes works but at a cost which is greater than the gains it produces. That is, while it kills cancer cells, it can hasten death and/or cause the life which it does extend to be intolerable to the patient.
Unfortunately, today's cancer treatments are sometimes feelings-based. I cannot count the number of times I have heard or read statements like, “My cancer was surgically removed, and the oncologist said the chance my cancer will recur is only 5%, but I chose chemo anyway because I need to know I did everything I could to beat this disease”. As a result, the oncologists prescribe long weeks of chemotherapy. There are other scenarios. Some oncologists, desiring to be “as aggressive as possible” against the hated cancer, prescribe chemotherapy even where the evidence shows clearly—or with significant weight—that chemotherapy is contra-indicated, often telling the patients that a significant factor in their decision to prescribe is the overall good health and age of the patient. I was told I’d “be able to tolerate it well”. When I asked the oncologist to address the medical research indicating I would not be helped—and perhaps even be harmed—by the chemo being prescribed, he told me it was irrelevant. I had to battle to get a second opinion, which confirmed that chemo was not indicated for my condition.
I get the psychology of this. I understand the patient’s fear that comes with a doctor’s pronouncement that a cancer is “probably gone”, and the nervousness that looks to chemo for greater assurance. But where is the evidence-based medicine? Where are the doctors arguing that chemotherapy, in many cases, is the wrong course of action? I fear that, in the best case, the doctor’s strident argument against chemotherapy is absent because the appearance of doing something for the patient is better than the appearance of doing nothing. It is even possible that there is a more disturbing reason, having to do with how doctors are compensated for their work: it is not efficient, either in terms of money or time, to spend appointment after appointment trying to convince a patient not to have treatment—treatment which the doctor will be paid for. And if these rather raw, cynical explanations are not in play, it is sadly true that doctors are simply not trained to try to convince patients that things are going to be okay without further treatment, nor are they psychologically prepared to deal with their own misgivings over not having prescribed chemotherapy when a cancer reasserts itself.
Evidence shows that sometimes doing nothing is at least as good as doing something, and sometimes it is even better. Evidence shows that quality of life is often a more important consideration to the patient than quantity. It also shows that a satisfying quality of life can itself often lead to an increased quantity of life—without the chemotherapy or medical interventions which would have only decreased the patient’s quality of life.
So, let’s begin to listen to the evidence, to our better judgements, and perhaps to our own mortality. And maybe we can begin to live better lives.
Evidence-based medicine is the idea that how we treat patients, how aggressively we pursue certain courses of medical action, and how we rank the use of specific drugs and techniques ought to be based on science and not on feeling or arcane knowledge. Evidence-based medicine is what caused us to abandon wide scale blood-letting and routine trephination (the practice of drilling holes in people’s skulls) in medical treatment: science says that these things don’t work, or at least not for most people in most circumstances.
We want to believe that we, as enlightened 21st century people, have moved past ill-informed or superstitious practices. When we see things which are obviously based on superstition and the remnants of animism and spiritism (like sacrificing chickens in hotel atriums and anointing the doorways of patient rooms with the resulting blood), we look askance at the practitioners, and then call the police.
But I propose that we are not really as enlightened as we suppose we are. For instance, we think nothing of Wayne Gretzky’s insistence on tucking one side of his jersey into his pants. We do not blink at playoff beards or lucky ties. And we rarely question whether a certain medical treatment has been scientifically proven efficacious in the situations when it’s prescribed.
Yet, it is a fact that some standard treatments are known to be ineffective but are still pursued on a regular basis.
You don’t believe me. Let me give you two examples.
We’ll start with something relatively benign: antibiotics. Antibiotics have been the salvation of many people and contributed to a great reduction in overall mortality. That’s because they are the cure for bacterial infections that often led to sepsis and death in the past. But antibiotics are not the cure for all that ails us. According to the website of the Mayo Clinic, antibiotics are highly overprescribed. They are prescribed for sore throats of all kinds, for colds, for influenza, and for stomach problems. However, unless you have bacterial pneumonia, tuberculosis, or strep throat—a disease caused by a bacterium called Streptococcus pyogenes—taking antibiotics is at best ineffective. At worst, it actually promotes antibiotic-resistant strains of bacteria.
So, if antibiotics are not effective for treating many of the ailments they are prescribed for, why are they prescribed? There are many reasons, but a prime one is patient expectation and satisfaction. Most often, patients go to a doctor to get problems fixed. They expect the doctor to do something to make them better. But many times the doctor can do nothing to help; patients must simply wait and get better on their own. However, that is often unsatisfactory to the patient, who becomes insistent that the doctor “do something”. So, the doctor does something: she prescribes antibiotics. Knowing that what the patient really needs is just good nutrition, rest, and time to get better, the doctor prescribes a week of antibiotics and, voilà, after that week the patient is better—no thanks to the doctor or to the antibiotics. And so the cycle continues, with the illusory efficacy of the treatment being seen as evidence of its success, and the patient’s reliance on antibiotics increasing. And, to make things easier on her end, the doctor begins to prescribe antibiotics as a matter of course, even if the patient does not ask, simply because it is expected and because the doctor can avoid long talks to explain the fact that there is little that can be done beyond nutrition, hydration, rest, and patience.
That makes doctors look bad, doesn’t it? Well, it’s not intended to. It’s simply to illustrate that, like many other people, doctors want to avoid confrontation, to have people feel satisfied with their services, and to take the path of least resistance. After all, patients can otherwise simply move on down the road to find a doctor who will give them what they expect.
Even though evidence gained through double-blind scientific study shows that this course of action is not recommended and can ultimately be dangerous, we (doctors and patients both) insist on it. That is not evidence-based medicine; it is convenience and wishful thinking.
So, let’s say that, using the above example, I have convinced you of our unscientific practice of medicine. Let’s move on to something much more emotionally charged, with seemingly much more at stake: chemotherapy. We know from clinical double-blind trials that chemotherapy works; that is, chemotherapy treatments have been shown to kill cancer cells and to shrink tumours. That is science and is reproducible both in the lab and in actual patients. But, we also know from clinical double-blind trials that chemotherapy does not work; that is, there are many circumstances under which chemotherapy is simply ineffective to remove or stop cancer. That is also science. And, to make matters just that much more complicated, we know that chemotherapy sometimes works but at a cost which is greater than the gains it produces. That is, while it kills cancer cells, it can hasten death and/or cause the life which it does extend to be intolerable to the patient.
Unfortunately, today's cancer treatments are sometimes feelings-based. I cannot count the number of times I have heard or read statements like, “My cancer was surgically removed, and the oncologist said the chance my cancer will recur is only 5%, but I chose chemo anyway because I need to know I did everything I could to beat this disease”. As a result, the oncologists prescribe long weeks of chemotherapy. There are other scenarios. Some oncologists, desiring to be “as aggressive as possible” against the hated cancer, prescribe chemotherapy even where the evidence shows clearly—or with significant weight—that chemotherapy is contra-indicated, often telling the patients that a significant factor in their decision to prescribe is the overall good health and age of the patient. I was told I’d “be able to tolerate it well”. When I asked the oncologist to address the medical research indicating I would not be helped—and perhaps even be harmed—by the chemo being prescribed, he told me it was irrelevant. I had to battle to get a second opinion, which confirmed that chemo was not indicated for my condition.
I get the psychology of this. I understand the patient’s fear that comes with a doctor’s pronouncement that a cancer is “probably gone”, and the nervousness that looks to chemo for greater assurance. But where is the evidence-based medicine? Where are the doctors arguing that chemotherapy, in many cases, is the wrong course of action? I fear that, in the best case, the doctor’s strident argument against chemotherapy is absent because the appearance of doing something for the patient is better than the appearance of doing nothing. It is even possible that there is a more disturbing reason, having to do with how doctors are compensated for their work: it is not efficient, either in terms of money or time, to spend appointment after appointment trying to convince a patient not to have treatment—treatment which the doctor will be paid for. And if these rather raw, cynical explanations are not in play, it is sadly true that doctors are simply not trained to try to convince patients that things are going to be okay without further treatment, nor are they psychologically prepared to deal with their own misgivings over not having prescribed chemotherapy when a cancer reasserts itself.
Evidence shows that sometimes doing nothing is at least as good as doing something, and sometimes it is even better. Evidence shows that quality of life is often a more important consideration to the patient than quantity. It also shows that a satisfying quality of life can itself often lead to an increased quantity of life—without the chemotherapy or medical interventions which would have only decreased the patient’s quality of life.
So, let’s begin to listen to the evidence, to our better judgements, and perhaps to our own mortality. And maybe we can begin to live better lives.
Dennis Maione is an author, speaker, and teacher from Winnipeg, Manitoba, Canada. He has been on a 20+ year journey through two bouts with colorectal cancer, in large part due to the presence of a Lynch syndrome mutation in his genes. He speaks and writes about his cancer journey, his insights into the medical system, and finding heroes and villains in the unlikeliest of places.
His latest book, What I Learned from Cancer, is available in electronic form at his payhip.com site: http://bit.ly/wilfc-ebook. Physical copies of the book are available at the Prompters to Life web store, where shipping on copies of the softcover edition is always free (except to the International Space Station). To order a paper copy of the book, visit: http://prompterstolife.com/shoppers
His latest book, What I Learned from Cancer, is available in electronic form at his payhip.com site: http://bit.ly/wilfc-ebook. Physical copies of the book are available at the Prompters to Life web store, where shipping on copies of the softcover edition is always free (except to the International Space Station). To order a paper copy of the book, visit: http://prompterstolife.com/shoppers
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