Hippocrates Shadow and More...

Hippocrates Shadow

This post is mostly about the book Hippocrates Shadow by David Newman, M.D.

http://www.amazon.com/Hippocrates-Shadow-David-Newman-M-D/dp/1416551549

The book is a few years old but a great read, especially for anyone interested in their own personal health or the healthcare system in general.  Newman is an Emergency Medicine doctor who intersperses his personal experience along with plenty of technical detail.  Part of what makes it a page turner is reading the short case descriptions that put context around the more scientific or technical topics. There are also solid references to the over 130 research papers published in top journals like the Annals of Internal Medicine, Lancet, JAMA, NEJM, and WHO that back up his assertions.  He also has a great TED Talk here.

My Post

My post will also tie in a few other concepts and ideas from other areas of science and medicine that relate to the topics covered in the book.  One thing to cover at the start is that this, like many other of my posts, challenges the status quo.  In Newman's book, he quotes a famous doctor who tells a medical school class to remember that in 10 years half of what they learned in medical school would be disproven.

That is good advice and yet extremely hard for doctors and the general public to accept.  Many people find comfort in the old ideas no matter how much science advances.  For example, the recent changes in the dietary guidelines to not treat dietary cholesterol as a health concern will likely not convince many people and practicing physicians and they will persist in eating egg whites for another decade or more.

Newman's book has many good examples, so we'll start with one about strep throat.  Many people have probably tested positive for strep throat or had a child who tested positive, and then they were given a prescription of antibiotics and went happily on their way.  Newman shows that treatment is based on flawed science and that the NNT (number needed to treat) of that protocol is close to 1 million... and has nothing to do with strep throat itself.  It is actually given to prevent rheumatic fever that might occur a month later, but that was based on events at an Air Force base in the 1940s and 1950s that has virtually nothing to do with what happens in the general population.  And yet... 60 years later we're still following the same treatment protocol. More here.

Sound incredible?  Let's start with a few facts and then apply Byron Katie's Four Questions.  Newman goes into great detail in the book, and

I'll only use part of the story to get at the theme of the chapter titled "We Won't Unlearn".

First, the questions are:

1. Is it true?
2. Can you absolutely know it is true?
3. How do you react - what happens - when you believe that thought?
4. Who would you be without the thought?

Many people believe that a positive strep test indicates a need to take antibiotics.  Not the case!  Less than 10% of people seeing a doctor for symptoms of strep have it,and 10% of the population is walking around positive for strep with no symptoms.  So, for 1 in 10,

Question 1 is No - you don't need to take antibiotics.
Question 2 is also No.
Question 3 might bring in some doubts.  Why would a doctor prescribe antibiotics if they aren't necessary?
Question 4, as you'll learn below, is "I would be a much healthier person and much better informed about the effectiveness of medical treatments."

In other words, somehow we've gotten into a situation, much like a bad relationship where Katie's 4 Questions are usually applied, and we can't find our way out to a better outcome.  Wouldn't you rather avoid taking unnecessary drugs?  Wouldn't you rather not spend the money on medical treatments that can be shown to be no better than placebo or no intervention at all?  Shouldn't you avoid taking antibiotics that can cause allergic reactions, diarrhea, or rashes?  Or what about the long-term use of antibiotics that Martin Blaser's book Missing Microbes suggests are linked to obesity, juvenile diabetes, and asthma?

What Doctors Don't Know, Don't Tell You

Okay, let's get to the content of Newman's book and then give some examples.  He takes aim at much more than ineffective use of antibiotics.  On the list are:

• Antibiotics for strep and other infections that most likely viral
• CPR
• Breast cancer mammography screening
• High blood pressure medicine
• Migraine treatments
• X-ray interpretation
• and even the G Spot (sorry... believe if you must)

All of these treatments and tests have been proven to be ineffective unless applied to a specific subset of high risk patients or simply they are not worth the cost and side effects of the treatment.  Let's look at the numbers related to antibiotics and strep:

"... today we would likely have to treat more than a million in order to prevent one case of rheumatic fever.  ...  But 1 million prescriptions for antibiotics will cause more than 2400 potentially allergic reactions... 100,000 cases of diarrhea and 100,000 rashes. (Pg 115)"  

Hmmm, that is not sounding like a good tradeoff for society or for the average person walking into the doctors office and yet the practice of prescribing antibiotics is widespread.  Very few doctors ever say "well, I'll give you these antibiotics to prevent a 1 in 1 million chance of something you'll likely survive with no consequences for the 1 in 400 chance you'll have a severe reaction to the antibiotic itself."  Most patients are actually happy the doctor gives them something and never ask any questions about effectiveness or consequences of the treatment itself.

While I don't have children, I do have dogs, and I look at antibiotics and other treatments much more skeptically these days as a result of learning about things like this.  If you do have children and you're constantly battling ear infections, sore throats, and other maladies of youth, you should seriously consider the cost / benefit.

Alternative Treatments

One part of the book discusses the treatment of migraines (Pgs 62 69), which are seen differently by ER doctors who treat patients with active migraines and neurologists who typically see patients at some point later.  Migraines often come with nausea, and for that antiemetics are given first so that the migraine drugs can be administered.  The interesting thing is that antiemetics happen to be very effective at stopping migraines and the migraine drugs are often not needed.  This section of the book also illuminates some of the issues with the FDA and the drug approval process in which a class of migraine drugs were compared within their class (triptans), but not against the antiemetics.  These
costly drugs ($60 per dose) were approved despite not showing effectiveness over much cheaper antiemetics ($4 per dose).

Number Needed to Treat

The NNT is a interesting concept that looks at how effective drugs are in the context of real patients.  If you break your leg and end up in the ER, then the NNT is 1.  One person with a broken leg is treated with a cast and one person is better off.  With drugs and other surgical interventions (see the TED Talk on stents), the NNT can be 3, 10, 1,000, 1,000,000 or infinite.  Where the NNT is high, we should be questioning whether the cost of the treatment

Here's an NNT graph of the use of aspirin in high risk patients.  These are people who have had a high risk event or have other underlying conditions that predispose them to another heart attack or stroke.  For them the NNT is about 100.

But what about the average 54 year old with no risk factors?  The NNT is 1176 (Pg 171).  While aspirin is cheap, why are we prescribing it when such a tiny fraction of people are going to benefit from the treatment?

Note:  The FDA recently stated that evidence does not support the general use of aspirin for the primary prevention of heart attacks and strokes, so that would tend to rule out the recommendation for anyone not in a high risk group.  More studies here and here.

Like many of the cases explained in the book, if we used NNT to decide whether treatments were necessary or effective, we'd come up with a vastly different and less costly healthcare system.

What To Do?

The book ends with a great section on how to be a better informed user of the healthcare system.  There are 8 basic concepts:

• On Knowing - doctors are not perfect and often disagree.  This is normal and patients should push to understand.
• On What Works - Take nothing for granted.  Some frequently prescribed measures don't work and could cause harm.
• On Communicating - Doctors and patients must both work on establishing rapore based on open and honest discussion.
• On Tests - there is a over-reliance on testing and they should only be done when there is a clear relationship between what the test might show and a plan to move forward.  
• On Unlearning - "It is an ominous sign when doctors are set in their ways and will not learn."
• On Placebos and Meaning - "Communication and a sense of being cared for are important components of the healing and health processes."
• On the NNT - The NNT is a clear way to understand potential benefits and make an informed decision.  
• On a New Paradigm - "If you choose to believe in health care that is honest about its strengths and weaknesses, ... then your doctor will,too.

Newman is still out there with his message.  Here's a recent post from March 2015 talking about the ongoing controversy of NNT and, more importantly, the need or better communication between doctors and patients.

There is hope... but only if we are better informed.  If you find this shocking, I recommend you read Hippocrates Shadow and, as necessary, use the 4 Questions to turn around your thinking about health and medicine.