6 ms·

I only know anything about one of the authors of this (Prasad). The history leading up to this article is relevant. His modus operandi is to severely criticise

by Gatsky 7y ago

I only know anything about one of the authors of this (Prasad). The history leading up to this article is relevant. His modus operandi is to severely criticise clinical trials to an audience that is only peripherally or not at all involved in the field. You can see why this works - being extremely shrill about something to people that don't have any idea tends to garner agreement, since they can't evaluate your claims and you seem so adamant about it. It creates the illusion of someone that is 'telling it like it is' and not just following the norms of the profession. The problem is that this doesn't generate anything of actual value, except for Prasad. It is easy to criticise medicine. It is easy to criticise any complex and difficult human endeavour. He takes the practice of critical thinking about studies and results and what they mean, something which all doctors do and are taught to do, and turns it into a blood sport which plays to the masses. There are plenty of academics who do what he does, and publish in well respected journals. At any conference where a major result is presented, people in the audience get up and ask questions about the value of the intervention, the conduct of the study etc, just the kind of things Prasad rants about. The difference is that Prasad has monetised this practice by pretending that he is the only one doing it. He writes books, publishes endless articles which are mainly reviews and rehashings of other's work and the person that hired him to a faculty position openly admits they chose him because of his propensity for scathing criticism. This article therefore, I find largely self-indulgent and in some parts sheer nonsense. The authors style themselves as custodians of some higher art, a priesthood of common sense and clear thinking. They pull the trick of trying to cement their importance by defending themselves against a bogeyman, the force of 'commercialisation'. Of course, there is no single person or group who is causing this commercialisation, so there is nobody to question them. They also bizarrely say that they are better placed at evaluating medical evidence than the people who know most about it ('content experts'), because the experts are too enthusiastic.

hash872 7y ago
What you've written sounds good, but how do I square this with the commonly repeated assertion that medicine has a replication crisis and many or even most treatments don't have a solid empirical basis? I'm not asking critically of you (or the medical establishment), just curious what I should do/how I should think about medicine as a non-expert but occasional consumer
- Gatsky 7y ago
  The gold standard of evidence for medical treatments, the randomised controlled trial, particularly if double blind, and meta-analyses thereof is not part of the replication crisis. The replication crisis refers to life sciences research and sociological and psychological research which use less statistically robust experimental designs. There are other problems in medicine, specifically bias due to funding, and non-publication of negative studies. The former isn't going away. The only entities which can fund large randomised trials on a regular basis are large pharmaceutical or device companies. That boat has sailed. The latter is improving a bit due to study registration, but is still an issue. It is true that many treatments don't have the kind of strong evidence one would like. There are multiple reasons for this. There are a few cases where a treatment has been shown to be ineffective, yet it is still widely offered. An example of this is orthopaedic surgery for back pain, or cardiac stents in certain circumstances. Usually, the reason for this discrepancy is obvious - the intervention is well compensated, and widely performed prior to evidence showing it isn't effective, so doctors just want to keep on doing it. The other reason for the discrepancy can be psychosocial factors. The use of antibiotics for children with upper respiratory tract infections is an example. Parents can be very demanding, and not surprisingly, there is a strong incentive to just prescribe antibiotics and get them out of the door. I will not go into conflicts of interest here. It's a big topic. There have definitely been inappropriate relationships between pharmaceutical companies and doctors. This has become less of a problem due to regulation, but it is not eradicated. There is still a conflict of interest problem for hardware, eg pacemakers or hip replacements. This is why for a procedure like this, a second opinion is recommended. Again some relevant history - there was an evidenced based medicine movement in the early 2000s that became popular. The gist of this was that applying high quality evidence to medical practice was paramount. The systematic review become much more prominent. This movement has died off, but the concept is still going strong. The problem was that this high quality evidence is often not available. The majority of systematic reviews concluded there was inadequate evidence. The second problem is that we want to move towards more precise tailored therapy for each patient, and by their very nature, randomised trials can only report average affects in large groups. They are thus well suited to relatively common problems with a clear diagnosis and relatively simple therapeutic interventions. Much of medicine isn't like this. So although medicine strives to be evidence based, this is in many cases an aspiration rather than the reality. Nevertheless, it is important to remember that most doctors want to use the best evidence available. As a consumer, the pragmatic approach I would take is as follows: 1A. Am I getting sound advice (part 1)? Ask the doctor for the evidence that what they propose works. This is the most efficient way. If they are vague or unhelpful in the consultation, you can ask them to send you something later. If they don't want to do that, you need to look elsewhere. I know this may or may not be practical depending on what is wrong and where you live. The best case scenario is to find a doctor you trust, and not worry about the rest so much. 1B. Am I getting sound advice (part 2)? Understand the incentive structure. When you go to a gastroenterologist for example, they get paid a lot more to do a colonoscopy than to talk to you. Unsurprisingly, they will tend to want to do a colonoscopy. This is why in my opinion, primary care is so important and the cornerstone of a good health system. What I mean is that you want to see a doctor who isn't a specialist first, who decides if sending you to a specialist is required. When you go direct to the specialist, you are at risk of getting biased advice, non-holistic care and unnecessary procedures. 2. Does the therapy make a difference? Know that effect size is important. Many treatments might be proven to make a difference, but the size of the difference is important. You should always be asking how much of a difference will this make? Do I want to have toxic chemotherapy that will extend my life a mean of 42 days? This is also inherently related to the value proposition of a therapy. You might want a chance at 42 days, the doctor might think you do or do not, so it is best to ask. 3. What level of side-effects can I tolerate? Educate yourself about side effects of drugs. It isn't feasible for a doctor to go over every side effect of a medication. They will tell you about the common problems, and also any problems which are severe and not extremely rare, and they should also tell you about side effects that may be particularly relevant to you eg if it makes you dizzy and you are a tight rope walker. Know that in placebo controlled trials, the placeboes do not have zero reported side effects, so that merely taking a pill can cause issues. Ask for detailed resources about side effects that you can take home and look at, but do not treat them all as equally likely. Decisions about whether a drug has too many side-effects or not are very individual. The final thing to say is that some medical systems like to get in the way of actually looking after people, and the USA is a good example of that. This is again a whole other topic.
luxuryballs 7y ago
> being extremely shrill about something to people that don't have any idea tends to garner agreement Well I have no clue about this but what you’re saying sounds right!
- awb 7y ago
  Then you can upvote, but you don't need to comment
- klausnrooster 7y ago
  I see what you did there.
DoreenMichele 7y ago
Thank you for your comment. At any conference where a major result is presented, people in the audience get up and ask questions about the value of the intervention, the conduct of the study etc, just the kind of things Prasad rants about. For people with incurable conditions, "dread diseases" and very deadly conditions, the current system is already too conservative. They denied approval for a non-drug treatment for cystic fibrosis because some participants had lung bleeds. Lung bleeds are common with CF. CF is extremely miserable and has a very short average life expectancy. There are many stories like this out there. People with horrible conditions hear the news that some new drug they were hoping would get approved has been denied by people who seem to be comparing it to some internalized standard for someone relatively healthy and not actually comparing it to "Is it better for this group of people than what they currently have?" There are very, very expensive drugs and surgeries that get approved at times and that's a whole other issue for such communities. But it's a very real problem that some people are dying and drug approvals don't seem to actually take that into account. I've seen people say things like "Just let me live the additional five years that it takes to get these horrible side effects instead of dying before then. I will worry about the horrible side effects then." Most people want to live, even when that involves terrible suffering. Most people want that chance. And our drug approval process is often maddeningly conservative already in the eyes of people with various terrible conditions who would be happy to be a guinea pig to have some kind of shot at survival. It's a logic that makes sense to the people enduring these diseases, but one the medical establishment recoils from.
- YeGoblynQueenne 7y ago
  >> And our drug approval process is often maddeningly conservative already in the eyes of people with various terrible conditions who would be happy to be a guinea pig to have some kind of shot at survival. Maybe some people are happy to become guinea pigs. That doesn't mean that other people should be happy to turn them into guinea pigs. "The patient asked for it" is no excuse for the dispensation of interventions that harm the patient.
  - tapland 7y ago
    Yes it is? Yes it is!
zby 7y ago
Sounds like https://meaningness.com/geeks-mops-sociopaths https://meaningness.com/geeks-mops-sociopaths

by Gatsky 7y ago

hash872 7y ago

What you've written sounds good, but how do I square this with the commonly repeated assertion that medicine has a replication crisis and many or even most treatments don't have a solid empirical basis? I'm not asking critically of you (or the medical establishment), just curious what I should do/how I should think about medicine as a non-expert but occasional consumer

Gatsky 7y ago
The gold standard of evidence for medical treatments, the randomised controlled trial, particularly if double blind, and meta-analyses thereof is not part of the replication crisis. The replication crisis refers to life sciences research and sociological and psychological research which use less statistically robust experimental designs. There are other problems in medicine, specifically bias due to funding, and non-publication of negative studies. The former isn't going away. The only entities which can fund large randomised trials on a regular basis are large pharmaceutical or device companies. That boat has sailed. The latter is improving a bit due to study registration, but is still an issue. It is true that many treatments don't have the kind of strong evidence one would like. There are multiple reasons for this. There are a few cases where a treatment has been shown to be ineffective, yet it is still widely offered. An example of this is orthopaedic surgery for back pain, or cardiac stents in certain circumstances. Usually, the reason for this discrepancy is obvious - the intervention is well compensated, and widely performed prior to evidence showing it isn't effective, so doctors just want to keep on doing it. The other reason for the discrepancy can be psychosocial factors. The use of antibiotics for children with upper respiratory tract infections is an example. Parents can be very demanding, and not surprisingly, there is a strong incentive to just prescribe antibiotics and get them out of the door. I will not go into conflicts of interest here. It's a big topic. There have definitely been inappropriate relationships between pharmaceutical companies and doctors. This has become less of a problem due to regulation, but it is not eradicated. There is still a conflict of interest problem for hardware, eg pacemakers or hip replacements. This is why for a procedure like this, a second opinion is recommended. Again some relevant history - there was an evidenced based medicine movement in the early 2000s that became popular. The gist of this was that applying high quality evidence to medical practice was paramount. The systematic review become much more prominent. This movement has died off, but the concept is still going strong. The problem was that this high quality evidence is often not available. The majority of systematic reviews concluded there was inadequate evidence. The second problem is that we want to move towards more precise tailored therapy for each patient, and by their very nature, randomised trials can only report average affects in large groups. They are thus well suited to relatively common problems with a clear diagnosis and relatively simple therapeutic interventions. Much of medicine isn't like this. So although medicine strives to be evidence based, this is in many cases an aspiration rather than the reality. Nevertheless, it is important to remember that most doctors want to use the best evidence available. As a consumer, the pragmatic approach I would take is as follows: 1A. Am I getting sound advice (part 1)? Ask the doctor for the evidence that what they propose works. This is the most efficient way. If they are vague or unhelpful in the consultation, you can ask them to send you something later. If they don't want to do that, you need to look elsewhere. I know this may or may not be practical depending on what is wrong and where you live. The best case scenario is to find a doctor you trust, and not worry about the rest so much. 1B. Am I getting sound advice (part 2)? Understand the incentive structure. When you go to a gastroenterologist for example, they get paid a lot more to do a colonoscopy than to talk to you. Unsurprisingly, they will tend to want to do a colonoscopy. This is why in my opinion, primary care is so important and the cornerstone of a good health system. What I mean is that you want to see a doctor who isn't a specialist first, who decides if sending you to a specialist is required. When you go direct to the specialist, you are at risk of getting biased advice, non-holistic care and unnecessary procedures. 2. Does the therapy make a difference? Know that effect size is important. Many treatments might be proven to make a difference, but the size of the difference is important. You should always be asking how much of a difference will this make? Do I want to have toxic chemotherapy that will extend my life a mean of 42 days? This is also inherently related to the value proposition of a therapy. You might want a chance at 42 days, the doctor might think you do or do not, so it is best to ask. 3. What level of side-effects can I tolerate? Educate yourself about side effects of drugs. It isn't feasible for a doctor to go over every side effect of a medication. They will tell you about the common problems, and also any problems which are severe and not extremely rare, and they should also tell you about side effects that may be particularly relevant to you eg if it makes you dizzy and you are a tight rope walker. Know that in placebo controlled trials, the placeboes do not have zero reported side effects, so that merely taking a pill can cause issues. Ask for detailed resources about side effects that you can take home and look at, but do not treat them all as equally likely. Decisions about whether a drug has too many side-effects or not are very individual. The final thing to say is that some medical systems like to get in the way of actually looking after people, and the USA is a good example of that. This is again a whole other topic.

luxuryballs 7y ago

> being extremely shrill about something to people that don't have any idea tends to garner agreement Well I have no clue about this but what you’re saying sounds right!

awb 7y ago
Then you can upvote, but you don't need to comment
klausnrooster 7y ago
I see what you did there.

DoreenMichele 7y ago

Thank you for your comment. At any conference where a major result is presented, people in the audience get up and ask questions about the value of the intervention, the conduct of the study etc, just the kind of things Prasad rants about. For people with incurable conditions, "dread diseases" and very deadly conditions, the current system is already too conservative. They denied approval for a non-drug treatment for cystic fibrosis because some participants had lung bleeds. Lung bleeds are common with CF. CF is extremely miserable and has a very short average life expectancy. There are many stories like this out there. People with horrible conditions hear the news that some new drug they were hoping would get approved has been denied by people who seem to be comparing it to some internalized standard for someone relatively healthy and not actually comparing it to "Is it better for this group of people than what they currently have?" There are very, very expensive drugs and surgeries that get approved at times and that's a whole other issue for such communities. But it's a very real problem that some people are dying and drug approvals don't seem to actually take that into account. I've seen people say things like "Just let me live the additional five years that it takes to get these horrible side effects instead of dying before then. I will worry about the horrible side effects then." Most people want to live, even when that involves terrible suffering. Most people want that chance. And our drug approval process is often maddeningly conservative already in the eyes of people with various terrible conditions who would be happy to be a guinea pig to have some kind of shot at survival. It's a logic that makes sense to the people enduring these diseases, but one the medical establishment recoils from.

YeGoblynQueenne 7y ago
>> And our drug approval process is often maddeningly conservative already in the eyes of people with various terrible conditions who would be happy to be a guinea pig to have some kind of shot at survival. Maybe some people are happy to become guinea pigs. That doesn't mean that other people should be happy to turn them into guinea pigs. "The patient asked for it" is no excuse for the dispensation of interventions that harm the patient.
- tapland 7y ago
  Yes it is? Yes it is!

zby 7y ago

Sounds like https://meaningness.com/geeks-mops-sociopaths https://meaningness.com/geeks-mops-sociopaths