Interesting article. Based on the title, I thought it would be in reference to “evidence gaps”- patient profiles or scenarios that were not directly addressed or accounted for in landmark trials…in particular as pertains to age, racial makeup-up, sex distribution, and comorbidities…such that even when there is a “trial for that condition”, there may not be a “trial for that particular patient” you are seeing with that condition.
But this was a very informative summary of some EBM principles. In particular for me, it’s good insight into how I should look at some trials with “negative” results.
My brother, a "skeptic," asked me just this week, to defend statins and sent me an interview of someone on the Joe Rogan Experience who "taught" by misleading. My first inclination was to send - as you have astutely stated - a "study." Instead, I sat back and decided to write, in my own words, a response that I believed was what I would explain to a patient who was asking a legitimate question, and not "baiting" me. Surprisingly, he was satisfied. I absolutely agree that research, studies, and medicine in general is "complicated," and it is our responsibility to not complicate it further. Somehow, the idea that "emergent," changing scientific data means we didn't/don't know what we are talking about. For several years, I knew the last living Nobel Prize in Medicine winner in our medical school faculty. His opinion was quite to the contrary. He believed that this was simply the nature of science and medicine, ever evolving, and ever revealing, and his advice was, "A good scientist never paints himself into a corner." It is always in the best interest of a patient to say, "I honestly cannot answer your question now, but I will investigate it, and I will get back to you."
But, are there ANY doctors that have the time to investigate and get back to a patient? How many patients are seen per day, per week? Maybe a concierge doc could afford to do that. I doubt there are many that can (or want to, after all, docs are just human).
I will agree that we are too quick to say "see, you don't know what you're talking about" instead of "wow, we're constantly learning new things about the incredibly complex biology of a mammal, and it is amazing that we have learned as much as we have in the past 100 years (or 50, or 10...)".
To be fair, sub-specialists, are "specialists." As Drs. Katz & Mackey mention below, keeping current is not impossible. I am in an academic environment, so it tends to be easier, but I certainly didn't make the make my comment to be flippant. Within the context of sub-specialties, there is always redundancy, and new studies are always subject to later confirmation & replication i.e. you are not necessarily going to make immediate practice changes based on a single new study.
This article is both importantly illustrative, and a bit discouraging. Do physicians have the time to read the important details of all the studies relevant to their practice? Most patients don't have the access or the background to do so. Maybe AI can be helpful in sifting through the literature and coming up with guidelines, although a human would need to check their sources!
We often treat the same things over and over again, and brand new practice changing studies aren’t published every day, so it’s hard to do, but not as impossible as it sounds
The same train of thought also applies to younger patients. I have had numerous pediatric patients with congenital anomalies who just did not fit within the parameters of studies indicating a certain response to a certain treatment. During nearly 4 decades I learned diagnosis and treatments tend to be a lot more fluid than some of the rigid dogma that was handed down in training. Really enjoy reading your view points about thinking outside the box when indicated.
I have elevated levels of LDL, lipoprotein (a), and homocysteine. I do take a statin and B vitamins, and at the age of 77, I have no obvious CVD. So far, so good!
So your conclusion is that "science should be trusted, but 'it's complicated'"? Yet you are all in on the idea (one example) that lowering cholesterol is a way to reduce risk of ASCVD? If I understand your previous writings, you are a believer in lowering LDL-C for ASCVD prevention. Despite the mixed results in a myriad of studies, many of which were subverted for a decade or two because the results were not what the financiers were seeking (Minnesota Coronary Study comes to mind).
I have advanced ASCVD. To the point that I had CABGx4 on April 18, 2023. The scleroses were found before I had any infarctions, thank God. I had been on 80mg of Atorvastatin for 2 years prior to that. Told with confidence there is nothing better at preventing a CV event than statin use. Yet my calcium score went from 400 to 600 in those two years. "Researchers" want me to believe that's a good thing, that a "cap" on soft plaque will prevent rupture and thrombosis, therefore preventing MI (though to the best of my understanding this is just a theory, no proof has been provided). My LDL-C was "beautiful", in the 40's! My cardiologist was ecstatic. Didn't believe that my sudden random dizzy spells could possibly be caused by atherosclerosis. After all, I had passed the Treadmill Stress test with flying colors (I was running marathons at the time, yet the TM stress test was seen as adequate to look for ischemia- news flash, I had no ischemia, just a deep, wide family history of ASCVD).
AFTER the surgery was when I decided it was time to learn all I could about this problem. It was then that I discovered how UNCERTAIN "science" actually is. Studies, no matter how well constructed, are subject to bias and human greed. Let's face it, paying researchers to maintain a study for even a few years ain't cheap. Keeping a cohort on track with no "cheating" for extended timeframes ain't easy. And the human body is a matrix of "SYSTEMS", not just a collection of individual Biomarkers.
While RCT's are the "gold standard", the studies that make the boldest claims (or I should say - make the biggest headlines) are frequently observational studies, which quite frankly are not worth the paper they're printed on, and gave us such hits as the Government Sanctioned Food Pyramid and Saturated Fat BAD, Carbohydrates GOOD.
And let's face it, RCT's, as careful as the researchers try to be, are subject to a huge array of confounding variables (see my comment above regarding SYSTEMS vs. Biomarkers).
My takeaway after 2 years of intense study (I'm not a doctor or a scientist, just a self professed "data geek") - I take every scientific study (as I do with my food now) with a significant grain of salt. I read studies in whole, not just the abstract. I study the charts. I look at opposing opinions.
I have learned that taking a medication that affects a Biomarker (even if it's in a positive direction) isn't the same as fixing the root cause. I have learned that, for example, just as many people have MI's with "beautiful LDL-C" as those with "sky high LDL-C". I've learned that the medical "industry" (NOT individual doctors for the most part), is about making money, and RADICALLY controlled, from Med School onward, by the drug industry; and that most people, when given a choice, would rather pop a few pills than make radical changes in their lifestyle. Therefore, we get what we ask for (more meds), and health outcomes continue to suck.
Lastly, I've learned that if you don't follow the crowd, and agree with the mainstream of pharma-controlled medicine, that you are looked at sideways, with a derogatory term applied to you - "crunchy mom", misinformed, disbeliever - or the ultimate slam "ANTI-SCIENCE"; when the facts are that the "science" is not actually all that believable when you really start looking at it. (/rant off)
I agree with the conclusion: essentially that you can’t cookie cutter treat your patients, which is prevalent in doctors’ offices and hospital protocols today. One important component that I did not “hear” in this article is the bias that is present in nearly every study done in western (modern) medicine. I am not an expert, but I have seen enough trial results to understand that there is typically an agenda behind the study that does not necessarily include actually healing a patient. We know that cholesterol, for example, is a necessary building block for testosterone, and that statins are not as safe as once thought as their use affects much more than the actual cholesterol numbers. I remember giving high dose Lipitor (80mg) post cardiac surgery to EVERY patient, and now we give low doses (20-40 mg). If every person responded the same to every medication, then cookie cutter medicine would “work”. For example, if Crestor 10 mg or Lipitor 20 mg lowered cholesterol by 50 points or 20% then there would be predictability in prescribing. But each patient responds differently and we don’t even know why. Also non-pharmaceuticals are rarely, if ever, used and most doctors have little training in dietary recommendations, as well as assuming that most patients are not willing to make lifestyle changes, but would rather take a few pills (paid for by insurance which is highly influenced by big pharma) than change their habits. Although I work in “healthcare” (sick care), I personally prefer alternative options and am very interested in functional medicine/naturopathic ideas for treating myself and my family for our minor health concerns. We try to eat healthy (so hard in today’s environment with so many unhealthy choices, chemicals on healthier options, etc). I am hopeful that RFK,Jr’s work will result in better choices for our future!
Interesting article. Based on the title, I thought it would be in reference to “evidence gaps”- patient profiles or scenarios that were not directly addressed or accounted for in landmark trials…in particular as pertains to age, racial makeup-up, sex distribution, and comorbidities…such that even when there is a “trial for that condition”, there may not be a “trial for that particular patient” you are seeing with that condition.
But this was a very informative summary of some EBM principles. In particular for me, it’s good insight into how I should look at some trials with “negative” results.
Every patient is different
My brother, a "skeptic," asked me just this week, to defend statins and sent me an interview of someone on the Joe Rogan Experience who "taught" by misleading. My first inclination was to send - as you have astutely stated - a "study." Instead, I sat back and decided to write, in my own words, a response that I believed was what I would explain to a patient who was asking a legitimate question, and not "baiting" me. Surprisingly, he was satisfied. I absolutely agree that research, studies, and medicine in general is "complicated," and it is our responsibility to not complicate it further. Somehow, the idea that "emergent," changing scientific data means we didn't/don't know what we are talking about. For several years, I knew the last living Nobel Prize in Medicine winner in our medical school faculty. His opinion was quite to the contrary. He believed that this was simply the nature of science and medicine, ever evolving, and ever revealing, and his advice was, "A good scientist never paints himself into a corner." It is always in the best interest of a patient to say, "I honestly cannot answer your question now, but I will investigate it, and I will get back to you."
Most people respond well to a discussion in good faith
But, are there ANY doctors that have the time to investigate and get back to a patient? How many patients are seen per day, per week? Maybe a concierge doc could afford to do that. I doubt there are many that can (or want to, after all, docs are just human).
I will agree that we are too quick to say "see, you don't know what you're talking about" instead of "wow, we're constantly learning new things about the incredibly complex biology of a mammal, and it is amazing that we have learned as much as we have in the past 100 years (or 50, or 10...)".
To be fair, sub-specialists, are "specialists." As Drs. Katz & Mackey mention below, keeping current is not impossible. I am in an academic environment, so it tends to be easier, but I certainly didn't make the make my comment to be flippant. Within the context of sub-specialties, there is always redundancy, and new studies are always subject to later confirmation & replication i.e. you are not necessarily going to make immediate practice changes based on a single new study.
This article is both importantly illustrative, and a bit discouraging. Do physicians have the time to read the important details of all the studies relevant to their practice? Most patients don't have the access or the background to do so. Maybe AI can be helpful in sifting through the literature and coming up with guidelines, although a human would need to check their sources!
We often treat the same things over and over again, and brand new practice changing studies aren’t published every day, so it’s hard to do, but not as impossible as it sounds
The same train of thought also applies to younger patients. I have had numerous pediatric patients with congenital anomalies who just did not fit within the parameters of studies indicating a certain response to a certain treatment. During nearly 4 decades I learned diagnosis and treatments tend to be a lot more fluid than some of the rigid dogma that was handed down in training. Really enjoy reading your view points about thinking outside the box when indicated.
Thank you!
I have elevated levels of LDL, lipoprotein (a), and homocysteine. I do take a statin and B vitamins, and at the age of 77, I have no obvious CVD. So far, so good!
So your conclusion is that "science should be trusted, but 'it's complicated'"? Yet you are all in on the idea (one example) that lowering cholesterol is a way to reduce risk of ASCVD? If I understand your previous writings, you are a believer in lowering LDL-C for ASCVD prevention. Despite the mixed results in a myriad of studies, many of which were subverted for a decade or two because the results were not what the financiers were seeking (Minnesota Coronary Study comes to mind).
I have advanced ASCVD. To the point that I had CABGx4 on April 18, 2023. The scleroses were found before I had any infarctions, thank God. I had been on 80mg of Atorvastatin for 2 years prior to that. Told with confidence there is nothing better at preventing a CV event than statin use. Yet my calcium score went from 400 to 600 in those two years. "Researchers" want me to believe that's a good thing, that a "cap" on soft plaque will prevent rupture and thrombosis, therefore preventing MI (though to the best of my understanding this is just a theory, no proof has been provided). My LDL-C was "beautiful", in the 40's! My cardiologist was ecstatic. Didn't believe that my sudden random dizzy spells could possibly be caused by atherosclerosis. After all, I had passed the Treadmill Stress test with flying colors (I was running marathons at the time, yet the TM stress test was seen as adequate to look for ischemia- news flash, I had no ischemia, just a deep, wide family history of ASCVD).
AFTER the surgery was when I decided it was time to learn all I could about this problem. It was then that I discovered how UNCERTAIN "science" actually is. Studies, no matter how well constructed, are subject to bias and human greed. Let's face it, paying researchers to maintain a study for even a few years ain't cheap. Keeping a cohort on track with no "cheating" for extended timeframes ain't easy. And the human body is a matrix of "SYSTEMS", not just a collection of individual Biomarkers.
While RCT's are the "gold standard", the studies that make the boldest claims (or I should say - make the biggest headlines) are frequently observational studies, which quite frankly are not worth the paper they're printed on, and gave us such hits as the Government Sanctioned Food Pyramid and Saturated Fat BAD, Carbohydrates GOOD.
And let's face it, RCT's, as careful as the researchers try to be, are subject to a huge array of confounding variables (see my comment above regarding SYSTEMS vs. Biomarkers).
My takeaway after 2 years of intense study (I'm not a doctor or a scientist, just a self professed "data geek") - I take every scientific study (as I do with my food now) with a significant grain of salt. I read studies in whole, not just the abstract. I study the charts. I look at opposing opinions.
I have learned that taking a medication that affects a Biomarker (even if it's in a positive direction) isn't the same as fixing the root cause. I have learned that, for example, just as many people have MI's with "beautiful LDL-C" as those with "sky high LDL-C". I've learned that the medical "industry" (NOT individual doctors for the most part), is about making money, and RADICALLY controlled, from Med School onward, by the drug industry; and that most people, when given a choice, would rather pop a few pills than make radical changes in their lifestyle. Therefore, we get what we ask for (more meds), and health outcomes continue to suck.
Lastly, I've learned that if you don't follow the crowd, and agree with the mainstream of pharma-controlled medicine, that you are looked at sideways, with a derogatory term applied to you - "crunchy mom", misinformed, disbeliever - or the ultimate slam "ANTI-SCIENCE"; when the facts are that the "science" is not actually all that believable when you really start looking at it. (/rant off)
I agree with the conclusion: essentially that you can’t cookie cutter treat your patients, which is prevalent in doctors’ offices and hospital protocols today. One important component that I did not “hear” in this article is the bias that is present in nearly every study done in western (modern) medicine. I am not an expert, but I have seen enough trial results to understand that there is typically an agenda behind the study that does not necessarily include actually healing a patient. We know that cholesterol, for example, is a necessary building block for testosterone, and that statins are not as safe as once thought as their use affects much more than the actual cholesterol numbers. I remember giving high dose Lipitor (80mg) post cardiac surgery to EVERY patient, and now we give low doses (20-40 mg). If every person responded the same to every medication, then cookie cutter medicine would “work”. For example, if Crestor 10 mg or Lipitor 20 mg lowered cholesterol by 50 points or 20% then there would be predictability in prescribing. But each patient responds differently and we don’t even know why. Also non-pharmaceuticals are rarely, if ever, used and most doctors have little training in dietary recommendations, as well as assuming that most patients are not willing to make lifestyle changes, but would rather take a few pills (paid for by insurance which is highly influenced by big pharma) than change their habits. Although I work in “healthcare” (sick care), I personally prefer alternative options and am very interested in functional medicine/naturopathic ideas for treating myself and my family for our minor health concerns. We try to eat healthy (so hard in today’s environment with so many unhealthy choices, chemicals on healthier options, etc). I am hopeful that RFK,Jr’s work will result in better choices for our future!
Always a lot of inter individual variability w anything
Exactly why cookie cutter solutions rarely are the best options.