White Coat Underground

Science-based medicine: we are not automatons

Opponents of science-based medicine like to accuse the rest of us of failing to be “holisitc”, of failing to see the whole individual who comes to us for health care. I’ve argued many times that this is not only wrong, but that so-called alternative docs, by recommending unproven treatments and giving false hope are actually harming their patients. The new USPSTF mammogram recommendations are likely to fuel this debate as well as the one regarding health care reform and rationing. There’s already been a great deal of debate new mammogram recommendations, most of it good. For a comprehensive analysis of the topic, go and read Orac’s take.

What much of the debate fails to recognize is that data are amoral. They are a tool. There is no reason to doubt the data the USPSTF has put forth, whether we like it or not. Data is useless unless it guides real decisions, and this is where our ethics as a profession and as a society come in. The new recommendations tell us that we would have to screen about 1900 women in their 40s for ten years to prevent a single breast cancer death. Many of the other women will undergo unnecessary imaging studies and biopsies, none of which are completely benign. A typical gynecology office may have about 1900 women in their 40s so if one office stopped screening women in their 40s, they might have one excess death—and a lot fewer sleepless nights worrying about an abnormal test, a biopsy, a breast MRI.

That’s the data. We are better served knowing it. What we do with will be a reflection of what we as a society value, both morally and economically. Using our values to make informed medical decisions is not anti-scientific, it is human. If we ignore the data, we are practicing medicine without a brain. If we ignore the human element, we are practicing without a heart.

Comments

  1. #1 rb
    November 21, 2009

    two points:

    yes better served knowing data, less served with recomendations.

    data supports shifting general screening to 60, not 50. personalized medicine approach to pre60… why didn’t they recommend that? (I know data is more complicated, but 1 in 1300 not much better than 1 in 1900)

    point three: the paper sucks. it is very poorly written. Scientists need to learn out to communicate (I am a scientist). Folks here like to piss on “framing” but framing is what we do when writing a grant, so time to learn how to frame writing a paper you know will be picked up by the public.

  2. #2 makarios
    November 21, 2009

    rb effectively proves his point that “Scientists need to learn out (?how) to communicate”

  3. #3 rb
    November 21, 2009

    fuck you makarios, ad hominem much?

    out=how, busy doing too many things at once.

  4. #4 makarios
    November 21, 2009

    THE “OUT” TYPO IS not the problem. The rest of your comment is near to incoherent, and your use of common profanity suggests a lack of effective vocabulary. I hope your doing too many things at once doesn’t impact your scientific work. However the fact that you read Pal’s blog suggests a degree of common sense.

  5. #5 Ramel
    November 21, 2009

    And makarios your belief that the use of profanity offers any indication of the extent of a persons vocabulary marks you out as a fucking dumbass. Although I do agree that rb’s comment that the paper was poorly written was in fact poorly writtten.

  6. #6 rb
    November 21, 2009

    I am writing a simple comment not a paper for publication, but you clearly got the point so it wasn’t too poorly written was it?

    Let me be clearer… if you look at cancer incidence rates for 30s, 40s, 50s, and 60s+, cancer death rates for those same age groups, years life saved, overtreatment, and overdiagnosis, there are two “breaks” in the curves where benefits sharply increase relative to risks. thost two breaks are between the 30s/40s and 50s/60s, there is no clear break in the curves at the 40s/50s point. So if they want to change the recomendation, from the data, they should have changed it to recomending broad screening from 60-75 and personalized screening based on doctor patient dialog and histories for women 40s (and earlier) through 50s.

    They should have emphasized the shift to personalized medicine not moving the screening.

    you are still guilty of ad hominem makarios.

  7. #7 MonkeyPox
    November 21, 2009

    Perhaps you should brush up on your language skills before commenting further.

  8. #8 rb
    November 21, 2009

    monkey or mak, you have any data to refute my position? if not shut the fuck up. talk about the frickin’ paper my my dumb hick grammar. go find cancer rates, cancer death rates, etc. go find the costs of mammograms etc. Bottom line, the recommendations make little evidence based sense, except by the slimmest of margins in the cost/benefit ratios. If they want to be bold and follow the evidence, no one should be routinely screened until late 50s (why do they follow age decades, there is nothing magical about 40, 50, 60, why not 41, 51, 61)the inflection points occur when women reach 40 and 60, there is little change at 50.

    you two clearly are automatons ditto heads, clearly not interested in evaluating the science of the paper. published doesn’t mean correct. when others evaluate the paper and data, I don’t think their recommendations will hold.

    And in case you haven’t noticed, I am not a knee jerkin’ how dare they delay access to mammograms. If anything, I am on the side of continue the evaluate the data, and find what populations, not just ages, are best served my early mammograms, and just screen them. and despite whay you all think of my nice broken english, I still argue that they presented the data in a poor fashion and therefore lost control of the message, which I do think was to get docs and patients to move towards more individualized medicine.
    As an afterthought, maybe I can emphasize this more by the fact that my wife and I have been looking at the data for years (i have a phd in onc.) and talked with her docs and have gotten one baseline screen (at age 46) and will likely not repeat until 50, because she is in a very low risk group for breast cancer.

  9. #9 makarios
    November 21, 2009

    rb since you ” still argue that they presented the data in a poor fashion and therefore lost control of the message,” Why aren’t you concerned about “my dumb hick grammar”?

  10. #10 Donna B.
    November 22, 2009

    rb is correct that the data doesn’t match the recommendations, but the most important point he makes is that finding the populations defined by something more discerning than age should be a goal.

    Another goal should be finding a screening method that doesn’t hurt like hell. I got my baseline mammogram at 40, and left in tears vowing to never have another one. Not only were my breasts sore, but I actually had bruises.

    Fortunately for me, after being hounded relentless over the years to get another mammogram, I did a little research and found I have almost none of the known risk factors. I’m not stupid to think that means I’ll never get breast cancer. And I’ve changed my mind about never having one again, but it won’t be until I’m over 60.

    As for pain from screening exams, I refuse to have my blood pressure checked by a machine. Again, bruises and soreness are a factor and neither of those things happen when it’s checked manually. My fear and anticipation of the pain actually raises my blood pressure which could result in my being over-treated. Does not something analogous happen with needless mammograms?

    @makarios: Where grammar is concerned, punctuation is just as important in conveying meaning as word usage, word order, capitalization, spelling, etc. Please let me know if you’d to have your comments proofread as critically as you seem wont to do with the comments of others. I’d be happy to oblige.

  11. #11 Necandum
    November 22, 2009

    From the report:

    “The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms. (Grade: C recommendation.)”

    If that’s not what you would consider personalised, what would be?

  12. #12 rb
    November 22, 2009

    Necandum,

    this is the point I was trying to make. They do not lead with the idea of evidence based personalized medicine. It comes as a tag at the end. They do not strongly contextualize that bolded phrase. In addition they make statements like breast cancer significantly increases at 50, yet the data does not show that, it increases yes, but the difference is not even close to what is seen at other “decade” marks, 30 to 40 and 50 to 60. given that we all (well those of us in our 40s) know many breast cancer patients, flies in the face of our common experience. That may be a statistically significant difference, but is it clinically significant? again, the paper does not fully explain its position, nor in a fashion that puts the position is stronger context of moving away for global screens to personalized approached. they simply through the tag line in.

    There is a final problem with all this. Personalized medicine where we have long good talks with docs assumes everyone has equal access to good docs (or even bad docs). and it assumes that docs are properly trained to deal with the stats and numbers and interpret them for the woman this of course is a far cry from the truth. (again, this is a far cry from the truth, I teach meds and premeds, as a population they hate math and genetics, always hoping PBL will help, but I’m not seeing it) on the upside, this could mean that along with folks like genetic counselors, we will be able to build a career in “medical risk counselors” who will be better trained to advise all of us as we go through life looking at risks and benefits to screens and treatments.

  13. #13 makarios
    November 22, 2009

    rb you can call it ad hominem or call me names. As a teacher I could see that you had something worthwhile to say but hadn’t taken the time or effort to make it clear. One doesn’t get a ph.d. with “dumb hick grammar’. Your last two posts suggest to me that raising your ire was worth the effort.

  14. #14 daedalus2u
    November 22, 2009

    The problem with x-ray screening for breast cancer is that x-rays all by themselves can cause breast cancer. If you have to irradiate so many women so many times to detect one cancer, how many cancers will you cause by exposing that many women?

    http://www.ncbi.nlm.nih.gov/pubmed/18826160

    This is not an easy question to answer, it takes a lot of good data because you are looking at small differences in large numbers. It is not an answer that can be gotten by people who don’t know what they are talking about.

  15. #15 antipodean
    November 23, 2009

    rb

    Can you imagine the uproar if they’d moved it to 60?

    daedalus2u- You’re on the money with your comment. It’s one of my favourite ways to explain to thinking people why you need public health people.

  16. #16 catgirl
    November 23, 2009

    I think this breast cancer study is actually a great example of science in action. We thought something was beneficial, yet we continued to study it, and found out that it wasn’t as helpful as we originally thought. Would any homeopath ever admit that they were wrong about the effectiveness of their product, or even bother to study it in the first place?