Ricochet is the best place on the internet to discuss the issues of the day, either through commenting on posts or writing your own for our active and dynamic community in a fully moderated environment. In addition, the Ricochet Audio Network offers over 50 original podcasts with new episodes released every day.
Searching for Problems and Ignoring Solutions
I took statistics in college, and we studied it in medical school, but for some reason it didn’t really affect me. Then, later in my career, I gradually came to the realization that many of the decisions I was making for my patients were based on guesswork. Educated guesswork. But still, I was mostly guessing. That is a terrifying realization for a physician to make. Although in my view, it’s more terrifying when a physician doesn’t realize it.
Anyway, at that point, I started studying statistics in earnest. I’m good at math, and had always excelled at calculus and so on in school. But I slowly reached the conclusion that statistics isn’t really math. At least, not in my view. It’s a way of looking at the world. In fact, the world doesn’t make much sense, until you understand statistics. At that point, things become a little clearer (or, perhaps, a bit less unclear), and decision making becomes simpler. Again – the use of statistics does not make things more complex. It makes things simpler.
I’ve given hundreds of speeches to doctors’ groups all over the country (mostly about heart disease), and I spend a lot of time on statistics. The number one complaint I get on my reviews is, “I’m not a mathematician! I’m a doctor! Talk about medicine, not math!” I respond simply that medicine is complex, and it’s virtually impossible to understand if you don’t understand statistics. Math is simply the language we use to precisely describe complicated things. I teach about math, because I don’t know how else to explain how heart disease works. But after having explained my point to countless doctors, and countless patients, I’ve noticed a few trends about how people look at complex problems. Perhaps you’ll recognize these trends, based on your experiences:
I think that in general, most doctors order way too many tests. They don’t necessarily understand exactly how those tests are done, or what they measure exactly, or what to do with the results. But if they think someone has heart disease, they just start checking every box on the “Cardiovascular” panel. I explained part of my concern about this in a previous post:
A couple years ago I was giving a lecture to a group of Cardiologists about advanced cardiovascular testing, and someone asked if I used a certain lab test. I answered, no, that I found it unhelpful. He protested that it was an accurate test. I agreed, but replied, “To me, it’s like an Obama sticker on a Prius. It may be accurate, but it doesn’t add any information that you didn’t already know.”
So I spend a lot of time trying to get doctors to think backwards, sort of. What can be done if the person has this disease? What tests will help you determine your course of action? What tests are unhelpful, and therefore potentially misleading? This is a big, complicated topic well beyond the scope of this post. But my point is that lots of very intelligent physicians struggle with relatively straightforward data analysis. And they do this for a living.
Imagine those with no background in math.
I’ve noticed that a patient’s inclination to treat a disease is often inversely proportional to their inclination to collect data about that disease. And I think that perhaps that dichotomy might help explain many of our social problems today. Let me try to explain. See if you agree with my premise…
“Susan” had dinner at her club last month with a patient of mine, who happens to be a retired cardiovascular surgeon. He went on at some length about how impressed he was with my efforts to approach heart disease in a rational, evidence-based manner.
Susan is very fit and focused on her health, because everybody in her family dies young of heart disease. Her total cholesterol is always over 300 despite her best efforts. She refuses to take statins or other ‘cholesterol drugs,’ but understands that she has a problem. She was so impressed by what her friend said that she paid her money and joined my practice. Our first visit was fascinating:
Susan: “I really look forward to working with you. Dr. Smith said you’re really good at heart disease.”
Me: “Thanks! I do the best I can. How can I help you?”
Susan: “I have really high cholesterol and a lousy family history. But I don’t want to put a bunch of chemicals in my body, and all my previous physicians have tried to put me on a bunch of drugs. I’ll be interested to hear your advice.”
Me: “Sure. Do you have any of your previous labs?”
Susan: “Here’s the last set of labs from my previous doc.”
* hands me a big stack of papers *
Me: * starts paging through every lab test I’ve ever heard of, and some that I hadn’t… *
“Wow.”
Susan: “Wow? What do you mean?”
I’m not sure what to say here. Either her previous physician had no idea what she was doing, or she was trying to show off by ordering lots of exotic tests. I suppose it doesn’t matter which one is true. I’m trying not to step on toes, so I ask, “So, um, what did your previous doc say about all this?”
Susan: “She tried to put me on a statin. But I’ve read that statins are bad for you.”
Me: “I can believe that.”
Susan: “You believe that statins are bad for you?”
Me: “No. I can believe that you read that.”
Susan: “What do you mean?”
Me: “I mean that if your previous doc had read your family history, and had looked at these labs, and decided not to treat, that I would call that doctor on the phone and ask what on earth she was thinking.”
Susan: “I don’t want to put a bunch of chemicals in my body.”
Me: “Do you take any meds at all?”
Susan: “No way. Like I said, I don’t want to put a bunch of chemicals in my body.”
Me: “Do you take any supplements?”
Not surprisingly, Susan pulled a Ziploc bag out of her purse, filled with every supplement I’ve ever heard of, and some that I hadn’t. I said, “Wow – that’s a lot of chemicals that you’re putting into your body.” I grab a bottle at random and show it to her. “What does the research say about this one?”
Susan: “What do you mean?”
Me: “Do people who take it live longer? Which people? Are you one of those people? How can we tell?”
Susan: * starting to get understandably defensive *
“Look, can we just repeat these labs, and see what we find?”
Me: “Not if we’re not going to treat it. If you’ve decided not to treat your heart disease, that’s fine. That’s your prerogative. But if we’re considering treatment, I think we should check some basic stuff, look for root causes of disease, and decide on a rational course of action here.”
Susan: “What about my SDMA? What about all those other inflammation markers?”
Me: “Those may prove to be relevant someday, but right now they’re very poorly understood. Let’s work with what we know – what we have evidence to support. We already have what we need. Let’s develop a plan of attack, based on your particular situation. Find the disease. Fix the disease. Move on with our lives. Checking the same meaningless tests over and over again is unhelpful. And if that’s your plan of action, then you don’t need me.”
Well, things went downhill from there.
She wanted to do more tests, but didn’t want to treat. I wanted to treat, but didn’t want to do more tests. The only reason the conversation went on as long as it did was that her husband was there, and didn’t want to walk away from potentially life-saving treatment.
I found it fascinating that she was so unwilling to consider treatments, but she was so insistent on doing more and more testing. Why do all these tests to find a problem that you have no interest in fixing?
Consider the global warming crowd. They want more and more computer models. Is the earth warming by 1.7 degrees? Or is it 1.9 degrees? Let’s do more studies!
Well, ok. But if fossil fuels are dangerous, perhaps we might consider nuclear power, which results in only warm water and tiny amounts of nuclear waste which can be easily contained and managed. Ok. Let’s get to work.
No. Let’s do more and more computer models. Which we refuse to act on.
How many studies have been done on the problems of children of broken families, pipelines, welfare programs, ethanol fuel, virus mitigation strategies, immigration policies, and so on? We keep doing more studies. And more and more and more.
But it’s easier to study these things than to fix them. So we search for problems that we fully intend to ignore. This seems odd, but it is not unusual behavior.
Now, I understand, up to a point. Our fears of statins, nuclear power, intact families, and so on prevent us from considering rational treatments, so we do more studies. Got to spend that grant money somehow, right? And maybe we might find a more palatable solution. Maybe.
But what if we don’t?
It seems to me that sometimes the more data someone wants, the less interested they are in fixing the problem they’re studying. Or something.
One problem here is probably that in order to improve most of our social problems, our government would need to do less, and spend less, rather than more. No politician can run for office on that, so they avoid exploring solutions (which might not work, which would look bad) and they spend more money on studies.
But I don’t think that’s it, entirely. I think there may be a parallel between excessive government studies and my patients who want every test under the sun run on them, regardless of the evidence behind these tests, because they want to “do something” about a disease they have no interest in treating.
“Susan’s” approach to heart disease seems similar to Nancy Pelosi’s approach to homelessness. And is similarly effective.
Perhaps this isn’t just political expediency – perhaps it’s human nature.
Or perhaps it’s not.
What do you think?
Published in General
I would call it acquiescence and some self-participation by the black families.
Great example of the principle that one should always ask whether a medical test will affect treatment in any way.
No – that’s actually legit. If the bone was even touched by that screw, then you’re probably on IV antibiotics for weeks.
?
Fair point too. I was thinking that bone contact/damage might affect the healing time in ways that might not be immediately evident, and going back to work too soon might result in further damage/complications.
No, it’s not.
I just bought an airline ticket to go visit family. I found it to be a simple process – not confusing at all – even though I don’t know anything about flying planes. But I chose an airline I trust, and I expect them to take care of the flying part for me. I could spend the next 5 years of my life online reading everything I can find about flying planes, but still, that pilot who has been actually doing it for most of his life will still be better at it than me. So I defer to his expertise. Because I don’t want to die in a fiery plane crash.
Find a good doctor (not always that simple, I know). Follow his/her guidance.
Focus on the research of finding a good doctor, not the research about cardiovascular inflammatory markers or whatever. Then let him fly the plane.
Maybe they were being ironic/sarcastic? But then, I think most Dimocrats are pretty Dim.
It must have missed, because I wasn’t on any antibiotics, and I was fine.
My father was a lab tech for 22 years in the Air Force, and another 20 years after he retired. We had to be seriously in danger before he’d take us to the hospital. I guess it carried over.
I was back to work as soon as they let me go. I think they gave me a band aid.
If it would have hurt a lot more with bone involvement, maybe that was also indicative. And they did mostly want to just bill more.
What I was going to say. Susan keeps wanting more tests because she’s hoping one will eventually give her the answer she wants to hear.
I’m not sure that’s true. I had my left ankle fused, and the pain was such that I didn’t even fill the pain-killer prescription.
Different people, then. I’ve never felt a need to use like Tylenol 3 after tooth extractions etc, or once when I got stitches inside my mouth after being “mugged” walking home from the laundromat. (He didn’t get any money, just a face-full of bleach.)
I have a relative who has a PhD in Pathology who is very anti-statin. She thinks that elevated serum (blood) cholesterol levels are not the main cause of cardiovascular disease (CVD).
She also said that there is no benefit in getting your serum cholesterol tested because blood cholesterol levels do not cause CVD and lowering blood cholesterol levels do not improve outcomes for people with diagnosed CVD. She also mentioned that the human body needs cholesterol in order to function properly.
Me, as a non-PhD in Pathology, tried to talk her out of the position she has taken regarding serum cholesterol and CVD. But that was a waste of time because if she thought that MDs and PhDs who argue that elevated serum cholesterol levels are the primary cause of CVD are wrong, hearing a non-MD, non-PhD like me try to make the case isn’t going to work.
This relative of mine is generally very smart but very wrong on this particular issue, in my opinion. Her double MD sister couldn’t convince her that elevated serum cholesterol levels do cause CVD but to no avail.
Bob – if it involves your heart, and there is an issue of concern, I think Dr. Bastiat would agree there is a problem in need of a solution that you should seek out?
Hmm. Is it possible that a pathologist actually knows more about what causes death than standard MDs?
Like the “public servants” in our county’s health Department.
I should also mention that some studies done on the relationship between serum cholesterol and CVD have concluded that serum cholesterol does not cause CVD but . . . . .
These studies often are based on populations where nearly everyone has elevated serum cholesterol levels. So, it’s like trying to figure out if smoking causes lung cancer by studying people who smoke 2 packs of cigarettes each day verses those who smoke 3 packs a day.
You just get a lot of statistical noise and end up concluding, “Well, I guess smoking doesn’t cause lung cancer.”
Also, some studies of serum cholesterol and CVD would fail to control for illness people had on study onset. For example, if someone is terribly ill, they might lose their appetite and not eat as much. Well, serum cholesterol tends to decline under caloric restriction. So you end up with someone who dies early with low cholesterol.
Did the low cholesterol cause the early death? Or did the illness which resulted in early death cause the low cholesterol. Even studies published in prestigious medical journals can reach wildly incorrect conclusions.
It’s possible in the abstract. But in this case this PhD in pathology relative of mine is just wrong. At least in the opinion of alot of PhDs and MDs.
But I guess at some point one has to choose which PhD or MD one will listen to, just as during World War II one had to choose which German physicist one would rely on to build the first atomic bomb.
I often wonder about this very issue. You didn’t mention any details regarding the evidence that convinces you and how she might have tried to disprove that case. I’ve taken a statin for more than twenty years but I do a number of other things that could also be involved in having prevented a heart attack or a stroke, so I cannot give any testimony to the effectiveness of the statin because I have no way to tell. I guess, as the post says, statistics make the case.
I don’t think we relied on any German physicists. I think they were on the other side.
Thing is, multiple MDs don’t necessarily know more than a single Ph.D, all of them having MDs suggest that they all know the same things, and those things are all less than a PhD knows or at least SHOULD know.
100 MDs could write 100 papers and a Ph.D could maybe write 1 in the same length of time, but all 100 MD papers could still be wrong. And 100 papers doesn’t just “outnumber” 1 paper. Even if all 100 collaborated on a single paper, it might still be wrong.
For a cruder example, 7 or 8 or 10 or 100 first-graders aren’t smarter than one 6th-grader.
I suppose I could get into the details. But that would take a lot of keystrokes.
I could recommend a few books.
I thought there were several German physicists who defected from Germany and helped the US develop the A-bomb. But if that’s wrong, just ignore my attempt at humor.
My point is that one can rely on “experts.” But one still has to choose which “expert” to listen to.
I guess from your position, you could be grateful that a pathologist probably doesn’t see many living patients.
Is this still allowed?
This is true.
Sometimes the single PhD is ahead of the curve and the other MDs and PhDs are either corrupt or mistaken.
But this isn’t always the case. So, each person ultimately has to decide, even those of us who don’t have a MD or a PhD.
Now, even as a non-MD, non-PhD, I think I could convince most people that elevated serum cholesterol levels are the primary cause of CVD. But notice I said “most” people, not “all” people. And as we know, the majority is sometimes wrong.
And it’s also pretty clear that some people have bad reactions to statins, and those people should not be pressed to use them anyway because “that’s the science.”
No. She worked in an aging lab at UCLA and then at a pharma corporation until she quit and became a stay at home mom while her husband, an electrical engineer, made a fortune in his fiber optics business. They are both still alive. So, perhaps that’s evidence supporting their position. That’s sarcasm on my part.
To be fair to “the other side” of this debate, there are lots of books with titles like “The Cholesterol Myths” that argue the opposite of what I am arguing. I suppose it wouldn’t hurt to read a few from column A and a few from column B. But who has the time?