Tuesday, 9 May 2017

How eating cheese helps puncture overbearing medicine

Doctors aren’t generally known for their modesty.

There are noble exceptions, of course, and they’re all the more impressive for being self-effacing. But in 34 years’ experience in healthcare informatics, I can tell you that they’re in the minority. For most, it’s a matter of where on the arrogance spectrum they fall, between barely tolerable and downright monstrous.

Now it has to say that they often have plenty to be arrogant about. They’re usually bright and well-informed. Unfortunately, however, a lot of them arent quite as bright or well-informed as they think.

It’s the quiet form of arrogance that amuses me most. This is where the doctor makes no claim to superiority but his – or her – quiet demeanour, the tilt of her head, the tone of his voice, simply floats that superiority out there as an unstated presumption of any conversation. None of us questions it, least of all her, because it’s simply beyond question.

This isn’t an attitude limited to medicine. It’s found at the rarefied top of many walks of life. Ever had a passport query abroad? Embassy and consulate staff make it clear that they’re doing you a favour by allowing you the privilege of being with them; why, they go so far as to be gently and ever so condescendingly polite to you. You see it too in the upper reaches of business in the leadership of political parties. These people are at the top because they deserve to be and, in a neatly circular demonstration, we know they deserve to be there because they are.

What I particularly enjoy about this attitude in medicine is that I know that, however authoritatively convinced they may seem today about, say, the dangerous effect of cholesterol, their predecessors spoke with exactly the same conviction two or three centuries ago about the benefits of leeches or bleeding. Aspirin was a panacea, then a dangerous toxin that wrecked your stomach lining, now a remarkable drug to be taken to avoid cardiovascular disease. Smoking was good for you until it was found to be lethal. Opium had a salutary effect on the system until it was deemed a dangerous drug.

Just as sure of themselves then as they are now
but marginally more likely to be wrong
There were doctors as patronisingly convinced of the good effects of a substance before it was found to be noxious as they were of its bad effects afterwards. Often, it was the same doctors.

That’s why I’d like to see them using phrases such as “I think” or “in the present state of our knowledge”. It’s not going to happen, though, and for two good reasons.

In the first place, a doctor taking a decision that might affect a patient’s life chances, or chances of quality of life, needs to feel confident that the decision is correctly based. Even if it isn’t.

Secondly, in most cases doctors are actually right, or as right as the state of science allows us to be. For instance, most of them know that childhood inoculation is vital both for the children inoculated and for the population as a whole: by maintaining general (“herd”) immunity, we prevent outbreaks of a disease, and therefore those who for one reason or another aren’t immunised (e.g. because they’re too young). Doctors’ defence of inoculation is strongly to be supported; populist refusal of it by prominent figures in some cases, including most recently the US president himself, is dangerous and needs to be resisted.

On the other hand, it is fun to see the arrogance punctured from time to time. I greatly enjoyed reading an article in the Guardian reporting on a study that shows that there is no evidence of increased risk of cardiovascular problems associated with consuming dairy products, including cheese.

All that skimmed milk? Forget it.

Low-fat yoghurt? You can have the stuff that actually tastes right.

Avoiding cheese? Get right in there and indulge. Well, in moderation…

This merely reinforces my long-held belief that, far though medicine has progressed in the last couple of centuries, it’s still in its prehistory. We’re constantly making new discoveries, but there’s still a lot more to discover than we already know. Besides, a lot of what we think we know is wrong.

It seems to me, for example, that if there are still people around a century or two from now, they’ll be looking back at our treatments for cancer as we look back on leeches. “What?” they’ll say, “they pumped patients full of toxins? As a curative measure? Didn’t it kill them?”

Having lost a friend to chemotherapy, I’d have to answer “yes” to that question.

This makes me pleased to be doing my present job. It’s based on a service aimed to put the latest, most reliable information at the disposal of physicians and nurses. The information may be superseded later – we update the system every single day – but at least it’s as good today as it can possibly be.

My job is to get clinicians to use it. I’d like to succeed, because I’d like them to admit, at least to themselves, that they don’t actually know everything. That it’s worth checking from time to time.

Meanwhile, when you’re next with a doctor and you find him arrogant, try to humour him. He may well be right. And even if he isn’t, he needs to think he is.

Still, it can’t do any harm to check your doctor’s opinion if you can. Her arrogance may be a defence mechanism that allows her to do her job. But don’t forget that one of the people she’s defending herself against may well be you...

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