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The gap between academic and real-world medicine is widening–Part 1 August 1, 2022

I’m a physician who sees and treats patients every single day. Yes, when I’m not in the clinic seeing my panel of patients that span a large spectrum of ages and medical conditions, I’m on call for them, 24 hours per day, 7 days per week (unless I’m on vacation, and even then I’m still on call a lot of the time). I say this not to complain at all about my chosen profession, or  how much easier it is to make money as a (fill in the blank), than to have become a doctor. I really am happy that I can provide significant value to society by being the best doctor I can be. 


I say this because as a doctor who practices medicine every day for over 20 years now, I have developed a perspective that is rather unique to the academic field of medicine. I try very hard to practice “evidence-based medicine”, a field that teaches us that we must base all of our diagnostic, treatment, and management decisions on the results of clinical research, published in reputable medical journals. You know, the “academic” side of medicine. 


I don’t want to be accused of being the “country bumpkin” who gave up on keeping up long ago, one who doles advice and prescriptions for ailments based on nothing more than “well, that’s how I learned it in school–why should I change now?” I don’t think anyone relishes the thought of being considered “incompetent”. So I signed onto the evidence-based medicine idea right from the start. I wanted to be state-of-the art all the way through my career. 


What I didn’t realize though, was how many independent variables there are when trying to apply “evidence-based” medicine to a very individual patient. A patient who breathes, eats, and sleeps just like everyone else, but who also has a myriad of genetic codes and quirks that make them especially unique, and unlike anyone else in the world. 


Evidence based research, as good as it is, and as much as I look for it, is fundamentally flawed. It still IS the best way to find an answer to a question. However, we must be extremely careful about how important we rest our final decisions upon when rendering medical advice. 


For example, let’s take the COVID medication, Paxlovid. It was (and still is) touted as a game-changer for reducing COVID related deaths and hospitalizations. That’s great, awesome in fact. It’s available in nearly every drug store and can even be prescribed and dispensed without a doctor’s prescription. Yet, since Paxlovid was approved in December 2021 and the following 6 months after (January-June 2022), there were more COVID deaths reported (219,197 deaths) in the U.S. than the first 6 months (March-August 2020) of the pandemic (190,132 deaths). Then there’s Paxlovid rebound, supposedly only happens in about 1% of patients who take it, but embarrassingly happened to Dr. Fauci and President Biden. Does Paxlovid reduce deaths and hospitalizations in high risk patients? Yes. Does Paxlovid reduce deaths and hospitalizations in average risks patients? Likely not. 


Then you have natural supplements. Let’s take magnesium for example. Despite multiple clinical research findings concluding the opposite, magnesium effectively, and substantially lowers migraine intensity and increases migraine free days in almost every patient I start it on. However, these studies find “no effect” in clinical trials. How can this be? How is it possible that I’m prescribing the equivalent of a placebo to treat (successfully, I might add) migraine headaches? 


There seems to be a widening gap between front-line and academic medicine. I feel like I’m caught in the middle. Could it be that all studies are fundamentally flawed or biased in some way? Do we associate only with people who see and understand our biases? How do we address our own biases in a way that best benefits the patient?

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