Vinay Prasad has an excellent post on Sensible Medicine about scientific fraud. He wrote about a recent Freakonomics podcast about bad science. Outright fraud always gets big attention. Whether it’s scientists making up data or doctors putting in too many stents. And, yes, of course, these are terrible events.
John, Good piece and very close to the mark. Consulting (hematologically) on an 85 year old scheduled to have a Whipple just caused my head to spin, spewing vomit. Yes, it is easiest to tell the family "We are doing something". (This is exactly the same idiotic behavior that drove well-known-to-be-worthless masking and antisocial distancing during covid. As with the surgery, doing something is usually worse than doing nothing if there is nothing to be done.) But the medical students ask, when we leave the room, "Why are we doing this?". And there is no good answer.
As others in the comments have noted, profit matters. There is no group to say "do not do that...it is likely that the non-cure is worse than the disease" because on Medicare the hospital will make a lot of money from the Whipple...and none if the patient is sent home to expire from their widely-spread pancreatic cancer. One can protest all one wishes...this economic sword of Damocles hangs over every decision. It is easier to make the decision that makes lots of money (none of which is actually paid by the patient so no intelligent economic decision making is made there) and that leaves everyone glad that "the doctors are doing something".
As noted above, this bothers lots of those entering the profession, but then we beat it out of them. Some of the beating we bring upon ourselves by trying to find (as you point out often) generally specious research that supports what we want to do. Cifu's recent article about the spikeshots saving millions of lives is solely based on a highly flawed (call it garbage) modelling study and no actual facts. But I am sure it made him feel better to quote it because he likely recommended lots of the genetic engineering to his patients and facing the fact that we were all lied to and propagated those lies to our patients is really difficult. Not picking on Adam; I just use this as an example because it applies to LOTS of things we do TO patients, putatively FOR them.
The question is "how does one begin to address this"? It would be of value for Adam to contemplate his reliance on bad science (the model designed to show a particular result [as are all models] but this one is consonant with what he wants to believe) in an article on how bad science is as an archetype of the kind of soul searching that we all need to do if we are ever going to put medicine back on decent footing. Otherwise, I see patient trust eroding daily...and I am not sure that it should not. This seems a very sad way to end my career.
There needs to be an awakening that matters. Perhaps you can help drive that.
Dr. K--I am a retired surgical nurse with open heart experience and I have seen the impractical surgeries , as you mentioned with the Whipple, on an 85 year old with advanced cancer. In most of these cases the surgeon didn’t make the decision to do the surgery it was the family because even though they knew the surgery wasn’t a cure and would most likely cause their loved one more discomfort they just couldn’t let go. We put G-tubes in comatose 90 year olds because the family couldn’t say goodbye. So when the medical student asks “why are we doing this?” the answer is because the family can’t let go. Perhaps more information , education and empathy for our patients and family and less --much less, advertising on television that leads the public to think that medical science has the cure for everything. The studies that the public have access to are so skewed and may only consist of a population of 10 but are enough to convince lay people of their accuracy. Hopefully, the work of Dr. Mandrola will expose these studies and give us more sensible decision making information.
I heard your podcast about p values and statistical significance.
Im really worried about trusting too much on the p values and not seeing the hole picture.
How do you interpret the results from the FOURIER trial with Evolocumab or the CLEAR OUTCOMES trial with Bempedoic acid where the total number and the cardiovascular number of deaths was higher on the treatment group??
I was one of the first Paramedics in Arizona way back in 1975, and I taught all of the standards that later became ACLS, practiced until my lumbar vertebrae could take no more. I taught human anatomy and physiology for the better part of 30 years and tried to stay current for my future PA, RN, and whatnot students. Now I am a Lutheran Pastor and at age 70 I am looking back on my earlier life and wondered why my doc doesn’t treat my unifocal PVC’s, and my own parishioners are on the receiving end of these ridiculous treatments that have zero chance of improving their quality of life. I often translate their physician decisions for them (and occasionally get to meet some if I can get to visit them before they are discharged) and just shake my head in disbelief.
Whatever happened to “evidence-based practice” that I read so much about back in the day? I now routinely advise those of my parishioners who are older than me to have their desires known....do they have their “orange card” ACLS Prehospital Directives so our Paramedics know what the end of life care decisions have been made by them and their physicians. To be fair, it is a hard sell to get those who would most likely not benefit from a full ACLS full-court press only to end up spending their last hours on a vent in a CCU....just sayin’
One brief comment. CCTA on elderly patients on statins is useful to see whether statins or other treatment plans are working--but without "angina" the calcium scan helps get the CCTA in my experience.
We win this thing with words. Check out my new word, coincidist, describing people who blame medical harm on coincidence. Coincidism is a filthy thing that goes right along with fascism and communism. Fake science is coincidism. We counter coincidism with creativity, humor and love.
John, Good piece and very close to the mark. Consulting (hematologically) on an 85 year old scheduled to have a Whipple just caused my head to spin, spewing vomit. Yes, it is easiest to tell the family "We are doing something". (This is exactly the same idiotic behavior that drove well-known-to-be-worthless masking and antisocial distancing during covid. As with the surgery, doing something is usually worse than doing nothing if there is nothing to be done.) But the medical students ask, when we leave the room, "Why are we doing this?". And there is no good answer.
As others in the comments have noted, profit matters. There is no group to say "do not do that...it is likely that the non-cure is worse than the disease" because on Medicare the hospital will make a lot of money from the Whipple...and none if the patient is sent home to expire from their widely-spread pancreatic cancer. One can protest all one wishes...this economic sword of Damocles hangs over every decision. It is easier to make the decision that makes lots of money (none of which is actually paid by the patient so no intelligent economic decision making is made there) and that leaves everyone glad that "the doctors are doing something".
As noted above, this bothers lots of those entering the profession, but then we beat it out of them. Some of the beating we bring upon ourselves by trying to find (as you point out often) generally specious research that supports what we want to do. Cifu's recent article about the spikeshots saving millions of lives is solely based on a highly flawed (call it garbage) modelling study and no actual facts. But I am sure it made him feel better to quote it because he likely recommended lots of the genetic engineering to his patients and facing the fact that we were all lied to and propagated those lies to our patients is really difficult. Not picking on Adam; I just use this as an example because it applies to LOTS of things we do TO patients, putatively FOR them.
The question is "how does one begin to address this"? It would be of value for Adam to contemplate his reliance on bad science (the model designed to show a particular result [as are all models] but this one is consonant with what he wants to believe) in an article on how bad science is as an archetype of the kind of soul searching that we all need to do if we are ever going to put medicine back on decent footing. Otherwise, I see patient trust eroding daily...and I am not sure that it should not. This seems a very sad way to end my career.
There needs to be an awakening that matters. Perhaps you can help drive that.
If I see one more Jardiance commercial I’ll scream...
To throw another perspective out there, it helps to look into the origins of modern medicine. I've done some work in this piece (https://unorthodoxy.substack.com/p/donating-to-a-good-cause-how-billionaires), but I think the underlying issue is that much of our medicine is profit first then patient care. We're seeing this play out with obesity and the GLPs that I discuss here: https://unorthodoxy.substack.com/p/the-hidden-struggle-in-health-care
Dr. K--I am a retired surgical nurse with open heart experience and I have seen the impractical surgeries , as you mentioned with the Whipple, on an 85 year old with advanced cancer. In most of these cases the surgeon didn’t make the decision to do the surgery it was the family because even though they knew the surgery wasn’t a cure and would most likely cause their loved one more discomfort they just couldn’t let go. We put G-tubes in comatose 90 year olds because the family couldn’t say goodbye. So when the medical student asks “why are we doing this?” the answer is because the family can’t let go. Perhaps more information , education and empathy for our patients and family and less --much less, advertising on television that leads the public to think that medical science has the cure for everything. The studies that the public have access to are so skewed and may only consist of a population of 10 but are enough to convince lay people of their accuracy. Hopefully, the work of Dr. Mandrola will expose these studies and give us more sensible decision making information.
We all know where the bodies are buried. How many call the feds to let them know? How can you when they are in the same organization that employs you?
Dr Mandrola :
I heard your podcast about p values and statistical significance.
Im really worried about trusting too much on the p values and not seeing the hole picture.
How do you interpret the results from the FOURIER trial with Evolocumab or the CLEAR OUTCOMES trial with Bempedoic acid where the total number and the cardiovascular number of deaths was higher on the treatment group??
I was one of the first Paramedics in Arizona way back in 1975, and I taught all of the standards that later became ACLS, practiced until my lumbar vertebrae could take no more. I taught human anatomy and physiology for the better part of 30 years and tried to stay current for my future PA, RN, and whatnot students. Now I am a Lutheran Pastor and at age 70 I am looking back on my earlier life and wondered why my doc doesn’t treat my unifocal PVC’s, and my own parishioners are on the receiving end of these ridiculous treatments that have zero chance of improving their quality of life. I often translate their physician decisions for them (and occasionally get to meet some if I can get to visit them before they are discharged) and just shake my head in disbelief.
Whatever happened to “evidence-based practice” that I read so much about back in the day? I now routinely advise those of my parishioners who are older than me to have their desires known....do they have their “orange card” ACLS Prehospital Directives so our Paramedics know what the end of life care decisions have been made by them and their physicians. To be fair, it is a hard sell to get those who would most likely not benefit from a full ACLS full-court press only to end up spending their last hours on a vent in a CCU....just sayin’
Yes, direct fraud is a low hanging fruit easy to pinpoint. 🍎
The wider methodological fallacies are much deeper issues that are not well understood or acknowledged.
Medical 🏥 and social sciences widely and firmly deviated from truth and usefulness.
Hard sciences and economics are holding quite well though.
One brief comment. CCTA on elderly patients on statins is useful to see whether statins or other treatment plans are working--but without "angina" the calcium scan helps get the CCTA in my experience.
We win this thing with words. Check out my new word, coincidist, describing people who blame medical harm on coincidence. Coincidism is a filthy thing that goes right along with fascism and communism. Fake science is coincidism. We counter coincidism with creativity, humor and love.
https://open.substack.com/pub/coincidism/p/ive-created-a-concept-i-call-coincidism?