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Editorial

Four Laws of Therapeutic Dynamics

Hadler, Nortin M. MD

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Journal of Occupational & Environmental Medicine: April 1997 - Volume 39 - Issue 4 - p 295-298
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Modern medicine enjoys a rich legacy of aphorisms. Ever since medical school, I have been taken with that tradition. The margins of many a notebook bear witness. Thirty years ago, these musings seemed whimsical. Ten years ago, I no longer thought they were so trivial; I started making gentle forays into the clinical literature. What follows is anything but a gentle foray; it is the strident prose of a physician who is hard-pressed to serve his patients or teach his students according to his conscience. Of all my aphorisms, the following four are incontrovertible. They are guideposts for any reader who feels the need to be a patient. They are a primer for any clinician trying to help a patient maintain healthfulness. They are the ammunition an occupational physician might use in protecting a work force from being savaged by that Byzantine, rapacious, chaotic demon, the American "health care system."

The First Law: The Death Rate Is One per Person

We are not meant to go gently into the unknown. But go we must; the issue is when. What's the most we can hope for? No science can answer that question with any certainty a priori-never for an individual who is well. The assumptions necessary to extrapolate from the past to predict your future are simply overwhelming. My personal philosophy rests on data, admittedly flawed, that promises an average life expectancy for our species that approaches 85 years. Anything beyond that is a bonus. So for me, the issue is to get my patient to age 85, smiling back at the journey and expecting to be comforted in passing when the moment arrives. If you share this philosophy, if you harbor not even a faint illusion of immortality, then you should also share my exasperation at the medicalization of advantaged America and my disgust at our callousness toward the disadvantaged.

Advantaged Americans, like advantaged citizens of most industrialized countries, are nearly there; we are all likely to reach the age of 85 in reasonable health. If you ward off obesity and avoid tobacco and other noxious exposures, your chances are excellent. I'm not suggesting that at 85, like so many lemmings, we'll meet our makers. There will always be tragedies-statistical outliers, if you will-those will die before their time and those who linger beyond theirs. I am asserting that we can do no better than to arrive at 85, that most of us will make it, and that very few of us have anything to gain from the medical "advances" touted as lifesaving. Let's take "cancer" and "heart disease" as object lessons.

Cancer has carried away many a loved one. But it is the specter of cancer that is the scourge. We are taught that "screening" and "aggressive" treatments are our salvation. Well, the truth is that only serendipity and the surgeon may make it more likely that some disease other than breast, prostate, lung, or colon cancer will carry you off at 85. No matter how we torture the data, no aggressive chemotherapeutic regimen increases that likelihood. That is not to say these cancers are rare. To the contrary, many of us will be afflicted with breast, colon, or prostate cancer at age 85. But few of us with cancer will die of that cancer; most will not even be aware of its presence. We will die, but we would have died anyway, with or without the cancer, at 85. Certainly there are tragedies-people who die before the age of 85 of cancer. They deserve all the compassion, palliation, and empathy we can muster. They do not deserve ineffective chemical heroics, nor do the rest who have cancer but have no change in life expectancy. Besides, succumbing to cancer at too young an age may not be just bad luck; these unfortunate people may harbor a genetic susceptibility, an Achilles' heel, that someday we'll learn to recognize before it's too late to attempt to protect their entitlement of 85 years. Today, any public "health" mandate for mammography, prostate-specific antigen assays, or screening of stools for occult bleeding is not up to the task.

Then there's cardiology and cardiovascular surgery. In mid-century, coronary artery disease was a scourge-but it is no longer. In fact, we are living long enough to manifest the diseases of old age, such as cancer. Nonetheless, we the people are not disabused, and they, the experts, are permitted the hubris of generations past. Cardiologists and cardiovascular surgeons make a practice of designing and purveying interventions based solely on "first principles," eg, the latest widget to image the myocardium or do violence to the plaques in arteries. But the "first principles" are wrong. That is the inescapable conclusion of multicenter study after study-each extensive and expensive, and each bearing its acronym proudly (TIMI, TAMI, GISSI, GUSTO, ISIS, CASS, etc). Whatever minimal survival advantage is afforded the tiny but vaunted subset with major disease of the "left main" coronary artery is overwhelmed by the peri-invasive mortality that is the only other readily demonstrable effect on survival. Despite the futility of doing violence to the ischemic heart, modern American cardiology and cardiovascular surgery conspires to purvey well over 400,000 cardiac catheterizations, some 300,000 angioplasties, and a similar number of bypass grafts each year. Americans would be better off if we spared their coronary arteries all known surgical assaults forevermore! If you don't believe me, ask your favorite cardiologist to defend any variation on the dialogue shown in Fig. 1.

Fig. 1
Fig. 1:
Template for a dialogue between a patient concerned about heart disease, and his or her physician.

The readership of this journal is part of a modern advantaged industrial society. Aside from a few exceptions, such as the treatment of some infectious diseases with antibiotics, of congestive heart failure with certain medicines, and of cervical cancer and some lymphomas, medicine can offer nothing to improve one's likelihood of living longer. But we market the myth and ignore the corollaries. The disadvantaged die young, and we look away. And the elderly die inelegantly, badgered and dehumanized-and we participate.

The Second Law: Never Poke a Skunk

I, and many of my generation in medicine, lived a myth-to my own detriment, I still live it. I believe that any profession, and certainly medicine, is a meritocracy. Each individual is personally accountable for knowledge, soul-searching, self-criticism, and self-awareness. And each professional is answerable to peers on all these accounts. How else do we safeguard the person who assumes the most vulnerable of stations in our society, that of patients? This myth has eroded. There were always those physicians who fell short, and there will always be. But never before did falling short lead to career options in medicine to the degree that it does today!

For two decades, the academy has been crawling with people who know more and more about less and less. They knew who they were, we knew who they were, and our students knew. I have decried the trend, but the patient did not suffer. Now there are people with medical degrees who don't even pretend to know more and more about clinically relevant phenomena. Rather they claim to know more and more about how best to serve "units" of care, and how best to organize "care givers." You can spot these anti-physicians by their shibboleths: "team players," "the good of the institution," he or she's a "good citizen," "must change to survive," "there's a new order," etc. They are the bloated, overpaid, self-congratulatory medical administration. Medical administration is no longer infrastructure. These "doctors" and their fellow travelers abound in the academy and out; they sell themselves as purveyors of truth, keepers of the key to a better future, and exemplars of nobility. No physician and no patient is a match for their self-service. To take them on, eyeball to eyeball, is to lose; we share neither language nor goal nor ethic. If only I could learn how to work comfortably around them, perhaps I could teach this essential skill. Someone more talented will have to take up the challenge and teach me.

The Third Law: There Has Never Been a Quack Without a Theory

Hubris. The scourge of the clinician since antiquity; to be so certain as to be unaware that you might be so wrong. In this century, how many tonsils were removed and thymus glands irradiated to stop pharyngitis from recurring? How many "retroverted" uteruses were removed to halt back pain? Radical mastectomies for cure? The list goes on and on, all examples of hubris. No wonder we all applauded when it became clear, only 30 years ago, that so many clinical inferences could be tested, even tested proactively. However, we are so enamored with the process that we have permitted distortions to set in that represent nothing more than New Age Hubris. It is easy to design studies and perform analyses leading to inferences that conform to some preconceived notion or promote some vested interest. Clinical medicine is being overwhelmed by the imperious P values that are imprimatur to a marketing exercise pursued with zeal by purveyors of techniques, pills, and facilities. To wit:

I don't know a well-trained scientist who is willing to perform a controlled experiment on 1000 inbred mice in the hopes of detecting a few percent difference in some biological outcome. Do you? Would anyone fund such an experiment? Any scientist worth his or her salt would tell you that there is so much biological variability even in inbred mice that a small difference is not interpretable, even if it is unlikely to occur by chance. Larger differences are likely to be meaningful. But larger differences can be detected in experiments with far fewer mice.

Nonetheless, every week, the "scientific" literature of clinical medicine offers up a conclusion based on a few percent difference in outcome when thousands or even tens of thousands of human beings are exposed to something that as many "controls" are spared. The authors avow confidence in the small difference because it is not likely to occur by chance more than one time in 20 (Probability [P] < 0.05). Smitten by this imperious P value, the lay press trumpets the inference. The lay press trumpets the inference even if it is the opposite of the inference trumpeted last week, or last month, or last year. Epidemiology is funded to degenerate into the scare of the week, the diet of the month, the drug of the decade. Much of this is another testimony to human foibles; it's nice to feel important and, in the academy, funding is credibility, if not power. But some of this may be more than human foibles. Some may be nefarious. When there is so much money at stake, the impartiality of science may be no match. "Peers" who review studies interpreted in a way that fosters their incomes and power are likely to suffer less dyspepsia than if the authors had offered a pejorative interpretation. That's human nature. But how about when drug companies contract other companies to undertake and analyze major studies of new drugs, often facilitating these studies by paying doctors to enroll patients, all in the quest of a P value that the Food and Drug Administration finds persuasive? That's a Faustian contract if ever there was one!

Imperious P values stalk the overweight, the smokers, and those patients whose families are riddled with individuals who died an untimely death. Clearly we have much to learn about the plight of these people, and how best to advise, educate, palliate, and comfort. Today we urge them on in the Sisyphean task of reversing their "risk factors," laboring under the assumption that if they do so, their risks will diminish. And we ply them with drugs on the basis of study after study in which data has been tortured to assert uncertainty, or discern unconvincing minimal effects, or excuse the negatives. The fact is, oral hypoglycemics, treating mild hypertension, and-with exceptions such as some rare genetic defects-lowering cholesterol have not been shown to increase the likelihood that anyone will reach the age of 85. Thanks to imperious P values, "me too" antibiotics, analgesics, and other classes of drugs stand in rows as "samples" in nearly every clinic. Thrombolytics are the standard of care for myocardial ischemia even though they pale next to aspirin in risk/benefit. The cardiovascular enterprise is the standard-bearer of the American medical "high tech" sophism; since we can do it, it must be good and valuable. The American heart is not the only body part that suffers the "high tech" sophism and thereby supports an industry: regional back pain warrants neither imaging nor surgery; arthroscopic knee, wrist, and shoulder surgery is in quest of therapeutic validation, as is most sinus surgery, and on and on … Some of this, as in days of old, is perpetrated in the absence of data. Much is perpetrated in spite of the data-driven by the flow of moneys that enrich the surveyors but succor the ill not at all, and justified by the presence of imperious P values.

The Fourth Law: Institutions Die; People Live

I have lived through four distinct institutions of medicine: proprietary hospitals built on hubris, the golden but fleeting age of clinical investigation, the corruption of unbridled fees for any service declared "necessary," and now, the leveraging of the healthfulness of the advantaged American.

I was too young to grasp the distortions of the proprietary hospitals fully. I came of age in that fleeting golden age of clinical investigation, which passed into legend by the 1980s. It was superseded by the age of the "interventionists" who took advantage of New Age Hubris to strut the stage, bloated with the largesse of Medicare. They silenced the clinicians, labeled them "second class," and dispersed them. The irony is that even though these clinicians abound today across the land, a sophisticated ministry to the ill and great American resource, they have no credibility even if they could find a voice; all medicine is tainted by presumption of conspiracy with the interventionists. Otherwise, medicine as a cottage industry could be championed: universal coverage by a single payer only for compassion, for ongoing counsel, for prescription of the few interventions available today that are supported by more than imperious P values, and for discerning those of value in the future.

Instead, since 1992, we have moved in the opposite direction. Industrialists have subjugated the interventionists and now command the institution. "Saving money" is a euphemism for profit margin. Top administrators of even small hospitals and managed "care" companies are paid more than governors, senators, and even the president of the United States. "High tech" is marketed at bargain prices, worthless or not, and "providers" are pressured by "purveyors" to spend less and less time, or none at all, with "customers" and "clients." This new institution is Orwellian. It is transparently and avowedly self-serving. It deserves to die. No doubt it will, and soon. The question is whether it is the last institution of medicine.

Nortin M. Hadler, MD

Professor of Medicine and Microbiology/Immunology; University of North Carolina at Chapel Hill; Attending Rheumatologist; University of North Carolina; Hospitals Chapel Hill, NC

A MATTER OF LIFE AND DEATH

What will happen to your small business when you die? … 65% of the members of the American Society of Chartered Life Underwriters and Chartered Financial Consultants say that most of their small business clients lack business succession plans. Such plans outline what would happen if the founder died, retired, or became disabled.

Why the laxity? 56% of the clients said they had no clear successor in mind, 56% also said they found it hard to give up control. Other reasons: no understanding of the importance of "business estate planning" (50%), avoidance of tough decisions (32%), lack of funds (27%), concerns over fairness or equity (26%), and difficulty in planning for one's own mortality (26%) …

From Metropolitan Business Report, Philadelphia Inquirer. July 1, 1996, p C1.

© Williams & Wilkins 1997. All Rights Reserved.