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There is an editorial in this weeks issue of JAMA by Drs. Sniderman and Furberg on the issue of medical guidelines, something that I have written about before, for example about how the National Cholesterol Education Panel (NCEP) came up with guidelines that would put 25% of the American population on statins, even if they were well. As I have written about before, men with few risk factors for heart disease and women without heart disease have no demonstrable benefit from taking statins, unless you have a relative who own stock in drug companies. Also countries like New Zealand (or any other rational country for that matter), who would put half as many people on statins per their guidelines, have NO differences in heart disease mortality from the US. Which means that there is something definitely wrong with this picture.
Rumours have it that Dr. Furberg once received death threats for his audacious role in pointing out the dangers of drugs like Vioxx, and I have written in my book quoting him.
Dr Curt Furberg testifying to congress on problems with med guidelines
In this week’s editorial, they write:
Doctors often feel entitled to, e.g. get lucrative speaking fees from the companies affected by the guidelines that they are writing, or to get freebies and dinners. But I think the American public is getting fed up. So for the doctors out there, here is a free bic pen that doesn’t have any drug advertising on it.
The anchoring authority of the guideline process is the belief that guidelines are evidence based, not opinion based, and therefore their conclusions flow directly from the conclusions of studies.
In other words, doctors assume (incorrectly) that guidelines are written by objective observers who are not serving as proxies for the pharmaceutical industry. In addition to conflict of interest issues, the writers point out that the guidelines do not undergo peer review, are not made available on the internet for public comment, are typically written by MDs with no epidemiologists or statisticians on the committees, inappropriately represent areas of uncertainty as definite, and serve as spring boards for doctors to go on to lucrative speaking careers funded by pharma based on the prestige of having been on the committees. They correctly point out that saying you consult to all drug companies and therefore do not favor any one of them in particular is not a valid argument. They argue for full disclosure of companies and amounts earned.
For all you do, this (plain) bic's for you.
Hat tip to Brenda Patoine.
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Whatever expertise I may have is essentially limited to psychopharmaceuticals. The problems you speak of are likely much more common in this area.
There is not a single science-based marker in the DSM. Everything in that disaster is based on assumptions or marketing. A company had a drug, so they needed a malady to which to apply it. They created PMDD and had their paid toadies put it in the DSM. Later they added another use (acne) which the FDA agreed to certify.
Why would there be a 40% increase in the number of ‘mental illnesses’ from one edition to the next? Are they really discovering that many new forms? I have never favored book-burning but the DSM has caused me to question my position on that subject.
I may be protected from any threats, as I don’t have a sufficiently high profile for them to register on their radar.
The medical profession used to be the most trusted profession, but the kickbacks by the profit-driven pharmaceutical industry have caused some doctors to become as corrupt as big pharma. I feel bad about not trusting my endocrinologist, but he has insisted on writing me prescriptions for Synthroid brand thyroid medication with no generic equivalent substitution allowed. The first day I saw him he showed me an article which “proved” Synthroid is superior to the generics. I no longer trust him or the article on this point, and I pay $30 a month for Synthroid versus $5 per month that I would pay for a generic. He’s a university affiliated doctor and I suspect his patients become part of his studies (without patient permission) because at my last visit he insisted I start Glumetza (metformin hydrochloride) 500mg off label for WEIGHT LOSS (I do NOT have diabetes.) I read about the drug on the internet and though it said a common side-effect is upset stomach, it is unconfirmed if it helps people lose weight. I am about 30 pounds overweight and am on a diet and exercise program of my own so do not feel I NEED chemical intervention (and don’t trust it). I see my endocrinologist today, and I plan to tell him that I refuse to participate in his Glumetza “drug trial” and that I refuse to buy Synthroid any longer. I am prepared to have him “fire” me as a patient. How do tell a doctor you don’t trust him to his face when you are the patient? Plainly, clearly, simply I guess. I may be shopping for a new doctor.
Good one Doug!!! Its amazing how they influence with glossy ads, and money, rather than experience and common sense. I would contribute to your cause, however I don’t have that kind of money and they would try to pay us to “hush up” anyway!! My credentials would not be of help either, I would be dis credited for my persuasive use of,….. you know….. ammunition.
Argh, these cardio docs drive me nuts. Talk about narrow-minded specialists. If they’d known how to treat heart patients with the entire body (and BRAIN) in mind, maybe Cheney wouldn’t have ended up such a depressive-paranoid Dr. Strangelove.
We already know that B vitamins, magnesium, and the like have a positive effect on cholesterol. And I’ll always remember the excellent New Yorker piece years ago, explaining how the doc behind homocysteine probably had a better-substantiated hypothesis but the cholesterol doc was a better schmoozer.
What perturbs me most about these statin-pushers — aside from the fact that they don’t know how to view bodily systems as, well, systems — is that they give pharmaceuticals such a bad name.
Other medications, including psychotropic ones, get tarred with the same brush.
And yes, Crawford, we have made quite a few discoveries in recent years about why humans do some of the wacky, destructive, and often violent things that they’ve done for centuries — and how to stop them. And yes, that often involves medication. Alleluia.
I’ve been reading today the comments to various news columns about Michael Phelps and his bong-sucking photo gaffe. It’s fairly appalling how widely accepted marijuana usage is – even seen as “normal” for teens and young people. People just don’t seem to realize today’s marijuana is not your father’s marijuana. Some THC levels are as high as 30 percent!
I’ve often wondered why so many people with neurocognitive disorders such as ADHD seem to have children with much greater impairments. No doubt, there are many factors at play. But could one factor be damage to sperm and eggs from parental marijuana usage? We know that even diet and alcohol affects long-term sperm/egg health. Why not this high-powered marijuana?
It’s also funny how the people who most rail at psychotropic medications and psychiatric diagnoses are the first to claim that marijuana is “natural” and “herbal.” I think we need more science education in this country.
(Therapy patient — Like your doc, I don’t trust most generics, either. Not for complicated formulations.)
Thanks Gina for the input. I will reconsider. When I saw my endocrinologist he ended up giving me a 6 month supply of samples of Synthroid so I would stay on it. That struck me as a commitment to his beliefs (even though those samples came to him as a result of schmoozing with a drug rep). He accepted that I chose to not take Glumetza (metformin hydrochloride) but he made another attempt to sell me telling me that a study shows that people who take it for 10 years or longer never get diabetes. 10 YEARS!!!?? as a prophylactic?
As I left his office I passed a drug rep waiting to get in to see him.
Therapy Patient, at least he gave you a six-month supply. And I know plenty of good doctors who accept the samples because they receive requests from patients with poor insurance or no coverage at all.
Then there are the other kind.
A friend asked me to accompany her to the endocrinologist’s office. She has ADHD, is in her mid-50s and needed some help sorting out the complicated threads of thyroid, hormones, ADHD, etc.
I saw the red flags when she checked in. Everything from the clipboard to pen to kleenex box to wall posters — in short, every item within sight — was festooned with drug logos. I mean, this stuff was EVERYWHERE.
Then there were THREE drug reps in the 2-doc office. They were bumping into each other, for Petesake!
Second strike: When we went explained to the doc about the ADHD and needing help teasing out the various hormonal issues, he looked at us like we were nuts — like the brain had nothing to do with the neurocrine system!.
Second strike: He said he was “hyperactive” as a boy, and ADHD isn’t really a disorder. blah blah blah.
Third strike: A few minutes later, he mentioned how his alleged ADHD behavior was never a problem for him, and by the way he has a new wife from China, and the implication was that she’s a mail-order bride who doesn’t speak English.
In short, this guy’s issues had issues, the least of which was that he was an endocrinologist (and a well-recommended one at that) who didn’t know that the brain is connected to the endocrine system.
I later took my friend to see my personal physician. NO pharma bling in sight. No pharma reps on the premises. Instead, we had a physician who actually understood ADHD and neurocrinology.
I say the two go together: The more a physician’s office drips with pharma trappings, the more poorly equipped the physician — (intellectually, mentally, and ethically). But it wasn’t the pharma reps who did this to the doc; he started out like that.
I might add, Gina, the issue of physicians who don’t understand that birth control pills like Yasmin, which flatten out the monthly cycling of female hormones, can cause depression and other behavioral problems, because these hormones have effects on the brain and therefore emotion.
Gina,
A 40% increase in such a short period of time is suspect. That is particularly so when credible scientific support is lacking. The one thing that is not lacking on the DSM panels is financial connections to the drug companies. There has been absolute SCIENTIFIC proof available since at least 1962 that a putative chemical imbalance could not possibly have any connection to mental illness. The initial study has been replicated and never refuted.
By the by, Alleluia means praise to god. Eli Lilly is not my god.
Yes indeedy, Doug.
There are many connections some physicians don’t make because they don’t understand them and, moreover, don’t even seem to be intellectually curious about the possibility.
Evidence Based Medicine Vs. Disease State Guidelines:
Upon information and belief, evidence-based medicine (EBM) is how health care providers practice medicine based on the efforts of evidence based researchers.
These researchers consider EBM the apex for their approach as they conduct randomized controlled trials.
The health care providers assess the risks and benefits of how they choose to treat or not to treat their patients.
This paradigm of a practicing fully utilizing EBM allows the health care provide to better predict the clinical outcomes from the ideal treatment options concluded according to EBM.
EBM implemented by health care providers recognize the need for improved quality in medicine. They also strive to place tremendous value on the restoration of the health of their patients- and they perceive the EBM approach to be the standard approach in their medical practices.
It is believed that there are three areas of evidence-based medicine:
1. Treat patients according to what is reasonable and necessary based on the evidence that exists regarding the treatment options health care providers select.
2. Health care providers review this evidence in order to judge and assess the best treatment for their patients.
3. Recognize that evidence-based medicine is in fact a movement that emphasizes the usefulness of this method to practice medicine.
A standard of care is created as a result.
It is also believed that there are two types of evidence-based medicine:
1. Evidence-based guidelines- Policies and regulations are produced to ensure optimal health care.
2. Evidence-based individual decision making- This is how restoring the health of others is practiced by the health care provider.
While critics claim that EBM is too restrictive in practicing medicine and treating patients, EBM seems to be the preferred way to practice medicine instead of relying on possibly biased medical guidelines. Rather than EBM being restrictive, it is in fact potentially improved by enhancements such as electronic health records.
Medical guidelines for a particular disease state are created from a combination of clinical studies in which conclusions are drawn to reflect national standards of care for a particular disease state.
Guidelines were implemented during the 1980s as an alternative to relying on only EBM.
At times, these guidelines are privately sponsored by those medical industries that are able to gain profit depending on what such guidelines state about treatment considerations.
This makes guidelines, at times, unreliable due to bias, as they are without independent systematic review or quality considerations by others.
Unlike evidence-based medicine, guidelines can have major flaws and inaccuracies due to toxic factors such as commercial sponsorship received to create such guidelines.
It is likely because of flaws such as this that most doctors do not follow medical guidelines, yet are rewarded and reimbursed by programs such as Medicare if they do follow medical guidelines that are established.
Dan Abshear