Before a rise in medical professionalism doctors were often considered con men. Their liberal use of leeches, their prescriptions to ingest mercury and other practices based upon the early Greek theories of the four humors were rarely effective. This resulted in a meme, or general reputation to run from doctors.
In the 20th Century, scientific developments blew away past misconceptions and new ‘truths’ were applied to the entire human race. Doctors became much more respected than in the 19th century and basic treatments, such as penicillin and the use vaccines, saved millions of lives.
This helped most people to embrace their doctors with respect and admiration. The meme of “modern medical miracle” circulated widely. Unfortunately, lately that meme has become more sarcastic than embraced.
The problem is that while many medical advancements remain absolutely true, as we delve deeper, we need to start understanding both context and individual variance.
Usually, when I say ‘we’ I am referring to myself and to you, my reader. This time, I need to call out that ‘we’ means the all of those in the medical community and all of us, the patients.
With the increasing complexity of the drugs, the doctors have an increased obligation to be aware of the nuances. With the increasing time pressures on doctors, we patients need to be more aware of possible side effects and communicate clearly with our doctors. Let’s explore some reasons why.
The truths of the 20th century still hold true. Polio kills. Measles can kill and we even suspect the disease depresses the immune system for several years. Our modern medical understanding of diseases and their effect on the typical human surpasses any previous point in time.
However, the diagnoses from the patient end of the spectrum are less certain. If you are running a fever, the likely cause is an infection somewhere. Bacterial? Fungal? Viral? Doctors see the symptoms, but from there, they have to guess.
Medical training tries to cover everything a doctor needs to know in 3-4 years. Yet what a doctor needs to know has grown enormously while the educational duration stays the same. How can they possibly learn everything well?
A doctor will have a fundamental grasp of the basics and the typical response to treatment for the typical patient. Yet, that typical patient is a stereotype and the responses to treatments are generalizations.
A few years ago this became painfully obvious to me. I had a successful nasal surgery to remove a fungal infection. Gross, but not life threatening. After the surgery, I took the pain medicine as recommended and, as the medicine warned, I became constipated. Also gross, but still not life threatening.
I tried resuming my high fiber diet, but the constipation continued and within a day I began running a fever. We called the surgeon and he said it was probably a normal post-operation infection so just keep taking the antibiotics and the fever should go away in a day or two.
I just kept getting sicker. After 4 days of high fevers, constant sweats and chills I finally went to urgent care. The urgent care doctor went through my symptoms, checked my surgical wound (clean), checked my blood work, went through my medicines, and then realized something that had been overlooked.
The antibiotics that I was taking killed the good bacteria in my digestive track. Their death allowed a naturally occurring bad bacteria, which is resistant to the proscribed antibiotic, to multiply and dominate my intestines.
That bad bacteria was poisoning me and causing constipation to prevent it from being pushed out of my system! The solution was not to take a different antibiotic, but to stop taking any antibiotics. One day after I stopped taking the antibiotic, I felt better. After two days, I was absolutely fine.
It is not really the surgeon’s fault that I suffered for a week. I was to ignorant to what was happening and my surgeon was playing the odds. When playing the odds, the advice will work for most patients, most of the time. I was just unlucky. The statistics that created the average medical stereotype simply did not apply to me.
Drug companies also use statistics to calculate how much of a dose to put in the pill. However, they calculate the dose based upon an average person with an average sensitivity to the drug. They do not typically account for an individual’s size, gender, metabolism, and sensitivity to the drug.
I believe my grandmother died because of a medical stereotype.
The instructions on my grandmother’s high-blood-pressure medicine carried the typical instructions. Something like “Adult: 1 pill.” The pharmacist faithfully follows the instructions of the doctor in preparing the medicine and the doctor faithfully followed the recommendation of the pharmaceutical company.
My grandmother also faithfully followed the instructions. Those same instructions would have been given to her or to my uncle. Yet the amount of drugs per unit of blood would vary incredibly between my uncle, who was over six feet tall and over 200 pounds, and my petite grandmother who was under five feet tall and well below 100 pounds!
When we go to a bar, the drug to body size seems obvious. A tiny lady with one shot of mezcal will be far more affected than a large man throwing back the same shot. Yet we rarely make the same considerations for prescription drugs. We simply don’t question authority.
Even when my grandmother began to get light headed after taking her blood pressure medication, she didn’t question her doctor. She faithfully took the prescribed amount every day until that one morning when she passed out, fell, and hit her head. She never really recovered from that fall and died shortly later.
Unfortunately, what seems obvious after the fact rarely crosses our minds in advance. We devote most of our attention to our lives and the issues immediately confronting us. As we can observe from the current Covid-19 pandemic, even when some medical professionals shout warnings years in advance, we often fail to properly prepare for rare instances. It’s too hard and seems too unlikely.
We always try to do more with less. Here, ‘we’ applies to us as individuals, to those of us running companies, to those of us running the government, and to those of us budgeting for our families. Over 60% of American’s don’t have $500 to cover an emergencies and our governments generally run at a deficit. There’s usually no buffer for emergencies.
The same mentality applies to medicine and drug testing.
The doctor needs to quickly diagnose the patient and move onto the next case. The drug company needs to get the basic data on their drug and move onto the next phase of testing or the commercial launch.
When doing drug testing, the pharmaceutical companies typically perform tests on the smallest, most homogeneous group of subjects possible to standardize results. But this results in biases- especially for women.
In Caroline Criado Perez’s book, Invisible Women, she illustrates many disturbing ways (not just medical) that we use data inherently biased against women. As a husband and father of two women I am outraged! As a victim of medical stereotyping, I am disappointed, but not surprised.
In Chapter 10 of her book, she reminds us that historically, medical education focuses on the male “with everything that falls outside that designated ‘atypical’ or even ‘abnormal’.” Medicine in most texts are based off of advancements from medical papers. The medical papers are based upon of research focused on the ‘typical 70kg man’.
70 kg. That’s 154 pounds. How many men do we know who are 150 pounds? That’s one crappy stereotype, but that’s the one at the center of all medical training and research. Everyone else is abnormal.
It is a hidden, implicit bias with fatal consequences. In fact it is just one of the fatal stereotypes.
Drug companies routinely run clinical trials primarily upon male subjects because female subjects have too many hormones that mess with the results. Even on drugs intended for women!
When doing animal research, only 22% of the studies mention the gender of the rats. But of the ones that do, 80% include only male rats!
Does it matter? Dr. Tami Martino researched the impact of circadian rhythms on heart disease and found that a heart attack that struck during the day triggered a greater immune response that correlates with a greater chance of survival.
But few years later, another research group found that the exact same response correlated with a significantly lower chance of survival. The difference in the study that yielded entirely opposite results? The original studies used male mice and the newer study used female mice.
Is this an exception? No. In studies that account for gender, researchers often discover statistically significant differences in sensitivity and response. Unfortunately, most researchers don’t have the bandwidth or the budget to check.
Women represent 55% of HIV-positive adults, but only represent 11.1% of the subjects included studies to find a cure for HIV. Females are 70% more likely to suffer depression than males, but one fifth as likely to be represented in animal tests.
The difference in response between genders extend even to medical devices. Advanced pacemakers are generally recommended by doctors only if it takes 150 milliseconds or longer for their heart to complete a full circuit. But researchers recently found that women are 76% less likely to die when the pacemaker is applied when their hearts take between 130-149 miliseconds to complete a full circuit. The tiny 20 millisecond difference is keeping doctors from recommending pacemakers to women and possibly increasing their mortality rate.
It turns out that even medical advice might need to be gender specific. For example doctors generally prescribe antihypertensive drugs and warn against resistance training if you have high blood pressure. They cite concerns that resistance training causes arterial stiffness and that this type of exercise doesn’t lower blood pressure.
However, it turns out that those results primarily apply to men. In 2008, researchers found the opposite applies to women. The antihypertensive drugs are ineffectual for women and women don’t suffer the arterial stiffness that men suffer from resistance training.
There are many, many more examples. Yet all of these examples are limited to the single most radical biological difference between people – gender. What about body weight or fitness level? What about high-protein diets versus vegetarian diets? Gut bacteria? Tolerance to drugs? None of these differences have been factored into the equation – and evidence mounts every day that each of these factors play a role in our health.
Meanwhile, the drugs become more complicated and less certain in their efficacy. Yet we don’t discuss this because we trust our doctors. Don’t feel bad, our doctors don’t discuss this because they trust their training and the research. We all assume science isn’t biased.
Science shouldn’t be biased. But apparently, we have allowed it to be. For the sake of chasing the quick results, we have pursued standardized research to eliminate variance. Standardization should eliminate biases, but by selecting an arbitrary baseline of a 70kg male, we have an inherent bias that applies to nearly all medical studies.
We do not have to remain victims.
When was the last time your doctor discussed the Theraputic Index or a Risk-Benefit Balance of the drug you were prescribed? Most people haven’t heard of it.
The Theraputic Index is the quantitative measurement of the likelihood of a beneficial benefit without side-effects or toxicity. In other words, will the drug make you better before it makes you sick? The Risk-Benefit Balance combines the quantitative measure with a qualitative discussion about side effects.
We patients need to proactively discuss these issues with our doctors. We need to actively do our homework and study the side effects we could receive from a drug and be vigilant in monitoring our health.
The once-simple drug to health relationships no longer apply so easily. The complexity of the drugs combine with the lack of variance in testing to create an environment in which receiving an adverse effect from the drug is the normal experience!
Please join me in watching out for medical stereotypes. Protect yourself, protect your family, protect your friends. Do a little homework before popping the next pill!