Scientific, Evidence-based Medicine Has Never Offered More Promise

 

A few days ago, a friend asked me this question. “From a data set perspective, what's your preferred "body of excellence" which logically follows incorporating 6,000+ years of medical knowledge with the growing 110 year body of allopathic (western) medicine?

Civilizations over these past six millenia have enjoyed much better health outcomes in terms of quality and quantity of life than the USA's abysmal overspending and short lifespans today as measured against Japan and other nations.”

My medical decision making is absolutely focused on treatments that have scientific evidence to support them. Otherwise, I can’t know if the treatment is effective or not.

Two thousand years ago, the average lifespan was about 30. In 1900, it was 47.  Now it is 78. Most of those gains since 1900 are based on scientific medicine: understanding how bacteria and virused work, antibiotics, vaccines, advanced surgical techniques, better treatment of vascular disease and cancer. If you want a healthier longer life, scientific medicine is the way to get there. I have tremendous confidence in that position. 

Consider the example of heart artery disease. I entered private practice in 1979. I started practice in a small southern town where half the people were dying of heart attacks and strokes. The nearest cath lab was an hour away. I was the only full time internist and the director of the new ICU in that town for eight years. I treated many patients with heart attacks and strokes.

I was sure, like everyone else, that heart attacks were due to chronically blocked arteries that got more and more blocked until they caused a heart attack. People with blocked arteries had chest pain and they had heart attacks and they died. It made perfect sense, but it was wrong. When we finally did the controlled clinical trials, we learned that opening a blocked heart artery in a patient with stable angina does nothing to prevent heart attack or sudden death. That was totally shocking to me! I knew in an instant that I had sent hundreds of people to have bypasses and stents who did not need them. I felt terrible even though I knew that I had acted in good faith.

Now we know that people have heart attacks, not because of the chronic stable blockages but because of soft, inflamed cholesterol deposits that rupture and set off a clot that blocks the artery. Best practice medical treatment stabilizes the plaques so that they do not rupture. The only way we sorted out the best treatment for coronary artery disease was through controlled clinical trials. Our reliance on controlled clinical trials is only three or four decades old. That is the most reliable information. Another reliable source of information is the large observational study. If you look at 100,000 people with type 2 diabetes who are taking metformin, how are they doing vs people who are not using metformin? That is the new science of medicine.

I also thought that I provided the best possible care for these patients, but I was wrong about that too. It made sense that a well-trained internist would be a great source of care. That made sense but that is not what the evidence shows. The new systems of medicine are just as important as the new science. Most medical quality improvement programs fail because they also do things that make sense but they don't follow the evidence."Many approaches have been tried to improve diabetes care but, with one exception, have been mostly ineffective. These include simply reminding patients about appointments; providing laboratory information on the patient to the physician, even when specific treatment recommendations for the individual patient were included; case management when the case manager could not make independent treatment decisions; education of physicians; and multifaceted quality improvement interventions in the practice setting....The one approach that has proven to be effective is using specially trained nurses or pharmacists, under appropriate supervision, with authority to make medication changes without consulting the physician as long as the changes fell within approved treatment algorithms."

The new science and system offer even more promise for a longer, healthier life. Over the last ten to twenty years we have learned that aging and chronic diseases are linked by genetics, epigenetics, and related molecular signaling cascades. Most importantly we have interventions that can change those pathways now to produce a longer, healthier life. That has been the dream of medicine for ages. Now there is proof that best practices can prolong healthy life by 11%.

When we combine the new systems and the new science in heart artery disease, we get much better clinical and financial outcomes. If you have had a heart attack, and you receive optimal medical therapy, you are ten times as likely to be alive in five years and you pay $20,000 dollars less a year for that longer, healthier life. Based on those facts and my experience in depending on approaches that make sense, I depend entirely on information from controlled clinical trials and large observational studies to make my recommendations. Bringing together best practice systems of care along with diet, exercise, and medical management provides the most successful path to a longer, healthier, more fully functional life. Everything else is a distraction!