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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
They could be. But they’re likely more ignorant.
We relied on German scientists after the war for rocketry, but I don’t think we relied on them during the war. I guess Einstein could be considered German, but Oppenheimer and Teller weren’t.
Well, I do also tend to think that individuals’ natural cholesterol levels can vary like individuals’ “normal” temperatures can. 98.6 was never really serious to begin with. And I certainly wouldn’t be surprised if some peoples’ “healthy” cholesterol levels can be higher or lower than what happens to be considered “normal” at any point in history.
I’m also wary of BP readings since I have “healthy” numbers when I have them use a manual sphygmomanometer* rather than the automatic. Maybe I “tense up” because the automatic ones always “squeeze too hard” at first? I don’t know. But I also wouldn’t be surprised if drug companies capitalize on many people having artificially high BP readings from the automatic gadgets which can lead to them having statins recommended.
* and I didn’t have to look that up!
I’m going to ignore it. If it kills me, it kills me. I’ve made my 3 score and 10. We all die of something.
The evidence that I think is very supportive of the belief that elevated serum cholesterol levels cause CVD is the studies that have been done on people with familial hypercholesterolemia (FH) and also people with hypo beta lipoproteinemia (HBL).
Both FH and HBL are genetic disorders.
People with FH have severely reduced ability to metabolize serum cholesterol. Many people with FH have heart attacks when they are children. These children generally aren’t heavy smokers or living a high-stress lifestyle. It’s just that their liver can’t clear the cholesterol from their blood and their serum cholesterol levels soar to 600 to 900 mg/dL.
People with HBL have a genetic defect which results in extremely low serum cholesterol. They often get LDL numbers under 30 mg/dL. They have 90 percent less CVD than the general population.
So, that’s very hard to explain if serum cholesterol isn’t a causal factor in CVD.
Those are at least suggestive, if not telling, but there’s always the possibility that those could be more like symptoms of something else, like the heart attacks or no heart attacks could also be symptoms, not causes or even effects.
For sure I’m doing things to try and keep healthy rather than “going with the flow” and then start taking statins if someone says I need to.
There used to be studies showing that moderate wine consumption helps, I don’t know if that’s still considered valid or not but it really doesn’t matter to me because I hate wine anyway.
No- missing bone involvement would be a serious mistake-greatly increasing the risk of osteomyelitis-hence the need for antibiotics. Since pain is subjective it is hard to rely on as a marker for such an injury. Additionally, excluding an intraarticular injury is important (into a joint space).
I knew it wasn’t that. It was in the tip of my finger.
There is the crux of the matter. How does one find a good doctor? How does one find a doctor one can trust? I think for most of us, it’s pretty hit or miss. Our company moves us to a new state. Our company changes the health plan, and suddenly we need to choose our primary care physician from a big book of listings which our old physician is not in. We ask around for the best advice we can get, but people evaluate physicians in different ways. And maybe some of the physicians recommended are not taking new patients.
We wind up picking randomly as the deadline approaches and get some guy who tells us with a sneer, “Oh, that can’t happen,” when we report that we had a reaction to a medication he prescribed. Even though the adverse reaction is listed as a possible side effect on the sheet that came from the pharmacy. Even though we double checked by skipping a day and trying again, only to get the same reaction. And so we’re stuck with this damned fool until the next enrollment period who doesn’t listen to a patient but is apparently more concerned about lawsuits or something than whether he prescribes the same thing again and kills the patient.
Lather, rinse, repeat three or four times with different physicians, and one stops going to physicians and doesn’t trust any of them anymore.
And now those same doctors seem to be saying “oh the vaccines are perfectly safe.” As if they all have Ph.Ds in pharmacology or something. What it might really mean is they don’t want to be fired for saying the “wrong” thing. Or they might really believe it, not sure which is worse.
My favorite doc was the one I saw when I went to urgent care with a bad cough. He told me I either had bronchitis or pneumonia and if I wanted he could send me to x-ray to find out. I asked if it would change the treatment (antibiotic script) and he said no, it would just take up more of my day and make me wait longer for treatment. I said no x-ray and went home with my script. Never did find out what it was but the script worked.
Ok. Lordy.
I shouldn’t have used statins as my example because they’re so polarizing, and I didn’t want this post to be about medicine. But just real quick:
Diagnosing heart dse by checking cholesterol is a losing game, and using statins to lower cholesterol makes no sense to me. Cholesterol is harmless in many people, but under certain circumstances it’s pure poison. So in my view, we should spend more time looking for those circumstances than looking for cholesterol.
There is no question that statins and other meds have enormous impacts on heart dse. It’s so obvious that they prolong life that the FDA won’t allow placebo studies anymore on event rates with statins. We know they work. We just don’t know how, exactly.
So the real problem is that we often give them to the wrong people. We should be giving them to those with heart dse, not those with high cholesterol.
Each one of these sentences is a one hour lecture that I would give at a conference, and I have no interest in explaining all this in this forum. This is just a quick summary, because this is not the topic of the post.
So let’s get back to the conflict between knowledge and wisdom, shall we?
If follow you @drbastiat, so I saw this post shortly after you posted it. It had no comments yet. I read the first paragraph and thought, “I’m gonna need a drink”. Magically, my wife pops up and says “Mexican tonight?”. (There a fabulous place within walking distance.) So I leave my browser open to this post…..
I split a 64-oz Margarita pitcher with my wife. She didn’t help much. We (I?) stagger home a little while ago and I peruse what I deferred. I am so glad I had that margarita.
Let me attempt to sum up this post and its comments to this point:
Engineers like me are all too familiar with these social/psychological phenomena.
Did I say that I am glad I had that margarita?
{ I have edited this post four times now to correct margaria-induced typos. Sorry. }
I just don’t want you to think I have been making all of this stuff up. So, I will provide one last reference to support what I have mentioned.
Twenty questions on atherosclerosis by William C. Roberts, MD
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1312295/
My pediatrician was Harold Hobart, a well-loved doc in DC. In my 30s and 40s I continued to encounter other adult former patients who all said that they wished they could have had him as their personal physician forever.
He had a gift for reassurance that was unique. It is hard to describe but he could go from a kind of wry chuckle that a mom or her kid could ever have been worried about these symptoms then become authoritative and serious when prescribing medicine and next steps. He came to visit me in the hospital one evening—I crashed a bike headfirst off a hill at age 12 with no serious injury but was kept for observation. He seemed genuinely concerned. The nurse told me later that he personally checked up on every kid of his almost every day.
I bring up Dr. Hobart because explaining the odds is largely pointless for most people, especially if fear has shaped their perception. (Like the joke about the man who is told that yes, he is correct that early stage brain cancer is painless and largely symptom-free and the man says that’s exactly why he’s worried because his complete absence of symptoms precisely matches that description.)
Hobart’s own contagious response to the case presented was much more persuasive than a dispassionate exposition of the odds of various outcomes. You immediately felt about your illness the way he did—more importantly, Mom did too. You did what he told you to do.
There were a couple of surgeons in the Army medical company I was in who had that QB-fighter jock-winner persona that I am sure enhanced outcomes by the increased level of confidence and hope they inspired in patients—whatever it is in there causing my problem, that guy will surely beat it.
Rational perception can be over-rated.
Maybe it would help to make people aware of their own risk acceptance before discussing odds. Do you ride in automobiles at night in the rain? Do you eat shellfish? Do you wear a helmet when using stairs of the bathtub?
Ultimately, you have a right to be kinda nuts but your doc is not allowed to join you there.
It appears all that’s left is to correct the spelling of margarita.
When I was going for my PhD, it was mandatory to attend the Friday afternoon seminars, where new research was presented, visitors presented their current research, and advanced PhD students presented their dissertation research. Often tangential discussions occurred.
Some of our faculty were the people who taught statistics courses in the medical school at the the university hospital.
They described teaching statistics to MD candidates as similar to trying to teach dogs how to use doorknobs.
The difference, of course, is that dogs have at least a passing interest in doorknobs, and understand that they’re somehow important.
Doctors tend to be lousy at stats. I’m not sure why. But it’s true.
No, that is exactly how it is spelled while in his state. (Think of a fine Dudley Moore delivery when you read it.)
I had two MDs as law school classmates. They had a very hard time grasping that in law (especially in the hands of law professors) there may not be a right answer and the goal was to understand what the competing options are and be prepared to take either side. I could easily see them resisting a probabilistic approach to anything—51% or 100% is the right answer. Period.
My last heart surgeon was an engineer at NASA when he decided to make a change.
You did realize that there is an actual peer-reviewed journal called Nature, and that it has been around a long time? I realize you were writing fiction, but that threw me.
And when it’s time for tenure review, I would think scientists would get points for condescending to interact with the public in a popular journal. They won’t get tenure based on that, but these days they might lose points for not doing some sort of public outreach. Officially, anyway.
I do both and have done both. I expect to have reasons explained to me, and if I get weasel words, I act accordingly. That doesn’t mean I reject the doctor or the advice, just that I do some of my own research. But I don’t expect to become an expert on a medical topic. I argue with my primary doctor, but I also listen to her because she knows a lot of things I don’t.
Last time her nurse said, “Oh, yes, I remember you.” I had got a little angry with her over the phone about the way they were dealing with my lyme disease last summer. When I had a second bout, they came around quickly. But that time my doctor also referred me to an infectious disease specialist. I had told her that I didn’t know how the tests could work for a 2nd bout–how they could distinguish a new infection from the old one–and she said she didn’t know either. The infectious disease specialist agreed that one can’t know, but I knew I was talking with someone who knew his stuff, and he did make a modification to my antibiotic regimen, admitting that it was based more on a hunch than actual data. I did what he said.
I was also going to tell the story of how I dealt with a prostate cancer diagnosis 20 years ago, as it, too, involved some of both of looking for the best doctor and doing my own research (though definitely not a deep dive into the medical literature, as some people think they need to do). But I long ago grew tired of telling that story.
It’s an interesting post framed in an interesting way. And it’s something I’ve been thinking about for a while.
I think the problem is that there is a glitch in our decision-making process.
I’m a lifelong fan of management by objectives (MBO) theory, which requires having a mission statement. MBO is often supported in the business world by hypothetical zero-based budgeting, whereby all budgets are set at zero rather than set at whatever was in them the preceding year. All of this is pulled together in the balanced scorecard. The scorecard makes it all work.
This framework gives people a way to compare their mission against possible budget, risks, and rewards of various courses of action. It also provides a way to think about measuring progress.
There is an underlying purpose for every single decision that is made. Where are we going?
I believe doctors think this way automatically. I don’t know if this comes from medical school training, or if the old doctors are looking for this innate ability in young medical school applicants and so that’s why they all have it. :-) Whichever the case, it creates decisiveness and leadership. A doctor is another word for leader. (Some say teacher, but what is a teacher but a leader?)
However, for whatever reason, every doctor I’ve ever had has considered possible courses of action in this type of analytical framework. I’ve always enjoyed talking to them even though I hated whatever it was we were talking about.
The only other time I have worked with people who consistently approach decision making with this type of analysis was when I had to work with a couple of lawyers my mom had at some point. They were senior partners at Hale and Dorr in Boston.
But you really have to climb up the responsibility and authority ladder to reach that kind of clear thinking. I haven’t noticed it in anyone lately except Ron DeSantis. For some reason, he thinks very clearly. It’s wonderful. By the way, so does Trump. He has flashes of genius insight that he reverse engineers to bring about whatever it is he can see in his mind. I’m impressed, but it’s a different process. I am more used to the DeSantis way of making decisions.
What’s frustrating to me is that to some extent, this type of analysis is just plain work. It can easily be taught. It’s a wonderful life assistant to put in kids’ back pockets. :-)
Prostate cancer is what got my father, back in 2002. It’s likely he would have had a lot more time, or perhaps even beaten it, except at that time Kaiser Permanente wasn’t doing annual PSA tests and it was discovered too late.
You mean you choose your own pilots? And get co-pilot opinions?
Yeah, that’s one of the areas where I look carefully at doctor’s advice. If a doctor is not ordering PSA tests because CDC studies show they aren’t cost-effective for managing the herd, then I don’t take the doctor’s advice at face value. And that is indeed close to the reason why some doctors weren’t ordering PSA tests back then, and maybe now. I know other people who have ended up with untreatable cancer before their time, because their doctors weren’t ordering regular PSA tests.
Same for other tests. If they’re thinking in terms of herd management, that’s not the way I want to evaluate my choices. Listen for the weasel words.
You mean like “herd immunity?” :-)
There may be a point or two of similarity.
Stats are way less interesting than the person in front of you.