Soft thinking is a like a contagious disease. If you don’t treat it early, it will spread to the masses and become endemic. Almost every day, I ask myself if I am guilty of soft thinking. Have I underestimated complexity? Have I accepted weak evidence?
Thank you, Dr. Mandrola, for bringing the ACCESS trial to my attention. As always, I appreciate the link to the open-access full text of that study, so I can read it for myself. Your thoughts about the study are also valuable. Soft thinking comes from both the right and the left, so it's good to sharpen our wits on a case study like this. I hadn't thought previously about the issue of medication adherence.
And here's a more general comment on the scope both "Stop and Think" and "Sensible Medicine". I would like to see both blogs broaden their coverage of medical and healthcare issues. The hosts' posts and podcasts about contentious topics in cardiology, oncology, and internal medicine are excellent, but in addition I would like to see how the principles of evidence based medicine are being applied (or not) in other fields. In particular I am wondering why there has been no discussion (at least since I started following your substacks) of how these principles relate to psychiatric medications, which must make up a large share of prescription medications.
Here is another example of a topic which has become increasingly important because of demographic change, and that I would like to see covered through the lens of evidence-based medicine: when do hearing aides improve speech understanding?
But I'm sure readers will have many other topics that interest them. You do have guest posts occasionally, which is good. But perhaps the hosts themselves or their guests could cast their nets a bit more widely to illustrate the evidence-based approach. (This was one of many things I liked about the excellent "Sensible Medicine" series, "Churnalism")
Perhaps, Dr. Mandrola, the scope of "Stop and Think" is restricted to cardiology; if so, my comments are better directed to "Sensible Medicine". So perhaps you, as a co-host of "Sensible Medicine", could pass my comments on to Drs. Prasad and Cifu.
It’s closed-mindedness and it’s rampant. So many biases get in the way with being open to an alternative approach or answer. It’s like earmuffs from Old School!
Patient perspective here. The key I see is, "the ability to take four drugs selects patients destined to do better." Those of us who take our meds diligently are those who reduce risk in most other areas of life. Those who are risk-apathetic in other areas of life don't take their meds. Is it that simple?
Thought provoking article once again. As you say, in controlled environments in the context of a clinical trial, we know these drug classes work (in isolation). We also know, per Salim Yusuf’s work I believe, as well as Secure study from ESC 2022, that polypill with several classes of agents is effective.
As you say, I don’t think this study negates those findings. However, it does raise questions about the translation of those RCT findings to the real world (which is and should always be a consideration). When you take these meds, they work; but they can’t work unless you take them. And there are myriad reasons why people don’t take them.
In this case, however, I would question the external validity of this study. The cost differential was only $35 a month. I don’t mean to make light of this for low/fixed income seniors (and I live in BC which is next to Alberta, and our drug coverage is similar), but it doesn’t necessarily apply to scenarios where the cost differential may be more substantial. Also, the PDC80 (their surrogate for scripts filled, and by extension, presumably pills taken) showed only 3-4% difference in both RASS blockers and statins. This difference was statistically significantly different, but I don’t know if that is a clinically meaningful difference.
So instead, I would interpret this study as showing that, when the medication Copay cost is not huge, and getting meds for free does not make a huge financial difference, it does not result in a huge or clinically significant difference in medication compliance. That small absolute difference in compliance does not translate into clinical outcome endpoint differences. Whether such a policy would make a difference when dealing with more expensive therapies, or where the financial burden is substantially higher in general, remains unknown.
This is self-examination. It's a trait that characterizes real people, as opposed to NPCs. A habit of self examination leads to self awareness, which is essential to developing emotional intelligence and avoiding the psychological manipulation attacks against you.
An important question is whether we allow the Overton Window to imprison us. If the beliefs inside the Overton Window don't mesh with the facts about reality from our analysis, do we have the necessary freedom to deal with the facts of reality? Can we talk with NPCs (who self-imprison in the Overton Window) about reality? It's important to realize that the Overton Window (OW) is managed by psychological manipulators, so that the OW can be used to manage the herd of NPCs that constitute the bulk of humanity.
Wonder how much of the 4 trillion dollars (!) spent in the USA on healthcare every year really advances anyone’s health. Consider the Number Needed to Treat for almost all preventative drugs, OTC products and lifestyle interventions. Take statins for example, using your estimate of 1 - 2% absolute benefit over 10 years. 98 or 99 people out of 100 swallow a lot of pills and get nothing for it. Now the pharmaceutical companies get something for it for sure, but they don’t need it. Providers point proudly to the thousands of lives saved among the millions taking the drugs. But it’s a long run for a short slide, even for this therapy that we consider a great boon to mankind.
And to your main point, sloppy thinking and hubris can lead to satisfaction with this and other similar states of affairs (like vaccinations), which from a little distance don’t look so wonderful. It’s no surprise to me when patients, from their more distant perspective, opt out.
People's lives are complex. What motivates them.what they long for. What obstacles exist.what befalls them. To imagine making something free is enough to overcome that is indeed hubris.
A common challenge for all professionals is to make decisions or judgments in an individual situation using averages. Conclusions based on averages don’t really apply to individual situations. There is a large amount of uncertainty.
So our job as a professional, especially when managing risk, is to understand the nature of uncertainty, key drivers and impact of potential intervention or no intervention.
Thank you, Dr. Mandrola, for bringing the ACCESS trial to my attention. As always, I appreciate the link to the open-access full text of that study, so I can read it for myself. Your thoughts about the study are also valuable. Soft thinking comes from both the right and the left, so it's good to sharpen our wits on a case study like this. I hadn't thought previously about the issue of medication adherence.
And here's a more general comment on the scope both "Stop and Think" and "Sensible Medicine". I would like to see both blogs broaden their coverage of medical and healthcare issues. The hosts' posts and podcasts about contentious topics in cardiology, oncology, and internal medicine are excellent, but in addition I would like to see how the principles of evidence based medicine are being applied (or not) in other fields. In particular I am wondering why there has been no discussion (at least since I started following your substacks) of how these principles relate to psychiatric medications, which must make up a large share of prescription medications.
Here is another example of a topic which has become increasingly important because of demographic change, and that I would like to see covered through the lens of evidence-based medicine: when do hearing aides improve speech understanding?
But I'm sure readers will have many other topics that interest them. You do have guest posts occasionally, which is good. But perhaps the hosts themselves or their guests could cast their nets a bit more widely to illustrate the evidence-based approach. (This was one of many things I liked about the excellent "Sensible Medicine" series, "Churnalism")
Perhaps, Dr. Mandrola, the scope of "Stop and Think" is restricted to cardiology; if so, my comments are better directed to "Sensible Medicine". So perhaps you, as a co-host of "Sensible Medicine", could pass my comments on to Drs. Prasad and Cifu.
Thanks for considering this.
It’s closed-mindedness and it’s rampant. So many biases get in the way with being open to an alternative approach or answer. It’s like earmuffs from Old School!
Holy cow, this one got my brain going.
Patient perspective here. The key I see is, "the ability to take four drugs selects patients destined to do better." Those of us who take our meds diligently are those who reduce risk in most other areas of life. Those who are risk-apathetic in other areas of life don't take their meds. Is it that simple?
Super article, thanks Dr M!
Is soft thinking a euphemism for thinking that we disagree with?
Thought provoking article once again. As you say, in controlled environments in the context of a clinical trial, we know these drug classes work (in isolation). We also know, per Salim Yusuf’s work I believe, as well as Secure study from ESC 2022, that polypill with several classes of agents is effective.
As you say, I don’t think this study negates those findings. However, it does raise questions about the translation of those RCT findings to the real world (which is and should always be a consideration). When you take these meds, they work; but they can’t work unless you take them. And there are myriad reasons why people don’t take them.
In this case, however, I would question the external validity of this study. The cost differential was only $35 a month. I don’t mean to make light of this for low/fixed income seniors (and I live in BC which is next to Alberta, and our drug coverage is similar), but it doesn’t necessarily apply to scenarios where the cost differential may be more substantial. Also, the PDC80 (their surrogate for scripts filled, and by extension, presumably pills taken) showed only 3-4% difference in both RASS blockers and statins. This difference was statistically significantly different, but I don’t know if that is a clinically meaningful difference.
So instead, I would interpret this study as showing that, when the medication Copay cost is not huge, and getting meds for free does not make a huge financial difference, it does not result in a huge or clinically significant difference in medication compliance. That small absolute difference in compliance does not translate into clinical outcome endpoint differences. Whether such a policy would make a difference when dealing with more expensive therapies, or where the financial burden is substantially higher in general, remains unknown.
"Almost every day, I ask myself"
This is self-examination. It's a trait that characterizes real people, as opposed to NPCs. A habit of self examination leads to self awareness, which is essential to developing emotional intelligence and avoiding the psychological manipulation attacks against you.
An important question is whether we allow the Overton Window to imprison us. If the beliefs inside the Overton Window don't mesh with the facts about reality from our analysis, do we have the necessary freedom to deal with the facts of reality? Can we talk with NPCs (who self-imprison in the Overton Window) about reality? It's important to realize that the Overton Window (OW) is managed by psychological manipulators, so that the OW can be used to manage the herd of NPCs that constitute the bulk of humanity.
Wonder how much of the 4 trillion dollars (!) spent in the USA on healthcare every year really advances anyone’s health. Consider the Number Needed to Treat for almost all preventative drugs, OTC products and lifestyle interventions. Take statins for example, using your estimate of 1 - 2% absolute benefit over 10 years. 98 or 99 people out of 100 swallow a lot of pills and get nothing for it. Now the pharmaceutical companies get something for it for sure, but they don’t need it. Providers point proudly to the thousands of lives saved among the millions taking the drugs. But it’s a long run for a short slide, even for this therapy that we consider a great boon to mankind.
And to your main point, sloppy thinking and hubris can lead to satisfaction with this and other similar states of affairs (like vaccinations), which from a little distance don’t look so wonderful. It’s no surprise to me when patients, from their more distant perspective, opt out.
Thank you. So important with all we do in this profession to stop and think.
Excellent,!
People's lives are complex. What motivates them.what they long for. What obstacles exist.what befalls them. To imagine making something free is enough to overcome that is indeed hubris.
And it also doesn't mean it shouldn't be free
Excellent, thought provoking essay!
A common challenge for all professionals is to make decisions or judgments in an individual situation using averages. Conclusions based on averages don’t really apply to individual situations. There is a large amount of uncertainty.
So our job as a professional, especially when managing risk, is to understand the nature of uncertainty, key drivers and impact of potential intervention or no intervention.
That is how we earn out paychecks!!