The gap between academic and real-world medicine is widening Part 2 August 8, 2022
Here are some solutions I see that can help bridge the widening gap between academic and real-world medicine.
- We need to address our own biases. I see a whole lot of political mud-slinging going on, especially around highly controversial and politically charged issues. We must constantly be asking ourselves as we investigate, “What if I’m wrong?” “What am I not seeing here that is so obvious to the other side?” “What can I learn from the other side that I hadn’t known before?” Seek first to understand, before trying to be understood.
- Academics need to realize that we are all humans, all different, all uniquely us, and not a confidence interval, nor are we a number needed to treat. We aren’t a relative risk ratio or a median or average anything. We are ourselves, and maybe what the evidence shows in some studies isn’t the evidence for us. Ivy towers aren’t for everyone, and sometimes for no one. “Consensus statements” are meaningless without some evidence to back it up.
- Front-line doctors need to get better at reading medical research, understanding things like sensitivity, specificity, number needed to treat, and confidence intervals. They need to make sure that they not only read medical literature, but challenge it in their minds, don’t just rely on “how things have been done in the past” or only “what I think is right”. We need to do less “shooting from the hip” and more standardized protocols based on independent, unbiased, randomized, placebo controlled trials. “Consensus statements” are meaningless without some evidence to back it up.
- Understand the power of placebo. If someone tells me that they are taking this supplement or that medication for a condition that I know has no evidence of benefit over placebo, I ask them if they think it is helping. If it is, then I tell them to continue it, as long as the benefits outweigh the risks. I’d be a horrible doctor If I told someone to stop magnesium for their migraines because the outcomes in some study are no different than placebo.
- Some natural remedies’ efficacy is grossly under-represented in mainstream medical journals. There, I said it. I really couldn’t care less that you call me a quack. I guarantee that I’ll find that anyone calling me a quack has their own personal set of beliefs that I could find just as “quacky”. With plenty of evidence to back that up. Nobody lives their life according to “whatever JAMA says” or “whatever NEJM says” all the time. So please, spare me your self-righteous indignation.
- We need more head-to-head studies. NOW. Is Remdesivir more effective than Ivermectin for COVID outcomes? Compare them! Is Januvia more effective than metformin for diabetes? Compare them! Is Levothyroxine more effective than Armour thyroid? Compare them! And on and on, and on! Why aren’t we doing more head-to-head trials? Why are we only comparing whatever it is to a placebo?
- We need to recognize that population based studies can’t immutably be applied to every patient encounter. Just because one drug resolved a particular problem 7% more than the other drug in 1000 people doesn’t mean that every person with this problem needs the drug. We need to be evidence-based, but we also have to be realistic, especially when that 7% drug costs $800 per month.
- We need to follow up with people over a longer period of time, not just 4-6 weeks. How about 12 months? 2 years? 5 years?
- We need to quit lumping everyone into one basket when the effects were only seen in a certain age group or gender or one ethnic group, or one personality group, or one political group, or one religious group. We need to quit over-generalizing results and outcomes that make for breathlessly authoritative sounding click-bait headlines for national news media. The “one size fits all” approach is an incredibly blunt instrument that requires delicate finesse. Results that aren’t so simple to define, and aren’t so easy to reproduce. Be honest about what we really don’t know.
- We need to realize that medicine is not a science alone, nor an art alone, but a harmonious blending of art and science that weaves into a beautiful tapestry. Both require humility, curiosity, tenacity, and courage. Both are just as important as each other. Let’s all remember that.