« Freakonomics Radio

268. Bad Medicine, Part 1: The Story of 98.6

2016-11-30 | 🔗
We tend to think of medicine as a science, but for most of human history it has been scientific-ish at best. In the first episode of a three-part series, we look at the grotesque mistakes produced by centuries of trial-and-error, and ask whether the new era of evidence-based medicine is the solution.
This is an unofficial transcript meant for reference. Accuracy is not guaranteed.
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something I don't know or you want to be contested. Please visit T M S idea, K, dotcom thanks We begin with the story of ninety eight point: six. You know the number right it is one famous numbers. There is because the body temperature of a healthy human being is ninety eight point, six degrees, Fahrenheit? Isn't it now, I'm gonna! Take your temperature. If you don't mind, is open your mouth, it up insert the thermometer perfect. The story Ninety eight point: six dates back to a physician by the name of Karl wonder lick. This is in the mid eighteen, hundreds wonder lick was medical director of the hospital at Leipzig University in that capacity he over
saw the care in the taking of vital signs on some twenty five thousand patients, pretty big dataset. Yes, twenty five thousand patients what did wonder lick determine he determine that the average temperature of the normal human being was. Ninety eight point, six degrees, Fahrenheit or thirty seven degrees centigrade. This is Philip Mukoki, a professor of medicine and medical historian at the University of Maryland. Will I in turn us by trade and aid infectious disease specialist by sub specialty. So my bread and butter. Is fever? There's one more thing: Milvey Atkins time by nature, a sceptic end. It occurred to me very early in my career that this idea that ninety eight point six was normal and then, if you didn't have it,
Richard. Ninety eight point, six, you were somehow abnormal just didn't sit bright, Philip Mukoki, I kept understand, cares a lot about what is called clinical thermometers and if you care a lot about clinical thermometer E. U care a lot about the thermometer that Karl wondered. Used to established. Ninety eight point: six is thermometer. Is an amazing key to this story of ninety eight point? Six, so you can imagine how excited Mccoy that was when, on a tour, a weird and wonderful Motor Museum in Philadelphia. The curator told him they, at one of wonder, licks original thermometers. I said good Heavens may I see it and she said Sure would you like to borrow it. I said, of course, and so I was able to take this thermometer
her back to Baltimore and do a number of experiments. The wonder like thermometer with OPEC realize was not at all the typical thermometer. First of all, it was about a foot. Long fairly fix them end registered almost two degrees centigrade. Air, then current thermometers or thermometers. That era two degrees higher centigrade o in it I know that it is a non registering thermometer, which means that it has to be read while its in place, so it would have been awkward. They use Mukoki had noticed something else about the original wonder: lick research investigating further. It became apparent that he was not measuring temperatures either in the mouth or the rectum, He was measuring Axel Larry or armpit temperatures, and so that
many many ways his results are not applicable to temperatures at or taken using current to thermometers and current techniques, as it turns out, the esteemed Doktor Carl Window It was not the most careful investigator ever to come on the scene. The more microbial looked into the wonder, look d and how the story of ninety eight point six came to be the more he wondered about its accuracy. So he set up his own body temperature study. He recruited healthy volunteers, male and female and took their temperature one to four times a day around the clock. for about two days using a well calibrated digital thermometer in the patient's mouths, when they find, the total number of thud temperatures that were taken only eight percent,
were actually ninety eight point six, and so, if you believe that ninety eight point six is the normal temperature than ninety two percent of the time the temperature was abnormal. Obviously, that's not even reasonable in his study, Mcculloch Fowl, the actual normal temperature, to be ninety eight point, two degrees, not a huge difference, and yet the who notion of a normal body. Temperature was looking for, more suspect, why a lotta reasons temperature varies Person to person, sometimes so much that one person's normal would registers nearly feverish for another person. It's almost like a fingerprint temperature varies throughout the day. its roughly one degree higher at night, then in the morning, sometimes even more and an elevated temperature, isn't necessarily a sign of illness and women goes up with obvious
creation during the menstrual cycle. The temperature goes up during vigorous exercise in this is a favour an so Mukoki had concluded. Looking at a rise in temperature is a reliable a sign of infection, or disease is inappropriately simplistic thing, inappropriately simplistic thinking, makes you wonder if the medical establishment believed for so long in in inappropriately simplistic story about something as basic as normal body temperature would also they fallen for what are their mistakes if they made hope you ve got some time along with you. Take a sick person, slice open a vein.
Take a few pints of blood out of drilling holes into people's skull. It was literally taking someone to Helen banned. It would cause a whole series of malformations and probably a lot of feed. All death. Lobata means the over use of mercury compounds, the Tuskegee case losing your teeth into having your gums bleed D S and the little maid. We, u sort of US cement hormone replacement therapy, the oxy content and appeared problem as a medical the story, and it is patently obvious to me that future generations will look at what we are doing today and ask themselves what was Graham PA thinking of when he Did that believe that now have to learn all over again. That science is imperfect and to me team a healthy scepticism about
everything we believe and do in life in general, but in the medical profession in particular on today show part one of special three part series of economics. Radio will be talking about. new era of personalized medicine, the growing reliance on evidence based medicine and especially pay attention. I'm gonna use a technical term. We will be talking about bad medicine I'm happy from w, and why see studios this is free, can mix radio the pod cast that explores the hidden side of everything. Here's your host Stephen Dogma. We a lot of ground to cover these three episodes. Medicines greatest hits the biggest
lawyers where we are now and where we're headed in the interest of not turning a three part series about bad medicine into it. twenty part series we're not even going to touch adjacent fields like nutrition and psychiatry, maybe another time but start very briefly at the beginning, Nearly twenty five hundred years ago, you had the greek physician. Hypocrisy is who still called the father of modern medicine. You ve heard, of course, of the hippocratic oath, the creed recited by new doctors. and you know the oats famous phrase- first- do no harm, even though, as it turns out that phrase isn't actually included in the oath came from something else, a backwards rope.
Or do many contemporary doctors recite the original hippocratic oath, there's a modern version written in nineteen sixty four by the prominent pharmacologist Louis Lasagna. The pledge begins. I swear to fulfil to the best of my ability and judgment covenant. It is a fascinating, inspiring document and I think before we go too far, it's worth hearing some of it. I will respect the hard won scientific gains of those physicians, in whose steps I walk in at least share such knowledge as his mind with those who are to follow. I will remember that there is art to medicine as well as science and that warmth, sympathy and understand may outweigh the surgeons knife or the chemists drug? I will now be ashamed to, say I know not. Nor will I failed to come my colleagues when the skills of another are needed for patients recovery. Above all, I must now, play at God S, room
that I do not treat a recharge cancerous growth, but a sick human beings whose illness may affect the person's family and economic stability, responsibility, these related problems. If I am to care adequately for the sick, I will prevent disease whenever I can, or prevention is preferable. Cure and ere long experience. The joy of feeling, those by its comforting to think about this for the new wants, the massive responsibility that doctors pledge before they attempt to diagnose or he'll how well has that pledge been upheld throughout medical history. Will talk to a variety of people about that today. Starting with this gentleman running New Palm Jenna Healthcare, economists and physician at Harvard Medical School, so Jenna as both a practitioner.
And an analytical researcher is especially useful for our purposes, because one of the themes will hit today several times is that medicine, even though its scientific or at least ninety it hasn't always been as empirical as you might think, ends sometimes not very empirical at all. Here's an easy question: can you tell me please the history of medicine, or at least western medicine in unknown three or four minutes. Let me first answer the meaning of life, is there going to be easier, that'll take about five to six minutes. You know I would say how about three words, trial and error. So I think, if you think about medicine words, how its evolved- let's just say in the last one hundred to two hundred years- the sorts of practices that at some point in history, people thought were actually medically legit
it included drilling holes into people's skulls lobotomies. Even as late as the nineteen forty snaking fifties, Lobata means were thought tat We have a treatment effect in patient with mental illness, be it schizophrenia or depression. The practice of bloodletting, which is basically trying to remove the corner quote bad humorous from the body, was thought to be therapeutic, patients, things like mercury, which we know are downright toxic were used as treatments in the past and that wasn't a time in place where I think it was very difficult to get evidence, but not only that there is probably a perception of the field They didn't allow for the ability. The question itself, and in the last fifty plus years, probably fit it's only five years. I think we ve seen terms.
The strides in the ability of the profession to constantly question itself, so it's easy to get indignant over the idea of these treatments that turn out to be so wrong. But Understanding wellness and illness is hard. Obviously, so, when you look back at the history medicine did those interventions strike. You is kind of shameful. You can't believe you're in a profession that tried things like that or is that just part of the trial and error process that you accept. I certainly wouldn't call it shameful only thing that shameful is when someone some believe that they have the potential for being wrong and they don't have that desire to enquire further about whether something actually works. It doesn't work, but the idea of trying things particularly trying things then you have a really strong plausible path of physiological basis. I think that there is nothing wrong with that. In fact, that's what spur scientific discovery
and many the treatments that we have now. So A broad question for you, the human body, is, I think, you and I would agree extraordinarily complex organism and over history. Doctors and others have learned a great deal about it. But if we consider the end higher human body from a medical perspective, only let's leave out metaphysics in theology and what have you from a medical perspective? How would you ask the share of the body and its functions that we truly understand and the share that we don't really yet understand her. That's a tough we made a lotta headway, but put a number on it. I would say: maybe thirty percent forty percent, that we don't know. That's a tough question for me. A quiet I asked the same question of someone else: monies Jeremy, green physician and a historian of medicine at Johns Hopkins. So what's greens answer
their Rumsfeld even answer of no known there are known, no zone unknowns, known announce, that is to say, we know there are some things we do not know their also unknown announce a different way of internet question would have to do with what our idea of relevant science have. Medicine is, for example, if you take, for example, the moment in the renaissance were either the salient moment when the opening of davers in description, rendering and precise three dimensional care. squirrel engravings at the human body was an exciting area for research that actually this humanist process of cleaning up cadavers showing that the innerds were not exactly what the ancient Greeks had described and fast forward that the twenty first century and how many organs are left still to be discovered. Now, please, Please Euro, although who knows exactly so as a historic
Rather than giving you a fixed price, where we are. I can give you as Zenos paradox that we keep on getting close to that fine a moment and then ran and a new broader room for us in happen in that's, because there's been a lot of progress in how were able to explore the human body there's, the gross anatomy of the body, which you can see with your own eyes. Unapologetic again they go. A further and were now at the microscopic anatomy of the body. So now what do the same of the body look like when they are diseased under a microscope and now now go away further, where you are now trying to understand things about the body that you can't even see with a microscope and that set say the level of the protein. The cell, or even further down the level of the dna that codes the protein
by the end of the twentieth century, there is a very strong genetic engineering which really helps to them. The excitement behind the human genome project gets that once we know the totality of the human genome will know all that. We need to know about that. It's in health and disease, Of course, we already know a great deal and to be fair for all all the mistakes and oversights in medicine there's been extraordinary progress. What are some of medicines greatest tits, I'm sure every historian of science, medicine would give you a different set of it, but Evelyn Hammons she's, a professor of the history of science and african american studies at heart. The ones that I typically think about are the introduction. no more efficacious therapeutics and medicines. I would put something like the discovery of insulin right up there near the top, that's cool.
The way he's at Princeton historian, who focuses on health policy. It transform diabetes from an acute disease into a disease that you live with to mean that is much more. The story of what medicine has been able to do in the twentieth. Their medicine that comes to my mind, is stands whose cardiologist by beliefs and should be in water by now. stands a remarkable drug, they ve been shown to have benefit in preventing heart attacks. in the pollination of life among people who had heart attacks and the same thing for stroke and other forms of cardio vast these, so they are probably at least in the last twenty years, the biggest improvement but there are many many drugs that are like that. These truly awesome interventions, for which we should all be thankful, one of the most remarkable developments over the past century and a half
is the unbelievable gain in life expectancy. In the U S and elsewhere, it nearly doubled. Now it might be natural to ascribe that gain primarily to break through medicines. But in fact, a lot had to do with something else. A lot of the advances in mortality and morbidity have come from really changes in the nature of social life. Infectious disease He says the source of high mortality in the early twentieth century began to drop long before penicillin and the interbank curios came along in the midst of a century because of improvements in housing, sanitation, diet and sort of tackling urban problems that really created congestion and produce the circumstances that made things like tuberculosis, the leading cause of mortality, for example. If you think about the reversal of the Chicago River used to flow into Lake Michigan in the nineteenth century and
forward dumping their waste into it. So every summer there would be hundreds of deaths of babies and children from infant diarrhoea, because the water was so contaminated. Reverse the flow of the river. So it flowed down river toward the Mississippi and that significantly improve the health of the people who live there. So we ve got public health improvements to thank and yes, better therapeutics in medicines, also new and better ways of finding evidence I actually think it the technology that really revolutionized how we think is the use of controlled experiments. That's been, precise. He is an assistant professor of medicine, at Oregon, health and Sciences, university, precise, treats cancer patients, but all the rest of my time. I devote to research on health policy on the decisions. Actors make on how doctors adopt new technologies and when
those things are rational and when they're, not rational, which means that precise is part of relatively new, relatively small movement, to make met. science a lot more scientific. You know Think about medical science for thousands of years. What was medicine but something that somebody of esteemed authority had done for many years and told others eddied work for me, so you better do it even though medical science seemed to be based on evidence, prison. Says the reality was that what we were practicing away, something called eminent space medicine. It was where The preponderance of medical practice was driven by really charismatic and thoughtful, probably to some degree leader Now, in medicine and in a medical practice was based on since scraps of evidence, anecdotes, bias, preconceived notions and problem a lot of psychological traps that we fall into and largely the time of hypocrisy.
Signed the Romans until you know, maybe even the late renaissance medicine was unchanged. It was the same four thousand years. Then something remarkable happen, which was the first use of control of clinical trials in medicine coming up on for economics, radio, how clinical trials began change the game. It really doesn't matter that the smartest people believe something works. The only thing that really counts is what is the evidence you have that it works? How some people didn't have much of an appetite for actual evidence. There was a great deal of hostility to it from say the medical establishment,
and in a strange twist how better science is pushing medicine, not always forward, but sometimes backwards. It is quite comment to see practices that end up getting reversed and the best estimates are that happens about fifteen percent of the time. I take it as read that your mouth in and out of Gaza, gay or more Furthermore, I knew Commagena is an empty and health care. Economists lifted israeli, listen to her in most developed countries. We tend
think of medicine as a rigorous science and we think of our doctors as if not infallible at least reliable. I think that the typical patient probably does look to their doctor for answers and day value very highly what that opinion is, but, as we ve been hearing, the history of medical science was often eminence based rather than evidence based when did evidence really start to take over Space medicine has become hugely important in the last twenty five to thirty years. The movement is a result. Genesis of at least two factors number one. We're doing more randomize control trials in that tells us formation about what works and doesn't work and number two improvements in computer technology have now allowed us to study data in a way that we couldn't have done thirty years ago,
It has also been a movement to collect and synthesize all that research and all those data saw our vision is to produce system reviews that summarize the best available research evidence to inform decisions about health. That's LISA, Barrow pharmacologist by training who studies the integrity of clinical and research evidence and am also care of the Cochrane collaboration. The Cochrane collaboration was founded in Britain, but is now a global network. The systematic reviews they produce are really the evidence base for evidence, base medicine and we ve been a lead In so many ways in developing systematic reviews, we were the first to regularly update these reviews. We are one of the first to have post publication, peer review and a very strong conflict of interest policy, actually we're that one of the first journals that was published only online, which means that way
a realm medical science. You're working on you can access nearly all the evidence on all the research ever conducted in that realm, constantly updated available on the spot. Compare that tell how things used to work. Looking up five or ten year old medical journal defined one relevant article that may well have been funded by the pharmaceutical company whose drug it happened to sell it. How is Cochrane funded where primarily funded by governments and non profit would about industry money? We don't take any money from industry to support any official Cochrane groups, which means in theory at least. That the evidence assembled by the Cochrane collaboration is pretty reliable evidence, as opposed to a whole variety of things, opinion. What the doktor had been taught. Thirty, as previously in medical school tradition,
what they had been told to do by or advice to do by drug company representative that had visited them a week previously. That is sir in Chalmers, who cofounded the Cochrane collaboration he's a former clinician whose specialised in pregnancy, childbirth and early, infancy. He was a medical student in the early nineties sixtys. When Chalmers observed his elders in practice, he was struck by how much variance there was from doktor to doktor. Ok, so some doctors would, if a woman had baby presenting by the breach would do us his section without any questions asked as it were, or they may take different views, were about the way that the baby should be monitored during labour or the extent. to which drugs should be used during pregnancy for one thing or another. So lots and lots of differences in brain
It's as long as your arm is madness. Isn't it when he became a doctor himself? Chalmers worked at a refugee camp in Gaza and as he discovered some of the things that I had learned at medical school, where LISA Lee Wrong like how you were supposed to treat a child with measles, I've been taught at medical school, never to give to politics to a child with a viral infection which measles is, as you might induce resistance to the and about resistance, but these children died really quite fast, have to get pneumonia from bacterial infection. And which comes on top of the viral infection. The measles and what was
frustrating was that it wasn't until some years later that I found that there had been six control trials, comparing antibiotic Prophylaxis given preventative Lee with nothing done by the time I arrived in Gaza and those studies suggested that children with measles should be given antibiotics, but Chalmers had never seen those studies So I feel very sad that in retrospect I let my patients down this lead Chalmers to embark on a years long effort to systematically create a centralized body of research to help attack the incomplete random subjective way that too much medicine had been practised for too long, he was joined by a number of people from around the world, many of whom, by the way, where more versed in statistics than in medicine, so we embarked on these systematic reviews better. Of Us- and that is
at the end of the nineteen eight is in a massive two volume, one and a half thousand page book. The same time started publishing electronically, and so the Cochrane collaboration became the first organization to really systematize, compile and evaluate the best evidence for given medical questions. You'd think this would have been met with universal praise, but as with any guild whose inveterate wisdom is challenged as unwise as it was may be. The medical community wasn't thrilled. There was a great deal of hostility to it from her I'd, say the medical establishment, in fact, I remember: a colleague of mine was going off to speak to a local meeting of the British Medical association. Hood basically summoned him to give
the count of evidence based medicine and what the hell did. People who is status, and other non doctors think they were doing. messing around and territory which they shouldn't be messing around it and he asked, before he drove off. What should I tell him? I said when patients start complaining about the objectives of evidence based medicine, then one should take. The criticism seriously happened then assume that is basically vested interests playing their way out. Long while, but the Cochrane model of evidence based medicine did become than standard. I would say it wasn't factually until this century. So one way you can look at it is whether, as death, there is hope as a cohort of doctors who rubbish did moved into written I went to their death, the opposition disappeared. Yes, that's right
the slower evolution that again. is when I preside from organ health in Science University, the very first studies with random zation concerned tuberculosis. This was in the late nineteenth and then from then, until relieve nineteen eightys, the end of nineteen eightys. We did use randomize trials, but they weren't man the Tory they were sort of optional, one big benefit of randomize trial You can plainly measure in the data the cause and effect of whatever treatment. You're looking at this may sound obvious, but it is remarkable how many medical treatments of the past were conducted without that evidence, Anupam Jena again, I think some of the biggest mistakes in the last century. Let's say the first from one thousand: nine hundred to nineteen fifty things like lobotomies to treat mental illness, either depression or schizophrenia
strike me as being some of the most horrific things that could be done to man without any really solid evidence base at all. This is one of the trickiest things about practicing medicine data day. Let's a Europe, doctor and patient comes to see you with a persistent headache. You make a diagnosis and you write a prescription. What happens next? In many cases, you have no idea the feedback loop, Medicine is often very very sloppy. Did the patient get better? Maybe never came back, but maybe we went to a different doc. Maybe died if they d get better. Was it because of the medicine prescribed, maybe or maybe they don't even fill the scrip, or maybe they did fill the script but stop taking it because a garden upset stomach or maybe they did take the medicine, and they did it.
But maybe they would have gotten better without the Mets. Like I said, you have no idea, but with a well constructed randomize controlled trial, you can get an idea when I preside again the moment, I think, in my mind, that kind of set us on a different course was. A study called cast cast stands for cardiac arrhythmia suppression trial, it was conducted in the late nineteenth eighties cast. Was a study that one of the things doctors were doing a lot for people after they had a heart attack was driving him an anti rhythmic drug that was supposed to keep those aberrant rhythm, those bad or our heart rhythms at bay that draw actually in a carefully than randomized trout, turned out not to emerge survival, as we all had thought, but to worsen survival, and that was a watershed moment. I think we're people realise that randomized trials can contradict even the best of what you believe,
Billy, doesn't matter in medicine that the smartest people believe something works. The only thing that really counts is what is the evidence you have that it works. The rise of randomize controlled trials led to arise in what are called medical reversals. Deny precise wrote the book on medical reversals literally, it's called ending, medical reversal? And you know what is a medical reversal? Doctors do something for decades its widely believed to be beneficial, and then a very seminal study, often better, designed better powered, better controlled than the entirety. Of the pre existing body of evidence. It contradicts that practice. It isn't just that it had side effects. We didn't think about. It was that the benefits that we had postulated turned out to be not true or not present incidents in the nineteen nineties, we would recommend tat, postmen apostle women to start take. estrogen supplements because we knew that women before they had menopause at lower rates of heart disease, and we thought that was because of a favourable effect of estrogen.
And in two thousand and two, a carefully done. Randomized control trial found that actually it doesn't decrees heart attacks and strokes if, in fact anything it increases them. I asked preside. What first got him interested in studying met reversal. So I started to get interested in this. Even when I was a student, and I saw that there were some practices that had been contradicted just in the recent past, but we still being done day in day out in the hospital. I mean that that exam that comes to mind. Is the standing for stable, coronary angina us It is a little folded metal tube that goes in a black coronary artery and the doktor springs it open and it opens up the blockage and stance are incredibly there able for certain things. If you have a heart attack and there's a blockage just happened a few minutes ago and a doctor goes in and opens at blockage up we're talking the tremendous improvement immortality, one of the best things we do in medicine, but standing like every. Medical procedure has something called education drift where yeah works great for us fear condition, but does it work just as good for very mild condition and so
Over the years doctors had used ending for something called stable, angina and stable engineers just that slow, incremental narrowing of the arteries that happens do sadly, all of us ass. We get older, but the bulk Something was this indication drift and we thought it worked and made perfect sense, and in two thousand and seven a well done study showed that it actually din improve survival and didn't decrease heart attacks, which were even to this day stuff show that most patients who undergo this procedure believe it will do those things and in fact it's been disproven for eight years and yet, whilst looking for stable angina did decline, it didn't disappear. The rate of inappropriate stunting preside, says, is still way too high, and this obviously starts getting into doctors, incentives, financial and otherwise, and we'll get more into that in part. Two and three
The series, as Prasad, makes clear. There is a long long list of medical treatments simply don't stand up to empirical scrutiny. Some common need surgeries, for instance, where orthopedic surgeon take a tiny camera, a tiny incision and go in there, and actually de breed and remove the sort of stuffed and scraped knees and, in fact, people sort of felt a lot better, They had improve range of motion. There's no argument there, but you ve studied it against we just taking ibuprofen or maybe just doing some physical therapy. What have you studied it against making the patient believe that you are doing surgery, but you don't actually do it and in fact they done those too Those are called sham studies. We give the appearance that we're gonna do this procedure and the only thing we omit is actually the debris meant. Many sky and the cartilage, and in fact, when you do it that way, you and that the entire procedure is a placebo effect, there's another
ample. Where we you sort of US cement, we inject into a broken vertebral bone and that again was found to be no better than injecting sailing solution in a sham procedure and the cement itself six thousand dollars- and I said you know at a minimum- you can save yourself the six thousand dollars and you don't need to use a cement. What would be the incentives for me to do the studied them It results in a reversal because we know how publishing works, whether it's in your field, in any academic field or in the media, as well. It's the juicy sexy new findings that get a lot of heat and it's the maintenance articles or the reversal articles that term? Nobody wants to hear about the so I would gather there a fairly weak incentives to doing the studies. It would result in more verses, which also makes me wonder if there is a woeful under supply of such studies, which means that they probably would be even more reversals than there are
Yes, I think, that's a fantastic question. One of things we did in the course of our research was we took a decade worth of articles in probably one of the most you just medical journals, the New England Journal of Medicine and there's about maybe thirteen hundred art. Those that concern something doctors do about a thought, of those articles were something new, something that came off that you're coming down the pipe I'm the newest anti coagulated, the newest mechanical heart valve, and if you tested something new, exactly as you would expect, Seventy seven percent of those publish manuscripts concluded that what's newer is better, but we also discovered about Three hundred and sixty articles tested something doc, we already doing. But if you tested something because we're already doing forty percent of the time we found that it was contradicted or reversal I'd love to talk about the various consequences of reversals, including perhaps a loss of faith in that in the medical system, So, if you find out, something you are doing for decades is wrong: that ye harmed alot of people you subjected many people to something ineffective, potentially harmful sitting.
costly, and it didn't work this. In harm. We say: is this lag time harm doctors in a we're like a battleship. We don't turn on a dime. We continue to do it for a few years after the reversal, and the third harm is loss of trust in the medical system and that's the deepest harm. I think we ve seen it in the last. gate, particularly with are shifting recommendations from mammography and for prostate cancer screening. Where people come doctrine. They say you guys can't get your story straight. What's going on, it's a tremendous problem, and I am afraid that Only what we are doing is we are making people feel like. There is nothing that the dock does that's really trustworthy and I'm afraid that that's sort of the deepest problem that you know we're face this loss of trust. Ok, so how do you not throw out the baby with the bathwater what're, some solutions to a practice of medicine and medical care search that results in fewer reversals, so that is a million dollar question one is met, the you know. We have
education, where, for two years, students are trained in the basic science of the body, only in the latter years. The third and fourth year of medical school are students trained in the epidemic. ology of medical science in evidence based medicine and thinking not just how does something worth, but what's the data that it does work and a yacht argued that that needs to be flipped on its head, that the route The basic signs of medical school is evidence based medicine. It's it's approaching a clinical question, knowing what data to seek and how to answer that in a very honest way, let one the next cadigan it is regulation, and this is you getting too in what is the FDA role and what is the FDA do, and I think many p Oh in the community, hope that the products that are approved by the FDA are both safe and efficacious for what they do. But you know we were faced with in the Eightys and Ninetys that we never faced before, which was the HIV Aids epidemic and advocates rightly said that we need a way to get drugs to patients faster me
he even accepting a little bit more uncertainty. I think that was right and I think that still right from many conditions that are very dire, for which few other tree and options exist and which some have very low incidence was very hard to do those studies, because very few people have it, but what's happened is that mechanism has been extrapolated to conditions that are not dire, that have very good survival, that dont have few options we have many options and that many people do have so we ve had again sort of a slippery slope for in a what qualifies for this accelerated approval. Setting, therefore, in which regulation can be adjusted, and I think the last thing is I'm the ethic of practising positions? Will you know we have to have an ethic aware offer something! Someone in there is uncertainty. We should be very clear about communicating uncertainty. I think it's a tragedy today that you know no matter what you the standing for stable, corny already disease. It's a trap
that so many people who are having done believe something that is clearly not true, that it lowers the rate of heart attacks and death. That's just actually not true, and the fact that many people believe that I think speaks to the fact that his doctors, allow them to believe in the mail One last question: I have a pretty good sense of having spoken to now forbid of what has prevented in the past medicine from being more scientific and more evidence based. But what do you believe are the the maid your barriers, still there still preventing it from becoming as evidence based as you'd want it to be, so we should be just about what medicine is and in the United AIDS, medicine is something that now takes near. Over twenty percent of GDP is colossus in our economy, we spend more on medicine than any other western nation. We probably don't get as much from it from what were spending, because such a large sector of the economy, the entrenched interests of the people who put company- and the people who really profit from the current system are.
Leslie, reluctant to change things. I think we see that with just for one instant, The pharmaceutical drug pricing problem we're having right now. I think it. No one will know Now that the pharmaceutical industry has made some great drugs, they ve also made some less than great drugs, but does every drug great or worthless have to cost a hundred thousand dollars per year, and I dont in that number, that's actually the because per annum, above the average cancer drug being up. Moved in the United States and in the last year well over. four thousand dollars per year of treatment. I there's gotta be a breaking point and people are recognising that next week on economics, radio in part, two of bad medicine. How do those drugs and the lesson great ones to get made and then have they get to market will look into the economic
new drug trials and how carefully the research subjects are chosen, not us for use for for a company that are trying to me Their treatment looked like is effective, but does the pot collation of people in this randomize trial really reflect the real world. people out there, what look at, who has been left out most clinical trials suggested that women shouldn't be included in clinical trials because of the potential adverse events to the feed us and have sometimes only thing worse than being excluded from a medical trial was being income the use of vulnerable populations of african Americans people in prison chill in orphanages, runner, populations like these have been used for cool experimentation for a fairly long time, its next time and for economics, radio for economic operators,
oh, is produced by w in my C studios and Dublin productions. This episode was produced by Stephanie Tam with help from earth Gunjay the rest, Staff includes Shelly Louis Christopher Worth Jake how it merit Jacob Gregg results No a courteous, Alison, Hockenberry, Emma Morgenstern, Harry Huggins, Ryan Gutierrez. You can subscribe to this Pakistan Itunes or wherever you get your podcast and one should come visit for economics, dot com. you'll find our entire podcast archive as well as a complete transcript of every episode ever made, along with music credits? Much more thanks for listening.
Transcript generated on 2021-01-24.