Why We Don’t Take Our Meds, Part 4

Primum non nocere. (First, do no harm.)

Imagine a random blogger who’s fed up with his doctors because, if they had their way, he would be on nine – count ‘em, nine – powerful drugs. He’s decided to see a new doc and has just met the fellow in the exam room.

“Ah, Mr. Smith,” says the new doc, “I see you have 1.8 children, you earn $51,371 a year, are a registered Democrat and can reduce your chances of having a heart attack by 25% by taking meds!”

Arrgh! The correct answers are “6”, “like hell,” “Independent,” and “try-not-to-think-like-a-freaking-moron.” In other words, we used to be patients but now we’re all just statistics – and, worse, as applied to any individual one of us, those statistics are patently wrong. How did the medical world sink into such a swamp?

Let’s start with mass innumeracy. We know that the people who conduct epidemiological and clinical studies, and the drug companies who sponsor them, have a huge incentive to exaggerate their results. Very often, they have formal conflicts of interest that should disqualify them from even undertaking these studies.

But why aren’t these tactics promptly exposed? Because all of us – the FDA, the AMA, Medicare, physicians, patients, the media – have no clue how to translate the results of mass studies into something that might be relevant to the individual patient. We all assume that if some over-hyped study showed that people on X drug had Y% fewer cancers, then that means that each and every one of us would have the same result.

Once this fundamental error has been made, everybody jumps on the bandwagon. The FDA approves the drug. The AMA certifies its use as a best practice. Medicare agrees to pay for it. Hospitals adopt it as a protocol that docs depart from at their peril. Malpractice insurers insist on it.

Imagine some poor doc – the best one in town, as it happens – who decides not to be a brain-dead automaton and actually takes a couple of statistics courses. He realizes, with a shock, that he hasn’t been treating his individual patients at all – he’s been treating this amorphous thing called “the public health.” He changes his ways and his patients are delighted and happy and healthy.

But, inevitably, one of these patients drops dead of, say, a heart attack. It turns out the patient wasn’t taking statins, diuretics, ACE inhibitors, beta blockers, vasodilators, PCSK9 inhibitors, who-knows-what-else. The patient would have died anyway, but the hospital and the medical malpractice carrier throw the doc to the wolves. Not only does he get hit with a huge malpractice judgment, but he loses his medical license and has to go to law school.

Our ex-doc graduates from law school and has decided to mend his ways, no more bucking the system for him, it’s too painful. As a newly minted lawyer he will focus on “the public interest.”

Sitting across the desk from him is his first client, a hapless fellow charged with armed robbery. The ex-doc, now reformed, has this conversation with himself: “I know from mass statistics that this fellow is almost certainly guilty. I know from similar statistics that if he isn’t sent up the river for a long stretch he’ll just commit more crimes. Ergo, the public interest will be served if I either don’t represent him or just go through the motions so he’ll be sure to be convicted.”

Oh, dear, big mistake. You see, in the legal world what matters is not some statistical nonsense called the “public interest.” What still matters is the interest of the individual client sitting across the desk from you. A good lawyer doesn't give a rat’s ass about the public interest. Or, more charitably, in the legal world the public interest is served through the vehicle of the interest of the individual client. Cops know better than to pick up any random person and charge him with armed robbery. DAs know that they’d damn well better mount a strong prosecution or they’ll be laughed out of court. And in this way the public interest is served.

Our newly minted lawyer, alas, has committed the crime of failing to “provide competent representation to a client.” His law firm and his legal malpractice carrier throw him to the wolves. Not only does he get hit with a huge malpractice judgment, but he loses his law license and has to become an accountant.

Say what you will about lawyers (full disclosure, I’m one of them), lawyers would never, ever, desert their client for some statistical fiction called the “public interest.” But every single day millions of physicians sacrifice their individual clients to something called the “public health.” In fact, that’s what the practice of medicine is these days: prescribing powerful drugs at the drop of a hat to some wretched fool because mass statistics suggest that, if you treated fifty million people that way you might save one net life.

Innumeracy and the desperate search for cost savings in the healthcare system have created a monumental confusion in the medical mind between the “public health” and the duty to treat the individual patient. These very different things have somehow merged into one awful dog’s breakfast in which physicians who genuinely care about their individual patients imagine that they’re treating them individually, when in fact they’re treating them all exactly alike.

Do no harm, indeed!