Thursday, December 19, 2013
The debate over conflicting experts
The New York Times published one of their periodic debates – When Medical Experts Disagree
This debate actually centers on the current cholesterol guidelines, but the problem recurs often. Different “experts” look at the data and develop differing opinions. We see this with prostate screening, mammography, and treatment decisions.
As one reads the varying opinions in this debate, an understanding of the affect heuristic makes the debate transparent. When we like something, we overestimate the value and underestimate the risks and costs. This explains most conflicts of interest, and importantly conflicts of interest are not just pharmaceutical.
The “experts” writing the cholesterol guideline are heavily invested in the cholesterol hypothesis. The higher the cholesterol the worse the patient will do. Amazingly, the data made clear that only statins have excellent outcome data, so the panel dropped cholesterol goals for primary prevention and high yield secondary prevention (patients between 40-75 with type II diabetes mellitus or very high LDL cholesterol).
The controversy rests then on primary prevention. The experts like lowering cholesterol. They have accepted the data that statins trump every other drug class, and that other drug classes do not have sufficient outcome data to either add to statins or use alone. They know that primary prevention does decrease cardiac events. Because they like preventing cardiac events, they favor an aggressive approach to primary prevention.
Many other physicians worry about treating very large numbers of patients with a drug that both has significant costs and side effects (mostly muscle pain). These physicians are not as enamored with statins, unless the patient has very clear indications.
As one reads the various debaters, one can understand their contributions as resulting from the affect heuristic. One debater sees the pharmaceutical influence as a major evil – thus blames the pharmaceutical conflicts of interest (while apparently ignoring other conflicts). One debater clearly focuses on drug side effects, and cautions against using any new drugs, unless the new drug has proven major benefits.
Seeking truth where there is no truth will always frustrate physicians and patients. We have to balance risks, costs and benefits, and generally make these estimates with incomplete information. For rarely can we have complete information. We want to worship at the altar of evidence-based medicine, but we still must assess values, and values will always contain a subjective component.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.
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