The lost art of context, nuance and appreciating shades of grey

The world has taken binary to whole new level. As a doctor I find it frustrating, fascinating, farcical, fanatical (would love to add to the alliteration more). The polarisation of simply everything, but especially "science".

....it seems one has a choice to either embrace entirely and wholeheartedly a position/narrative/belief, or if questioning even some aspect of it, one gets labeled as an "anti"-(whatever).

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As clinical doctors know well, and what is drummed into us during years of study and training, is that determining what might be wrong with a patient, what investigations to do, and what treatment to give (or rather suggest) requires context. It is not unlike how insurance doctors think when we assess or underwrite life insurance. The medical history, symptoms, lab results are taken in context of the applicant - who they are, what they do, how old they are etc. For example high levels of urinary creatinine might be a red flag in an average applicant, but a professional footballer has far increased muscle breakdown, and hence higher serum and urinary creatinine levels, and we are likely to accept far higher values as "normal".

The likelihood of someone having a certain condition, which is so dependent on the individual (age, sex, risk factors, medical history, family history...and on and on) has to be considered, as there are always both risks and benefits of testing for it, empirically treating it etc. EVERYTHING has pros and cons. Its why we shouldn't give every kid an antibiotic for a fever and cough. Its most LIKELY viral. Not only do antibiotics mostly not help, but they have side effects individually, and harms for society at large by increasing the likelihood of resistant strains of bacteria.

Benefits vs. harms - we should always be considering this, and acknowledging it is different for different individuals

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Imagine a doctor in ER with 2 folks the police have brought in - found on the side of the road. Someone smelling strongly of alcohol, clinically seeming a little drunk, and walking unsteadily. The second wearing cycling clothes, no helmet, seeming quite out of it, also walking unsteadily. Both have some head trauma evident - likely from falling. We would not necessarily send both for a CT scan, and we would not necessarily give paracetamol and just "watch and wait" to see if they improved after some sleep with both. Its about context.

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Similarly a 25 yr old overweight female with burning chest pain, some previous history of heartburn, who ate and drank excessively the night before would not be sent for a cardiac workup. The assumption has to be its that its reflux. But a 55 yr old smoking prediabetic overweight male may likely get a troponin and ecg to exclude a cardiac event.

(important to note that the illustrative scenarios above may well be very nuanced depending on the ancillary information, situation, previous medical history and investigations, collateral history etc).

?Statins

So one of topics relentlessly debated, often without context, are statins. So much conflicting views and opinions. Here are just 2 very recent ones.

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1: NICE in the UK want to expand access to those with even low risk. (up to 25 million adults in the UK)

2: Review in "Atherosclerosis" co-authored by Dr Rita Redberg, cardiologist and editor in chief of the prestigious JAMA internal medicine.

The article states : "When healthy patients without cardiovascular disease are prescribed statins they do not live longer, and they have only a marginal reduction in the risk of ischemic events. Furthermore, statins cause numerous side effects which substantially limit their net benefit."

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While different views per se are not the issue, what is frustrating is when someone questions the value of statins for certain individuals, they are often immediately labelled as a statin deniers or being anti-statin. I have seen this first hand from who I thought were objective and scientific minded colleagues. Not only labeling like that clearly not accurate or fair, it also stifles debate. The discussion about the merits or not of the data and evidence, the benefits to certain groups, the harms that may be caused, and for both parties to walk away with slightly expanded knowledge and understanding, even if not agreeing, is replaced by personal attacks and bucketing people in a binary way as a statin believer or statin denier. What nonsense.

Statin studies show a mortality benefit for secondary prevention (folks who have had a cardiac event, stroke etc). Studies on primary prevention (preventing a first CV event) - have NOT conclusively shown a mortality benefit, only a slightly reduced future event rate.

Stating then that its probably not worthwhile for an average 45 yr old male to be on a statin for PRIMARY prevention, even with some increased risk, may then seem "reasonable".

It does NOT equate to being anti statin. It means one is interpreting evidence, and considering side effects (of which there are many debates - large studies show low rates of side effects; clinically and real life anecdotes tell of awful quality of life impacts on a material number of people).

?Simply "accepting" the narrative which we know is significantly/mostly driven by profit motives seems not all that "scientific".

And then the profit motive of the pharma companies who fund all the studies, the selection of what is published, and the lack of transparency with the data of those trials, make it even harder to ascertain a "truth". And again, questioning a study and the conflicts of interest does not mean one is "anti" or a "denier". It means rather that one is thinking critically, considering all aspects, acknowledging bias and influence, being analytical, and being a "real" scientist. Simply "accepting" the narrative which we know is significantly/mostly driven by profit motives seems not all that "scientific".

This is even more relevant when considering some of the reviews of study robustness and bias. This is one of my favourites by John Ioannidis from Stanford.

?It can be proven that most claimed research findings are false.

We need to do better. We need to embrace debate, acknowledge that a binary approach in medicine is not only wrong, but detrimental and harmful to better debate, finding the best benefit/harms balance for an individual, and better patient outcomes.

Additional points, but would make this too long, is to consider that the benefit of statins mostly through their anti-inflammatory effect rather than a cholesterol lowering one.

And also that lifestyle interventions improving metabolic health and insulin sensitivity improve not only lipids, BUT THE UNDERLYING CAUSE, and without the side effects of statins. Reasonable to think some folks would prefer that to taking pills.

Look out for a post on the triglyceride lowering success of a new drug, but that does nothing for CV mortality, as the underlying cause is of course not addressed.