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Thursday, April 19, 2012

Really Good Book

You can get a free copy here of Testing Treatments.

I'm so mad and disgusted about the economic data that I am forced to divert my disgust into something I can do something about. That something ain't the economy.

However, we actually could do something to lower medical costs and achieve better outcomes, and this book is a good way to start thinking about the problem.

Medical science in the US is compartmentalized and terribly bad at handling aggregated risks. This has largely happened because of insurance companies, so they won't be the solution.

Periodically I dream of what a really good medical AI system could do. Right now we are mandating that most the monies being spent be thrown away, and it's a tragedy. To begin to understand that tragedy read Testing Treatments.

Speaking of treatments, saw today that Vioxx' short time in the market positively correlates with the entire US' mortality.

"A cursory examination of the most recent 15 years worth of national mortality data provided on the Centers for Disease Control and Prevention website offers some intriguing clues to this mystery. We find the largest rise in American mortality rates occurred in 1999, the year Vioxx was introduced, while the largest drop occurred in 2004, the year it was withdrawn. Vioxx was almost entirely marketed to the elderly, and these substantial changes in national death-rate were completely concentrated within the 65-plus population. The FDA studies had proven that use of Vioxx led to deaths from cardiovascular diseases such as heart attacks and strokes, and these were exactly the factors driving the changes in national mortality rates... Perhaps 500,000 or more premature American deaths may have resulted from Vioxx, a figure substantially larger than the 3,468 deaths of named individuals acknowledged by Merck during the settlement of its lawsuit."

My emphasis. Reminds me of the Stalin quote on the difference between tragedies and statistics.
I read where the book says something like "thinking medicine is both an art and a science is an oxymoron" These people have not been either Doc's or Mechanics. To assume either of these are all equal and will get equal results is an insult to observational rationality. Two people can do the the same thing with different, even opposite results. My associate and I both do U/S guided biopsies. Our long term referring docs want only me to do them and all of the U/S staff would only come to me because results are much better despite doing things the same way. They all want him to read their MSK MR exams. We all have our strengths and weakness. There is far more to medicine than statistics. SM
Perhaps Vioxx was approved by the SSA.
SM - I utterly agree.

I would call the practice of medicine a craft based on science. The science must provide the tools, but the ultimate effect of use of the tools in the individual patient will be determined largely by the skill of the treating professionals, and part of this skill is knowing when NOT to use a treatment.

This is Niels Bohr territory:

Technology has advanced more in the last thirty years than in the previous two thousand. The exponential increase in advancement will only continue. Anthropological Commentary The opposite of a trivial truth is false; the opposite of a great truth is also true.


There are two great truths in medicine, and they are becoming ever more true as we expand the science. Medicine is a craft and medicine is a science. The science will become ever more destructive if not properly guided by the craftsmen, but the ability of the craftsmen to heal is largely dependent on the science.
Sm is correct which is what really scares me about Romney/ObamaCare. All those plans really do is expand on the concept that is causing the current problems. Doctors who join HMO's and programs of that nature get paid based on how many patients they see - and this results in docs getting paid to limit the amount of time they spend with each patient.

This results in docs ordering more and more tests and analyzing reports and statistics instead of treating patients as individuals. One can't really blame a new doc for doing that as he/she has big school loans to pay off; and by the time the loans are paid off a person has gotten set in their ways.

Having insurance plans cover routine care only exacerbates the problem. I don't need insurance for health care, I need it for emergency and extreme illness care. I like the trend of moving routine things to drug-store clinics, but unfortunately this isn't starting any undoing of the assembly-line nature of the remaining doctor/patient visits.
Allan - but Vioxx (rofecoxib) is a novel drug in some ways.

It's a great drug that should still be on the market, but it shouldn't be prescribed AS IT WAS.

Vioxx clearly has CV risks and they are major. Whether its use in any single patient is warranted, especially long-term, is a matter of clinical judgment.

I think the drug was over prescribed because it worked so well on pain.

Right now, letrozole is a drug out there which really does work to prevent recurrence of hormonally-responsive breast cancer. But it also has high CV risks (about half probably of those of Vioxx), and I guarantee you that some older patients are being killed with it.

We have to shift our medical practice to proper risk-balancing.
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