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    Friday, September 29, 2006

    Thoughts on My Profession: This conference, the yearly American Academy of Family Physicians Scientific Assembly is, as always, very good. Unlike most conferences, you don't have to sit all day listening to one lecture after another. You choose them like you would a high school or college curriculum. And there are plenty of good CME topics and lectures from which to pick and choose.

    I've been concentrating my efforts so far on the evidence based medicine lectures. Each of the lecturers in this series has made an effort to weigh the research evidence in an unbiased way. For instance, what is the best treatment of chronic kidney disease, congestive heart failure, or diabetes? So far, none of the speakers at the lectures I've attended have admitted to any drug industry ties, though the series is supported by grants from the pharmaceutical companies. And, to the Academy's credit, they've doubled the continuing medical education credits attendees can claim to encourage attendance at these sorts of lectures.

    However, even given all of that, the take home message of all of them so far has been to load up patients with drugs at the earliest possible stages of disease. I'm oversimplifying, but only a bit. The chronic kidney disease message was don't be afraid of polypharmacy. Ditto the congestive heart failure message. Ditto the diabetes control. Putting someone on four drugs to control their hypertension is fine as long as it lowers their blood pressure. Oh, and while you're at it, put them on a statin because it might delay the progression of kidney disease, too. If they have diabetes, don't be afraid to put them on three more drugs to control their diabetes. If they have heart failure, be sure to add a beta-blocker. And you know what? If that beta-blocker makes their heart rate go down too low, put a pace maker in. It's worth it if you can get them to stay on the beta-blocker.

    Whew. The problem here is that the composite patient with all of those diseases is not a rare bird. He's the American robin of American medicine. Most diabetics at some point will also have hypertension and chronic kidney disease and eventually heart failure. Follow the recommendations of the evidence and they could end up on nine or ten different medications. This is not necessarily a good thing. The studies which support each of these recommendations were done on pristine populations - people who had either hypertension or diabetes but not both. And the real kicker is, that there are no studies comparing the fates of patients taking all of the medication recommended by the evidence with those taking none, or only the minimal required to improve their functional capacity. This is an important distinction, because much of the evidence based therapy is aimed at preventing death or hospitalization, not at making the patient feel better.

    More drugs means more potential for side effects, interactions, and medication errors (Both on the part of patients in taking them correctly and on the providers in refilling them correctly. It's hard to keep track of long lists.) There may be a very real downside in taking all of those we recommend for each separate condition, but no one has done the studies to find out. And why would they? Medical research funding is dominated by pharmaceutical companies. They aren't going to pay for a study to find out if people shouldn't be taking their drugs.

    My profession has been co-opted by the pharmaceutical industry.

    posted by Sydney on 9/29/2006 11:43:00 AM 5 comments


    Further complicating the problem is the way the medications are developed. Generally, there is a range of doses, sometimes three or four, that are tested for safety & efficacy. Each dose obviously needs a test subject pool along with at least one set of controls. That's a lot of people. Statistically speaking, one needs to find a significant impact to justify efficacy, and to do that you either need large numbers of test subjects, or high doses of drugs. And, of course, there's practically no adjustment for body size. Putting these things all together means that doses are probably more than necessary, for most people. Sometimes one can easily detect that (e.g. too low of a blood pressure or glucose) but sometimes one cannot.

    Since I am currently a victim of polypharmcy myself, I have noticed that a). doctors just want to make people happy and perceive all whining about symptoms as a call to do something, and b. some doctors just like to have you on drugs so they can have a (relatively) pleasant and high-paying patient to interact with. Honestly, I can't blame them on that one, either. So I have actually told my doctors, "Look, I'm just telling you how I feel, you don't actually have to do anything about it since (in my case at least) it won't kill me just yet. I used to be a medication tinkerer myself until I figured out what was some patients really need. Sometimes they just want to vent. Doctors don't always have to do something about it, though conventional wisdom says people want prescriptions, sometimes they just want to talk.

    By Anonymous Dani, at 2:06 PM  

    Are you sure that these talks really were from an evidence-based medicine perspective, and that the speakers really weighed the evidence in an "unbiased" way?

    I would guess that their recommendations were really not based on EBM, which means they really were not based on
    - a systematic search for the best available evidence
    - rigorous critical review of each study
    - pursuing the goal of maximizing each patient's benefits while reducing harms, while taking into account the patient's values.

    Take the diabetes lecture, for example. I'm betting it was on Type 2 DM. The best trial of intensive versus less intensive treatment for Type 2, the UKPDS study,(1) found that intensive treatment did reduce micro-vascular complications, e.g., it lead to a small absolute decrease in the rate of any microvascular complication: 2.8/1000 patient years. However, it did not lead to statistically significant decreases in clinically meaningful outcomes associated with microvascular complications, such as amputation, renal failure, or blindness. On the other hand, intensive treatment lead to an increase in severe hypoglycemic reactions for about 3-11 per 1000 patients per year (the number depends on which particular treatment was used.)

    Thus, it is not clear that the benefits of intensive therapy outweighed the risks. For every patient who avoided a (sometimes minor) microvascular complication, a patient suffered a severe hypoglycemic reaction.

    So I just wonder if these lectures were that unbiased and were truly done in the EBM way. Maybe the grant support from the pharmaceutical companies for the lecture series had some influence.

    1. UK Prospective Diabetes Study Group.Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complicatons in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837-853.

    By Blogger Roy M. Poses MD, at 2:14 PM  


    I agree with you regarding diabetes and the consequences of rigid, intensive control. Especially in real world practice.

    Regarding the speakers: They seem to be earnest about trying to stick to the evidence. They present things in terms of absolute risk and number needed to treat rather than relative risks and "expert opinion," and they don't have financial ties to the pharmaceutical industry. That is what is especially disheartening.

    We've had a shift in thinking in medicine in which we only consider the part rather than the whole. (Especially disheartening for family medicine because we were trained to consider the whole.)So, if a physician has a special interest in diabetes or kidney disease, or heart failure - even if they are family physicians - they (and we) consider only the benefits of treating that disease without considering the implications for the total body. We're failing to take into account that the living body is a synthesis of interactive systems and that we should weigh the consequences of what we do to a part on the whole.

    By Blogger sydney, at 5:06 PM  

    A huge part of the problem is that for every variable you add to a study the difficulty of performing the study goes WAY up. I can't even imagine the statistical jiggery-pokery that would have to take place to study the diabetic with marginal renal disease that has CHF vs. the COPDer with renal disease secondary to chronic renal stenosis and stable angina. It's too complex. It's the same reason why the whole P4P thing is going to devolve into tracking markers and checkboxes rather than outcomes (i.e. how many patients were offered smoking cessation or how many patients were offered mammography vs. did the patients get better).

    By Blogger Bladedoc, at 2:13 PM  

    At least, it's a kind of relief for me to see this kind of debate in your country. Now, add to the equation in underdeveloped world: the suspicion with big pharmaceutical corporations needing to test its effects with more "innocent" patients, the dire situation of the medical class as a whole (I'm talking about continued education here), the abandonment of public health, etc.
    You'll probably say: "what the ... this brazilian doctor is doing here?"
    (sorry, I think I got the wrong address). However, sometimes I keep wondering who is in worst situation, really...)

    By Blogger Oscar, at 10:03 PM  

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