Thursday, November 9, 2017

Doctors. Part 2

Here is another view with a crazy dichotomy.

Doctors may be divided into two groups. Let me call the first group the Harvard Group.  These docs are up to date with the latest research and recommendations. They have baskets in which to place everything. These physicians function within comfortable boundaries. They are OK with the notion that 40% of patient symptoms remain unexplained. They believe medical practice must be based on evidence and science, with strict adherence to the creed and this makes them the best doctors possible, in keeping with the current state of the art.  These docs are smart and have encyclopedic knowledge, without question. They are as sharp as the scalpels they expertly wield.
The doctors share core beliefs.  Leaders of the group are held in very high esteem and are granted unbridled authority to orchestrate policies and beliefs. Members of the group go to many of the same meetings. Group members, or congregants  if you like,  do the bidding of the leaders and their controlling agencies. Group members believe they alone have a path to truth. It is my thesis that wittingly or otherwise, said doctors are members of a religion order.  
The second group of doctors, let’s call them the “hippie” doctors, know the science and guidelines alluded to, although the Harvards are sure the hippie docs are unaware, because they are certain the hips would follow the guidelines if they knew about them. They are wrong.  The hippie docs have different guiding principals. Hips values empiricism, the notion that clinical experience is meaningful and invaluable, and an indispensable source of information.  This idea makes the Harvards shudder.  Heresy. The hippie docs are not limited to published guidelines. They are not guided by the religion of absolutism, but instead they are guided by a patient-centric view of medicine.  The Harvards see the hippies as ill-informed and reckless, placing their patients at risk, venturing outside “The Standard of Care.”. The hippie docs have a different view.  They feel the standards are a carefully manufactured product of a system which cranks out policies, volumes of truth as it were, to be followed meticulously -- the basis of the religion of Medicine, which is to be follow with unflinching fealty. The believers believe. Everything you need to know is right there. Hippie docs disagree. The recommendations have worth, but are only a starting point. The hippie world is relative, not absolute and imbued with change, learning and curiosity and guided by the bond between patient and heeler. Don’t they know? Those precious guidelines change all the time. 
Hippie docs ask the impudent question:  If Harvard, Mayo, Hopkins and others have thoroughly evaluated patients, and their high priests and temples of Medical orthodoxy have found no answers and offer nothing for patients whose suffering is great, even to the point of suicidal thoughts and actions, why are they so troubled and angered when a hippie doc tries something different. Repugnant? Heresy?  It’s your faith, not mine.
Is medicine a science? Certainly, the practice of medicine is not science. Science describes methods and processes which lead to the discovery of new truths about the universe around us. 
The revered medical study is the basis for the religion of modern medicine.  Typically, a cohort of patients is identified, thought to have the same disease. A hypothesis or theory is to be tested. Is treatment A is superior to treatment B?   The cohort of patients randomly receive either A or  B and perhaps C, a placebo – if it is safe and meets ethical requirements.  The investigators, the doctor-scientists, are blinded, not knowing who is getting A and who is getting B. At a preplanned time, treatment is stopped and the patients are assessed for predetermined outcomes,  by a metric which will decide which of the treatments was the most helpful.  The results are given to statisticians who help interpret the findings.  Results may be reviewed by “peers,” experts in the given field, and written up and published in an appropriate journal.  
Sound great. What’s wrong with this?
Details. Is the cohort really homogenous or composed of numerous subtypes? For example, with most diseases, the genetics have not been worked out. Perhaps the cohort is not homogenous. Maybe it is comprised many subtypes predicated on genetic variable that have not yet been discovered. Perhaps the results measure an average which may not apply to an individual member of a subgroup.   Were the right outcomes measures and how were they measured? To what extent can the results be generalized, extrapolated to provide a greater, more clinically useful purpose?  This thing is a lot harder that is sounds. 
Here is a big problem:  repeat studies consistently come up with different results?  Different investigators looking at the same thing get different results.  To get around this, doctors like to combine multiple studies, which don’t agree, and average them out.   Seriously. Let’s assume only one study is accurate. The best study with the most accurate results might be cancelled out when averaged with a lot of other studies that missed the boat.   More studies are done, looking for clarification. New medical headlines daily proclaim results from the latest study, informing us what is really true. Extra, extra, read all about it.   The revered evidence based guidelines change all the time, and sometimes change they back again as the famous pendulum swings to and fro. We have investigator biases.  Who funded the study? Who do they work for? A pharmaceutical company?? This stuff is really hard to get right. 
Classically science is done like this. A scientist develops a hypothesis. He/she constructs an experiment which sets out to prove whether the hypothesis is correct.  For the results to be considered valid, the exact same result must be found repeatedly, over time, in different places and under the aegis of different investigators who follow the same procedures and processes which are clearly described. 
Medical studies are nothing like this.  Investigators rarely agree.  OK. So, medicine is a “soft science.” 
Let’s look at the world of Lyme. How do we find cohorts?  There is vast disagreement regarding: clinical features and symptoms of the disease, manifestations of the disease and the meaning of laboratory tests. That’s a problem.  What has been studied is a small subset of patients defined by investigators determined to show that chronic Lyme does not exist. That’s a problem.  The cohort is always the same: documented history of acute Lyme disease history ofearly treatment, subsequent chronic symptoms and tests positive with a particular, unusual finding on a test. It is one cohort which is hugely atypical of the group. That’s a problem. Most Lyme patients in my orbit aren’t diagnosed early and don’t have typical manifestations defined by former Lyme investigators. What about treatment A?  It is always the same: IV Rocephin. Is that the only intervention that should be studied?  What are the metrics and endpoints?  On the face of it, the challenges might seem unfathomable. 
For the sake of argument, let's say one of the Lyme studies was spot on. The question then is, what was proved?  Most studies reveal a fragment of a fragment of a piece of a very large puzzle. The disease and its permutations and then the construction of appropriate clinical studies to fill in many blanks is so complicated it makes your head spin to contemplate.  Studies provides a single point of data, a dot you could write on a blank piece of paper.
Did I mention the investigators were biased?  Despite these objections, some of the investigators draw vast conclusions with vast generalizations and extrapolations from something very small.  I would say they paint a masterpiece, like Renoir’s Boating Party, hanging in the Phillips collection in D.C., using only a single period at the end of a sentence. Very skilled. 
What are we to think of the guidelines? Another masterpiece. Perhaps the portrait of a young woman, wistfully looking out a window, in chiaroscuro, by no less than the master Vermeer, hanging in the National Gallery. A must see.
A thing of great beauty. And to think, made entirely out of whole cloth.   
The gospel of Saint IDSA. 

And the poor patients? They wish they could make the trip to the national gallery. The Harvards, wagging their bible, sanctimoniously have thrown the patients under the bus.  Remember Vietnam? Who had it right? The hippies who protested against the war or the Harvards led by Kissinger who egged Nixon on?  OK that’s pretty stupid. At least I admit it. 
There is clearly a war about Lyme disease. Should we debate guidelines? Absolutely not. We are so far from that making any sense. 
How do we care for our patients? 
We have spent an awful lot of time and an awful lot of energy looking for ways to help our patients, and we keep learning and getting better at what we do. I value the traditions of medicine: patient histories, physical exams, organization of problems, logical thinking, the Socratic method of learning.  This is the heart and soul of the medicine I like to remember.  Maybe someday the two groups of doctors currently fighting to the death will learn to treat each other with mutual respect. That will be a great start.

This piece is satiric or at least sarcastic. Its all tongue and cheek. (except the part about science) Doctors are not binary. Doctors are a very diverse heterogeneous collection of folks.  The opinions of doctors, no matter their affiliation,  go everywhere. That's why getting doctors together is famously like herding cats. 

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