Three Words That Let You Know You’ve Got a Great Doctor
Most of the time, when doctors change their minds, it is for a good reason. We are trying our best to stay at the forefront of knowledge about health and disease, and that forefront is ever-changing. If we are being honest with ourselves and our patients, we can say the three most powerful words in Medicine: “I was wrong.”
You want your doctor to be comfortable saying those words because all doctors will be wrong sometimes. We can be overtly wrong—ordering the wrong drug for the wrong patient or making the wrong diagnosis—and we must be completely transparent when those mistakes occur.
But even the most conscientious doctor can’t see into the future of medical science. We can’t know what the best possible treatment will be ten years from now. All we can know for sure is that it will probably be different and better than what we are doing today, which is, in turn, different and better than what we were doing yesterday. Yes, we are always changing our minds. Yes, it may seem fickle. But in reality, it is growth. It is the evolution of Medicine into a more perfect science.
Many doctors feel that these types of changes are admitting defeat somehow, compromising our air of infallibility. Well, you know what? We are all fallible. The willingness to course-correct, if done collaboratively, honestly, and transparently, can actually build trust.
The Temptation of the “One Simple Thing”
Many patients are hoping for a miracle. And medical miracles do happen. But they don’t happen through magic. They happen, more often than not, after decades of laborious research, of wrong turns, errors, and missteps. Medical miracles are hard-earned. It is for that reason that
the idea that one simple thing can cure your ailment frustrating. Not only does it belittle the true miracles that are out there, but it overshadows them. The bright, shiny promise of the quick fix can lead people away from the real fix. We need to recognize the hype and beware of easy promises.
the history of Medicine is littered with breakthroughs that might sound like quick fixes. Think of Ignaz Semmelweis convincing obstetricians to wash their hands—a practice that cut maternal mortality in half. Or think of the discovery that ether could put patients into a sleeplike state where they didn’t feel pain, transforming surgery from distilled barbarism to the elegant art form it is today. Think of Alexander Fleming and penicillin, or Jonas Salk and the polio vaccine.
But as our understanding of human physiology and pathophysiology has developed, the low-hanging fruit has increasingly been plucked. We lead the long, relatively healthy lives we have now because of a century of medical discovery. We are the beneficiaries of hundreds of quick fixes that we now refer to as “standard of care.” Breakthroughs like those still happen, of course. But “one thing” medicine isn’t really about breakthroughs. It’s about easy solutions to complex problems.
In Medicine and in life: If it seems too good to be true, it probably is. A wrist magnet cannot cure your arthritis. Increasing your quinoa intake won’t prevent a heart attack. A multivitamin won’t make you more energetic, and avoidance of red dye #40 will not make you immune to cancer. Those who offer easy solutions to difficult problems should be viewed skeptically.
Once you recognize the allure of the quick fix, whether it is in an ad or a Facebook post or a magazine article, you will be able to avoid it much more easily. You’ll recognize those who promote quick fixes as (in the worst case) charlatans or (in the best case) people caught up in those incredibly powerful forces—the allure of secret knowledge, the power of meaningfulness—that can so easily entrap us if we are not on the lookout.
The downside is you’ll realize that the real solutions are rarely simple. For some, that may be a bleak conclusion; we don’t always have all the answers, and even when we do have solutions, real change requires real work. But for most of us, the realization can be liberating. It means we don’t have to pore over the latest wellness blogs or articles, trying to figure out what the secret is. We don’t need to throw away all the food in our cabinets and replace it with the latest “superfood.” And, critically, it means we can speak with our doctors and face the harder truth of the treatments we have in front of us. We can trust them when they tell us that it won’t be easy, that we have work to do, that there isn’t always a straight path or one simple trick.
Good Medicine May Not Be Good for You
PATIENTS OFTEN BELIEVE that there is a single, “right” answer to their medical problem. And while we can all be led astray by “one thing” medicine, there is still the implicit belief that when we have to make a choice between options, there is a right one and a wrong one. Really, all of medical science is about trying to figure out what the right choice is in a given clinical scenario. Even studies that compare a new drug to a sugar pill are implicitly studying a choice: Is taking this drug better than doing nothing? (Often, the answer is no, and the drug does not make it to pharmacy shelves.)
But medical studies look at groups of people, and you are not a group. You are an individual. Making good medical decisions doesn’t always mean doing what has the best chance of success, on average, because you are not average. No one is. Teasing apart the individual benefit of a medical intervention from the population-level benefit is complicated and something most doctors don’t fully understand. But to be able to really talk with your doctor, and to explain why you might be making a choice that seems “wrong” to him or her, you need to understand the difference between the “average” person and you.
To talk to your doctor about personal risk (instead of population risk) requires you both to understand the biggest secret in Medicine. It is a secret not because of some vast conspiracy, but because it is poorly understood. The typical story goes that we are being silenced by Big Pharma or taking kickbacks, and the whole system would come crashing down if word got out that a bit of turmeric is all you need to cure acute lymphoblastic leukemia.
This is, of course, ridiculous. First, because most doctors are not psychopaths. But even more practically, keeping secrets is really hard. You probably know from experience that the more people who know a secret, the more likely it is that that secret will come out. Couple that with the fact that, as
most medical researchers have a deep and abiding interest in becoming famous for curing some terrible disease, and you will realize there is really no way a miracle cure would be kept behind closed doors.
But there is one secret that the entire medical establishment seems to keep, likely because most doctors aren’t thinking deeply about it. If you understand it, you will be way ahead of the curve of most patients and many doctors. Stated simply, it is this: Chances are, the medication you are taking isn’t going to help you.
Chances are, the medication you are taking isn’t going to help you. But it might. Scientific studies show us with a high degree of certainty that a medication will help some people with a given condition. The problem is, we have almost no ability to know specifically who among the people with that condition the medication will help and who it won’t.
Put yourself in the shoes of a physician treating patients with high blood pressure. Let’s say you have a panel of one thousand people, and you’ll be treating them for just over three years. If you adopt the SPRINT practice of intensive blood-pressure treatment, you can expect thirty-three of your one thousand patients to die. If you stick to the older practice of standard blood-pressure treatment, forty-five of your one thousand patients will die. That means that your choice, intensive versus conservative treatment, will save twelve lives.
But what is the cost of that choice? To save those twelve lives, you need to treat one thousand patients with additional medications to get their blood pressure down to below 120. We can divide that one thousand by twelve to arrive at a statistic called the “number needed to treat,” or NNT—the number of people you need to treat to save one life. In this case, the NNT is 83.
Is it worth treating eighty-three people with a certain practice to save one life? The answer, like so many answers in Medicine is, “It depends.” If the intervention is cheap, without side effects, and widely available (like a vitamin C pill or a daily walk), then, sure—go for it. If the intervention is highly toxic and expensive (like chemotherapy), it may not be worth it. In the case of blood pressure, the burden and cost of an additional blood-pressure pill is not too bad, but reasonable minds may differ here.
No Such Thing as Incurable
IF YOUR MAJOR source of medical news is the mainstream media, however, you may think that, with rare exceptions, medical research is simply a parade of astounding successes: SCIENTISTS HAVE DISCOVERED THE KEY TO TREATING ALZHEIMER’S DISEASE; NEW TREATMENT MAY CURE MULTIPLE DIFFERENT TYPES OF CANCER; FOLLOW THIS SCIENTIFICALLY PROVEN METHOD TO LOSE THOSE EXTRA POUNDS. The reason medical successes (or studies that can be spun to sound like they are successes) get so much press attention is because they are exciting. They generate engagement. The press is giving its readers what they want to hear.
No one would be interested in more realistic news articles that accurately characterize the state of affairs in Medicine: DRUG WITH PROMISE TO TREAT ALZHEIMER’S PROVES WAY TOO TOXIC FOR HUMAN CONSUMPTION; CANCER TREATMENT EFFECTIVE IN PETRI DISH, NO DATA ON HUMANS YET; DIET LEADS TO, AT BEST, TRANSIENT WEIGHT LOSS. This is not entirely the fault of the press—the author doesn’t like writing about negative medical studies either—but it does create a very false perception.
Failure isn’t the exception in medical research; breakthroughs are the exception. Safe, effective treatments are the exception. By the time a medication reaches wide use, it has passed through a veritable gauntlet of potential failure points, from lack of efficacy to unacceptable toxicity. Our pharmacopoeia is a book of gold-medal winners, survivors, the cream of the crop. Which is why physicians are so skeptical of new treatments, especially those that have not gone through the rigorous vetting process of clinical trials and FDA approval.
We believe that there are cures for every disease (even if many are undiscovered), but we also know that those discoveries come at a cost—that long string of failures. Cures don’t happen out of the blue. For any given disease or health problem, there is a time before we know whether or not a given treatment will work: before it has been tested in the robust causal framework. In those situations, we find ourselves in a scientific twilight zone, where there is no conclusive proof that a treatment will work, but no conclusive proof that it won’t work either. A question that comes up from patients all the time in these twilight areas is “Why not try?”
The pat answer is “Side effects.” Doctors are quick to trot out the risk of side effects to avoid prescribing a medicine without a strong evidence base, but, to be honest we overplay this card. While most medications do have side effects, most side effects are mild and self-limited. And if they develop, you can usually stop the drug and you’re no worse off than when you started.
Doctors also take an oath to “first, do no harm,” which we take seriously. That part of the Hippocratic oath leads us to be a relatively conservative bunch. We do not like to take risks with our patients, and any medication without a solid causal link to improved outcomes constitutes some risk (however minimal) without obvious benefit. But the risk-benefit language is not entirely justifiable. After all, people aren’t asking us to prescribe arsenic. In general, these issues revolve around a medication or substance with a relatively benign safety profile and a biologically plausible (but not yet proven) mechanism of benefit
Moving Together: How doctors and patients must change to trust one another again
Medicine would be the first step toward healing a rift that has been growing between the public and doctors over the past several decades. Some people told it would have the opposite effect, that exposing the limitations of Medicine and medical science would make people trust their doctor less, not more.
But people are intelligent enough to embrace the central contradiction in medical science: that an enterprise that is often focused on profits over people, that largely ignores huge problems like social isolation and non-life-threatening illnesses, can still be a force for good, that it can still be the single endeavor that has alleviated more suffering in humankind than any other. In other words, look where we are, but imagine where we could be.
For patients, this book asks you to think about Medicine in a new way—less like a miracle pill and more like a stock investment. Doctors help you invest in your health, but there are no sure things. The book also asks you to recognize how powerful the idea of a sure thing is, and how other people—some with good intentions and some with bad—can use that idea to take advantage of you when you are in a time of need. This book asks you to appreciate how Medicine continues to evolve, with new discoveries overturning old beliefs, inching us closer to real truth. It asks you to recognize your own human biases, to avoid believing something because you want it to be true or because it comes from someone you want to believe.
This book demands something of physicians as well. Fundamentally this book forces doctors to ask a simple question: “Whose side am I on?” And to realize that there is no difference between being out for ourselves and out for our patients—because doctors and patients are on the same side.
It is doctors and patients who fight together against disease, death, pain, and suffering. It is doctors and patients who fight to improve the human condition, to create the world we live in today—a world of breakthroughs and a world of cures. With those battles under our belt, there is no reason we can’t fight together to ensure that every human being gets cared for when they are sick, or that lifesaving medications are affordable.