Doctor draws our attention to the uncertainty of medical practice

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The week before last I was talking over breakfast with a delegate on a wellness programme I was delivering with some colleagues. Somehow (I don’t remember quite how) we ended up talking about the evolution versus creationism debate. I am a believer in evolution. The delegate (let’s call him Greg) believes in creationism. Many scientists believe that evolution the only rational, tenable explanation for the myriad of life forms that exist on this planet. However, as I happily conceded to Greg, evolution is but one example of something that is difficult to prove beyond a shadow of a doubt. In other words, some doubt might remain in the minds of believers of evolution, and this is not necessarily a bad thing.

This is no different to a lot of things taken to be ‘fact’ in science and medicine. Very rarely, if ever, is anything completely clear-cut in science. And I think good doctors and scientists do need to remain open to the fact that we live and work in a world that can so often be quite uncertain.

The conversation with Greg went from my mind quite quickly after we had it, but came back to me this morning while I was reading this week’s edition of the British Medical Journal. Specifically, I was reading a piece [1] by columnist Dr Des Spence, a general practitioner based in Scotland. I don’t know Dr Spence, but regularly read his writings and always enjoy them. He’s something of an iconoclast, and does not shy away from questioning conventional medical practice. While I do not know Dr Spence, but he strikes me as a doctor with integrity, honesty and an ability to think freely. I don’t have a doctor, but if I did, I think I’d like him or her to be like Dr Spence.

Here are the opening sentences from Dr Spence’s column this week that struck a chord.

We are scientists. But the Big Book of Medical Facts is in fact just a pamphlet printed at home, with two paragraphs in a very large font. The only certainty of science is uncertainty. Medicine is often little more than an opinion, a faith system: we believe that what we do is right. This is despite history telling us that what we do now is almost certainly wrong. Our faith has invented words, rituals, elaborate costumes, and a culture of reverence and deference.

The column goes on to draw our attention to that fact that much of cardiological practice is open to question, including the fact that:

  • The risk assessments models used to guide treatment decisions have not been properly tested over time.
  • Often, doctors do not even assess risk, but merely ‘treat the numbers’ (e.g. ‘raised cholesterol’).
  • The recent doubling in the use of statins has had no effect in the real world.
  • Much of the research is conflicting.
  • Many people don’t understand probability, numbers needed to treat, or the treatment paradox (the fact that the majority of people treated will not derive benefit).
  • Illegitimate terms such as “prehypertension” have been coined.
  • That ‘cardiology jumbo jet circuit of international conferences’ exist, in which ‘pharma anointed experts’ receive undisclosed fees and research grants.
  • The research sponsored by the industry is stopped early or that the authors have potential financial conflicts of interest.

Dr Spence goes on to point out that cardiovascular disease is in decline, which means that increasing numbers of people need to be treated for one to benefit, and calls into question the wisdom of treating individuals without established disease.

In other words, Dr Spence takes issue with the supposed certainty that appears to underpin much of cardiological drug treatment. He ends with the following words:

“My objection is cardiology’s certainty, for certainty is always bad medicine.”

How refreshing, I think, to see a doctor admit to the fact there is so much that we simply don’t know.


1. Spence D. Bad medicine: cardiology. BMJ 2011;342:d670

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