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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


What Your Doctor Is Saying What Your Doctor Is Saying
 

Not So Fast: Why Your Doctor Is Skeptical


February 27, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center

 

Last reviewed on February 27, 2013


Perhaps this has happened to you: There's a news report in the paper about a new drug that sounds great, seems safe, works well and is intended for symptoms you have, such as arthritis, heartburn or allergies. At your next doctor's visit, you bring in the article, fully expecting to get a prescription for it.

Not so fast. Your doctor raises one eyebrow and seems unimpressed and begins a speech that sounds like it's been delivered many times before, about why that drug isn't for you, how an older, generic medicine might work just as well, or how you really don't need a medication at all. And so you wonder: Are you getting the latest and best treatment? Why was your doctor reluctant to prescribe the medicine?

Is Your Doctor a Skeptic?

For every true medical advance or "breakthrough" reported in the news, literally hundreds of promising stories never make a significant impact on the health of those hearing or reading them. In other words, while medical research is vitally important, it tends to happen in fits and starts, with many dead ends. Even after a drug is approved, it may not have any major advantage over older drugs with a much longer track record.

Other factors also may play into your doctor's reaction to medical research:

    • Generalizability — The findings of a study may not apply to your particular situation. For example, a drug found to lower the risk of stroke among people with high blood pressure may not provide any benefit for people with normal blood pressure.
    • Relevance — Reports of major breakthroughs are sometimes based on animal research. While that's often a critical step in discovering the cause of an illness or a new treatment, it may turn out to be irrelevant to humans.
    • Power — In statistical terms, power refers to the ability of a study to detect differences between two groups. In general, the fewer people enrolled in a study, the less it is able to detect differences. Such a study is said to have inadequate power. This often comes up when the disease is rare (making it hard to study a lot of people) or the outcome is rare (such as a side effect of treatment). Because many studies lack power, a somewhat effective medication or a rare side effect easily could be missed. In fact, that is why rare side effects may become obvious only after a medication is approved and taken by thousands of patients.
    • Chance — Almost any result can be observed just by chance. For example, imagine a study in which 10 people receive a new blood pressure pill and 10 others receive a sugar pill. If blood pressure drops in the first group, it would be tempting to believe that the medicine might make a good treatment for high blood pressure. Yet, because blood pressure normally varies, there could be lower blood pressure levels in the first group just by chance; in fact, the same study could be repeated with opposite results. This is particularly important when the outcome being studied tends to vary widely, or when a small number of people are included, so that just a few readings could sway the average result. Fortunately, statistical formulas are routinely applied to medical study results to calculate the possibility that results are due to chance. If you've ever read a medical journal, you've seen references to the "p value." The lower the value of "p," the lower the likelihood that the observed findings are the result of chance.
    • Logic — Sometimes, results just don't "make sense." While we shouldn't rely entirely upon intuition, it pays to pay attention to common sense. For example, a person with high cholesterol might read a study about a low-carbohydrate, high-cholesterol diet for weight loss. Even if that diet were useful for weight loss, it probably wouldn't be a good idea to switch to a high-cholesterol diet when you already have high blood cholesterol. Researchers generally have to justify the logic of their research design to their peers, their supervisors, or to whomever is providing funding; otherwise, every outlandish idea could be studied (at great expense) with little hope of useful findings. While there are celebrated examples of important results that defied logic at the time (for example, the notion that bacteria cause stomach ulcers), the vast majority of accurate and useful medical research is supported by past, preliminary research and provides a logical extension of existing knowledge, backed by a reasonable understanding of why it might be so.
    • Impact — Research may be flawlessly designed and executed, with dramatic and accurate results, but with findings that have very limited impact. For example, your doctor may not embrace a new test that predicts who will develop a rare disease that cannot be prevented or treated. While such research is interesting and eventually could lead to a better understanding of how the illness develops, getting the test will not necessarily be helpful to you. Therefore, the impact of the research may be low, at least for the time being.
  • Predicting the future — A new treatment may be better than previously available options, but it takes considerable time for doctors to know what to expect. Many physicians don't want to "expose" their patients to something new before many people (as in thousands) have been treated, just in case there is a rare but important side effect. Such an approach may be even more likely if your doctor has had a bad experience treating patients in the past with a new drug.

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Are You a Skeptic?

When you learn about something new, do you think about the source of information or do you tend to accept it as true, especially if it's on the news? While there are many reliable sources of information, there are also many ways to be misled, especially when the source is trying to sell something or convince its audience of a particular point of view.

It makes sense to think about where the information is coming from and whether there is any reason to think that balance and accuracy may be less than optimal. An example is a television advertisement for a prescription medication. While it may provide accurate and useful information about the condition, it's unlikely you'll hear much about treating the condition without medication or with a competitor's medication, even if those options are also effective.

It might seem like your doctor is stuck in the past, unwilling to learn "new tricks" of the trade. And you might be right. But sometimes a healthy dose of skepticism — both yours and your doctor's — can be good for your health.

Don't believe everything you read. In fact, feel free to challenge every point I've made! But, do the same thing when you read about medical news. You may be surprised at how often a preliminary or promising discovery winds up doing little to improve health — and it may even make things worse.

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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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