Prior To The Flexner Report most American medical universities were trade schools run for profit with low admission standards and an absence of rigorous medical science. The Flexner report in 1910 changed all that. Michael Millenson talks of Flexner’s crusade as a vigorous corrective action campaign against these charlatan medical schools. The Oxford Dictionary defines a charlatan as a person who pretends to have skills or knowledge that they do not have, especially in medicine. A charlatan is a fake—a quack. Snake oil salesmen were abundant prior to Flexner.
Here is the major reason science is so important to medicine. The provider delivering your care can know if a particular treatment works or does not work—not believe, think, or hope. Proof exists that scientific treatment works. Here is an example of how science in medicine works. Jardiance (empagliflozin) is a medication that was developed to treat type 2 diabetes. Because patients with diabetes die of heart attacks, strokes, and congestive heart failure, FDA regulations require research on a new drug for diabetes regarding these complications. Does the new medicine reduce complications or does it make them worse?
In this congestive heart failure study, there were 4860 patients with heart failure taking empagliflozin and 4858 taking a placebo. Neither the patients nor the researchers knew which patients were on the real or fake medication. At the end of the study, the code is broken so that the rate of complications can be compared between those taking and not taking empagliflozin. In the patients taking empagliflozin, the rate of hospitalization for heart failure was reduced by 30%. Now we know that empagliflozin reduces the risk of going into the hospital by 30%. We don’t believe it. We don’t think it. We know it. It has been proven. Another important factor in these studies is only half of these patients had diabetes. This “diabetes drug” prevents hospitalization for heart failure whether the patient is diabetic or not.
This research—these facts—are important to you even if you are young and enjoy perfect health. Medicare and Medicaid represent nearly 20% of all federal spending and you pay for it in your taxes. Medicare alone is 10% of the federal budget. Congestive heart failure generates a third of all Medicare spending or 3% of the entire federal budget. Jardiance is expensive and costs nearly $600 a month. Forty percent of patient deaths in Medicare occur in patients with a heart failure diagnosis. Over half of all readmissions in the Medicare population occur in patients who have heart failure.
Jardiance lowers heart failure admissions by 30%. Optimal medical therapy (OMT) reduces heart failure admissions by 70% during twenty-one years of follow-up. Hospital admissions generate most of the cost of heart failure management. OMT is outpatient treatment that prevents hospitalization.
More patients in a medical study means there is a much greater likelihood that you can show results that are real and not due to chance. The fancy medical jargon is statistically significant. It took almost 5000 patients in each arm of the Jardiance study to show real results. The study that showed a 70% reduction in heart failure admissions over 21 years only involved 80 patients in each arm or 160 patients total. I had more patients with diabetes in my own small-town practice twenty years ago. We know what causes heart failure in most patients—hypertension, heart artery disease, and diabetes. The study that reduced heart failure admissions by 70% was not even a heart failure study. It was a study of OMT vs usual care in patients with type 2 diabetes and chronic kidney disease who have a very high risk of other complications. Ten patients in the OMT group were hospitalized for heart failure during follow-up vs twenty-four in the usual care usual care group. This difference is almost certainly a medical fact. It is highly statistically significant. (p= 0.002) Every diabetic complication was similarly reduced. Patients in usual care had three times as many leg amputations and three times as many patients developed blindness. OMT early for patients with hypertension, diabetes, heart artery disease, and chronic kidney disease makes a huge difference. That single intervention has the potential to reduce total federal spending by 2%. As they say in South Carolina, “that’s a pretty good lick!”
Most of the remedies that you see on television and in the medication aisle at the grocery have not been tested in this way. Advocates may believe passionately that they work, and they may even know someone who had a great result but this is only belief or opinion. It is not science. Most of it is snake oil. If we are to have better health at lower cost, following excellent medical science is the only path forward.
Bill: Part of the problem is that people believe, actually believe, the lies. I went to busines school to earn an MBA at University of Texas, from 1988 to 1990. And I do mean earn. As the only physician in a class full of “executive MBAs” most of whom had over 5 years in real businesses, I was challenged. What I learned was a lot of the language of business, along with accounting, management, quality control, and so on. But what I also learned was the business of business is to make money, nothing else matters. If you don’t help the firm earn higher and higher profits every year, then you’re not going to succeed. And who doesn’t want to succeed? No one. Does such a system (capitalism) require lying? No, it doesn’t. But it doesn’t discourage bending the truth, or exaggerating, and it tolerates a lot of outright lying after a while. For a simple example, how many companies have you seen advertise themselves as “national leaders,” who are neither national in scope or any sort of industry leader? Or, as another example, how often have you been approached by individuals, especially consultants of some sort, who say they are “experienced,” when they are really just fresh out of school? No harm done, right? But people in groups dedicated to a single purpose like making money tend, over time, in my experience, to develop a culture that increasingly justifies whatever it is they do, as long as they are successful monetarily. We all are subject to these pressures. And in medicine, the declaration sometime in the 1970s that “medicine is a business” started that ball rolling and it is now completely out of control. Science, evidence, no longer really matters. So…yes, we do need a new Flexner Study and completely expose the falsehoods and lack of evidence as the basis for modern medicine, hospital care, and pharmaceutical manufacturing and sales. So glad you are tackling these tough issues.
I think you’re saying that doctors, hospitals, pharmaceutical companies, and other “health care providers” lie to us all the time, and are not to be trusted. It’s not just “bad apples” any more. It’s systemic and industry-wide lying, in order to make money and maintain power. So, what else is new?