“Since fear precedes and forestalls knowledge and reflection, it is quite useless to try and convince the frightened with rational arguments and evidence; more than anything, fear denies them access to a reasoning process that would preclude fear itself…. It has been evident for quite a while that science has become our time’s religion, the thing which people believe that they believe in…. “
-Giorgio Agamben
Many people believe that doctors nimbly negotiate the perilous path between medical myth—often sewed by drug companies and other organizations intent to profit off patient fear and trust—and scientific fact, steering their patients toward the latter and helping patients to make individual choices based on accurate information. Sadly, the health care landscape for many decades has veered far from being an objective den of healing, gravitating more to robotic absolutism derived from misinformation and drug-company designed obfuscation of medical truth. Health care has become a bastion of dogma.
Two recent studies highlighted in our Holiday 2023 newsletter illustrate why medical dogmatism—which I define as an absolutist approach to often complex and nuanced medical situations that neglects facts—is so dangerous, and why we must as doctors push back against both scaring and deceiving patients into believing that only one right answer exists when it comes to health care decision making.
One article looked at blood thinners (Eliquis, Xarelto, to name two) and their impact in atrial fibrillation (afib) among frail elders. Frailty is something experienced by many elderly people; it could mean poor balance, impaired vision, or some confusion. And in no prior study of blood thinners have frail elders (those over 70-years-old) been included. Atrial fibrillation is a heart arrythmia fairly common with age, and typically it causes no problems if the high heart rates it triggers can be medically managed. But there is a slight risk in afib that a clot will develop in the heart and break off, triggering a stroke. Most strokes caused by this are too small to be noticed, and among those that cause symptoms (labeled as debilitating strokes), about 75% of those ultimately resolve. But given the fear of stroke, doctors often push blood thinners like Coumadin (Warfarin), Eliquis, or Xarelto to mitigate the risk. While these drugs can reduce the risk of clot-triggered strokes (including tiny ones that are found on CT scan, but which cause no symptoms) moderately, they reduce the risk of disabling clot-triggered strokes only by about 0.6%. In other words, let’s say the risk of a noticeable stroke is 3% in people with afib (a fairly accurate number), then if they take a blood thinner only 2.4% of them will get a stroke. Again, many of these disabling strokes are small, and about three quarters completely improve, but these medicines do at least lower that number a bit.
But at what cost? Studies show that among people who take these blood thinners, the tiny reduction in stroke is countered by an increased risk of brain bleeds; about 0.6% more people on these medicines die or develop bleeds in their brains (also forms of disabling strokes, most of which do not improve) than people who don’t take them. In other words, people on blood thinners still can get both types of strokes, but they get about a half-percent fewer strokes caused by clots and about a half-percent more strokes caused by bleeding. Thus, the benefit of stroke reduction is erased by the risk of bleeding strokes. Also, those on blood thinners often develop severe and life-threatening bleeds elsewhere in the body.
In the elderly, this calculus is more difficult to negotiate since few studies (all of which are paid for and designed by the drug companies that make blood thinners) include people over 70. When a colleague and I attempted to determine the impact of blood thinners in the elderly, we concluded that their risks and benefits were similar to the general population, but this came with a caveat: anyone with a bleeding risk or fall risk was excluded from these studies. Hence, the new study conducted in Europe is quite revealing, in that it included people with some degree of frailty such as falling or bleeding risk. It did not look at the benefit of reducing disabling strokes, but rather pointed its gaze at the risk of blood thinners in this population, and the results are quite telling. Whereas we know that these drugs reduce risk of clot-based stroked by about a half percent, they caused 1% of people to die of bleeds, they caused 1% of people to get disabling strokes from bleeding, and they sent 15% of people to the hospital with severe life-threatening bleeds, all in just a year. With this new information, it would seem almost insane to take these drugs if you are elderly and have afib; the risks are far higher than the benefits, and those risks include death and strokes. And yet, these medicines continued to be poured into elderly bodies by their doctors like mana from heaven, with doctors assuring patients that the medicines eliminate strokes that are otherwise inevitable and have minimal risks. This is medical dogmatism in a nutshell: the myth of blood thinners in afib is so entrenched in our medial liturgy that even when facts entirely dispute the singular unassailable fiction doctors are peddling, those facts whither when juxtaposed with the fear and myth sewed by doctors who refuse to accept nuance or to provide information that is accurate.
The benefit of treating prostate cancer is another mythical dogma promoted by doctors and the medical establishment subjected to a recent study. About a third of men develop prostate cancer in their lifetimes, and only a tiny amount of them die from the cancer. In fact, a ten-year study showed that the death rate is about 1% over 10 years, and that rate did not decrease even with aggressive treatment. Now the 15-year data is available, and while the death rate is a bit higher over that time span—it’s now 3%--treatment did not reduce that rate. In other words, even though we preach that all cancers must be treated, and that leaving a prostate cancer alone could spell doom, the truth is that treatment does not save any lives, and in fact treatment is toxic, sometimes deadly, and very often debilitating.
The medical community squanders tens of billions of dollars on blood thinners, likely causing more damage and death with this expensive intervention than saving anyone from having a stroke. Drug companies slurp in the benefits of this dogmatic myth, preached by doctors with such absolutist conviction as to frighten any patient who harbors doubt. We in the geriatric community have seen an epidemic of bleeds in our patients subjected to this myth, but it continues unabated; even the current study has not slowed the tide. Many drug companies keep hundreds of millions of dollars in their war chest to pay off patients’ families who bled to died or sustained strokes from these medicines; best to quiet those whose grim reality does not follow the rules of the dogma and deflect obsequious doctors from lawsuits, which is exactly what these companies have done. We also squander tens of billions—maybe even more—on treatments for prostate cancer, enriching doctors and medical centers (as well as drug companies) and sewing an illusion of cancer cure, but in fact helping no one and hurting tens of millions of men.
Medical dogma is difficult to confront because it seems to make sense. How could treatment of prostate cancer not be good? If blood clots develop in afib, how could using blood thinners to dissolve those clots not make sense? And when trusted doctors and endless ads on TV promote dogmatic cures, how can anyone dare dispute their value, especially since we all know people with afib on Eliquis who didn’t get a stroke, and we know people with prostate cancer still alive who received aggressive therapy? Forget the fact that 97% of people with prostate cancer would be alive after 15 years even they just walked around a tree three times rather than subject their bodies to a medical assault that weakens them and sews the illusion of cure. Facts be damned; truth only gets in the way of dogma, and dogma is the engine that makes our health care system profitable.
Many organizations estimate that we spend as much or more on unnecessary tests/procedures/medicines than for effective interventions; dogma is expensive, dangerous, and deadly. Then why does it persevere? How can deceptive physician absolutism not be expunged by studies clearly proving that the dogma is wrong, as in the case of blood thinners and prostate cancer treatment?
Part of the reason is that doctors are usually trained to follow protocols and ask no questions. They are given data and even calculators programmed by drug company studies that lead them to conclusions clearly erroneous, and instead of critically analyzing the data, instead of treating each patient as an individual and understanding the nuances of intervention, they grasp dogma and sell it to vulnerable patients who are seeking a simple, effective solution to a complex problem.
But even more than physician complicity in the perpetration of medical dogma is patient acceptance of it, and that occurs because much of the dogma seems to make sense; patients look to their doctors and our miraculous medical technology to save them, and dogma is far more comforting than messy reality. Who wants nuance and to hear about risk when a doctor promises cure? We’ve seen this in the cardiology world, where hundreds of billions of dollars are wasted on stress tests, echocardiograms, cholesterol treatment, and stents that studies clearly show don’t work. We know that treating cholesterol prevents no heart attacks or deaths, but doctors continue to prescribe tens of billions of dollars of these often dangerous and harmful pills, demonstrating their success through the lowering of cholesterol lab tests, a dogma that is contradicted by every study (including two this year, discussed in prior newsletters) that show no benefit in reducing meaningful outcomes. Doctors love to treat numbers and not patients; numbers are easy to fix, while helping patients is much more complex and difficult. We know that doing regular stress tests and echocardiograms save no lives, but they are done at the rate of almost $100 billion a year, money that finds its way into the pockets of doctors who sell the dogma of “finding heart problems early” as being necessary and prudent. And what happens when a stress test reveals that a heart blood vessel is blocked? Then the caring doctor will reach into his or her bag of miracles and disseminate another dogma: putting in a stent to open the blocked artery will avert a heart attack. This is a myth that has been shot down by dozens of studies; unless done during an acute heart attack, every study shows that stents do not reduce the risk of death or dangerous heart attacks, but they do increase the risk of strokes. Still, doctors sell stents as being lifesaving, and patients readily accept this dogma and believe that the stent indeed saved their lives. How could a procedure that fixes a 90% blockage in the heart artery not be helpful? Dogmatic myth appeals to our own desire for simple cures, and that is exactly what the medical system sells us, at a cost of many lives lost and about $1 trillion a year.
We in health care—those of us who read studies and understand the danger of dogma—are consistently thwarted by doctors and institutions who sell dogma for profit. Dogma is always more appealing than truth. Facts are messy and not always what people want to hear. We knew before COVID hit our shores that masks would not protect anyone or slow transmission of infection; a hundred years of data from flu studies demonstrated this, Cochrane published an analysis of this in March 2020, and even past generations of doctors understood the fecklessness of masks in prevention of a virus that passes through them as easily as flies go through chain linked fences, which is why we have never seen them used in the past for viral respiratory infections. A compilation of 78 randomized trials during COVID hammered home this fact: masks don’t work, they can’t work, and during COVID they didn’t work. Still, the dogma of masking, of 6-foot separation, of hand washing to prevent a virus that doesn’t live on hands, all of that stuck in the public imagination—we still are subjected to mask mandates in long term care even as masks have not slowed the virus one bit in that environment—because doctors preach it and it seems to make sense. Had the medical community pushed back against mask mandates and done what many of us suggested—focusing on testing and early treatment in vulnerable populations—then likely hundreds of thousands of lives could have been saved, but the appeal of the mask did (and still does among many) provide a more facile if deceptive means of combatting a frightening virus, especially since the medical community promotes it as unassailable dogma. My own medical license was threatened by the State Board of Physicians when I stated, factually, that our long-term care patients were getting COVID despite a well-enforced mask mandate. I was told that such “facts” were dangerous, and I had to apologize for being truthful; that is the state of our medical religion today, and I was punished for daring to question dogma. This is true too of treatments like Paxlovid, touted to be effective for COVID but never having been shown to save any lives in a randomized trial; in fact, as we have discussed, Paxlovid could be very dangerous to the elderly given its drug interactions and its propensity to promulgate recurrent COVID. And yet just today, a regional nurse in one of our long-term facilities told me that I would essentially be dismissed from the facility if I did not treat all my COVID patients with Paxlovid, a dangerous dogmatic response that puts religious faith over scientific fact and could well lead to death and disability in vulnerable people who have never been studied with this experimental pill. She treated the situation as a binary right-wrong moral issue; this is religion, not science, not compassion, not good medical care. It is frankly frightening; especially given how she had not studied the drug at all but rather relied on someone else’s opinion to announce her dogmatic verdict.
Drug treatment for dementia, aggressive treatment of diabetes and hypertension, MRIs for back pain; all of these useless interventions continue to be pushed by doctors and accepted by patients despite clear and undisputable data that shows they don’t work. As a doctor who seeks to tell my patients the truth, and to protect them from the dogmatic claws of a medical system willing to peddle myth for profit, it is hard to argue that a blood thinner may cause more strokes than it prevents, that prostate cancer is best left alone and in fact never should be looked for in the first place, that there is no treatment for dementia, that measuring and fixing cholesterol hurts people and helps no one, that looking for and then opening blocked heart vessels is more harmful than helpful, that masks and Paxlovid don’t prevent COVID or any respiratory virus and in fact can cause harm. People love dogma; it’s simple and appealing, it transforms doctors into saviors, it provides facile solutions to complex problems that are frightening. But medicine should not be a dogmatic profession; it should be a science, not a religion, a science that acknowledges uncertainly and nuance, a science that constantly evolves and does not anchor its proclamations on myths, a science that must separate itself from industry meddling. As Osler said: “The greater the ignorance the greater the dogmatism. Without faith a man can do nothing, with it all things are possible.” Yes, all things are possible in a mythical world of snake oil cures; faith and dogma are appealing elixirs, promising to combat complex problems in simplistic but ultimately dangerous and deceptive ways, but science has shown us that they don’t work, and sadly science has been buried by dogma far too often. It is up to us to let you know the truth and to combat the dogma that so litters our profession and the entire medical landscape, and that’s exactly what we promise to do. Sometimes it certainly feels like an uphill battle!