Show 1409: From Hippocrates to Hypocrisy: The Hidden Risks of Healthcare

This week, an expert from Australia helps us examine the hidden risks of healthcare. Healthcare providers have the best of intentions, but they simply cannot truly uphold the (apocryphal) part of the Hippocratic oath that urges “do no harm.” How can patients and their families become more familiar with the pitfalls of modern medicine and avoid them as much as possible?

From Hippocrates to Hypocrisy:

Historically, medical students were expected to take the Hippocratic oath upon graduation. Although the original Greek does not actually contain the warning to do no harm, the oath is widely believed to carry that intent. Yet it may be difficult for doctors to avoid harming some patients. We’ll examine where patients should be especially vigilant and how the evidence from careful studies can help. Other portions of the Hippocratic oath are also routinely violated in the context of current medical practice.

One problem is that we don’t always have evidence for the medicines or other interventions physicians are using. For a long time, rheumatologists prescribed hydroxychloroquine for their patients with lupus, expecting that it would be helpful. They had no real evidence that it would help until finally scientists conducted a randomized clinical trial. This showed that hydroxychloroquine is, in fact, better than placebo for treating lupus. That lack of evidence is one of the most serious hidden risks of healthcare.

Knee arthroscopy is another example. Surgeons assumed that looking into the knee joint and removing any bits of collagen debris they found there would reduce knee pain and improve function. But when a study was eventually done to confirm that assumption, it turned out not to be true.

When drugs are tested prior to approval, many people may be excluded from the clinical trials because their conditions might make the findings harder to interpret (or potentially make the benefits harder to see). Once a drug is available, do doctors also avoid prescribing it for those who were not included in clinical trials? Usually not. Also, if it was approved for a fairly narrow indication, healthcare providers may start using it far more widely.

The Cochrane Collaboration:

Dr. Rachelle Buchbinder is Coordinating Editor of the Cochrane Musculoskeletal, Back and Neck division, along with many other responsibilities. Many people have not heard about the Cochrane Collaboration, so we asked her to describe it. Volunteers trained in objective methods of assessing clinical trials examine all the clinical trials that have examined a specific intervention. Quite often, what they find is that the existing studies have a lot of flaws. But occasionally, their high-quality systematic review shows that, yes, the research shows that this approach works for this problem. Or possibly, no, we should not use such an intervention for that problem. For example, a Cochrane review demonstrated that despite popular opinion, medical cannabis is NOT effective against chronic pain.

Direct to Consumer Television Ads:

Americans can’t watch television without being bombarded by commercials for powerful prescription pharmaceuticals complete with lengthy lists of terrifying adverse effects. No worries, though: the people in these ads are all having a marvelous time as the side effects are listed. This does not happen in Australia. New Zealand and the United States are the only two countries in the world that allow drug companies to advertise prescription drugs directly to consumers. Isn't this among the hidden risks of healthcare?

Problems with Diagnosis:

Dr. Buchbinder and her co-author also look at problems with getting an appropriate diagnosis. When a patient’s condition is not diagnosed correctly, they can’t be treated properly. That’s why missed diagnoses are problematic. Wrong diagnoses are also a problem. Sometimes serious conditions are underdiagnosed because the stereotype directs the provider’s attention elsewhere. For example, women may not be diagnosed with heart disease when the provider has been taught that it’s primarily a male problem. Conversely, men might suffer with horrible migraines and not get the correct diagnosis because these headaches are seen as far more common in women. Dr. Buchbinder also describes the problem of overdiagnosis, using as an example, thyroid cancer in South Korea.

The Hidden Risks of Healthcare by the Numbers:

Chances are you know something about the numbers that could be used to describe your health. Your blood pressure might be 120/80…or not. Your cholesterol may be over 200. Doctors use blood tests to measure HbA1c (a marker for blood sugar over time), TSH (a way of determining thyroid function), PSA (prostate-specific antigen, a way of tracking a man’s prostate gland) or any of hundreds of other markers. These can all be helpful, but providers need to be careful not to treat the numbers without looking at the big picture.

Just getting blood pressure down to 120/80 might make some individuals too dizzy and put them at risk for falls. Prescribing a statin to lower cholesterol makes sense for someone with heart disease. To tell if it is appropriate for a healthy person who is physically active and finds that the medication interferes with exercise needs to be determined with more attention to the patient than to the number.

Links Between the Pharmaceutical Industry and the Medical Profession:

The United States is not the only country where drug manufacturers have a lot of influence over doctors. The experts who serve on committees to draw up guidelines for doctors often have conflicts of interest. Sometimes these are disclosed, but not everyone reads the guidelines carefully enough to pick up that fine print. In addition, hospitals, clinics or individual providers may also be paid by pharmaceutical firms. In the US, patients can find out whether their own doctor has been paid (and how much) by going to the CMS website OpenPayments. This offers us the opportunity to evaluate just how objective a provider might be when recommending a procedure or prescribing a drug.

This Week's Guest:

Professor Rachelle Buchbinder AO
MBBS (Hons) MSc PhD FRACP FAHM
NHMRC [National Health and Medical Research Council] Investigator Fellow
Dr. Buchbinder is Head of the Musculoskeletal Health and Wiser Health Care Units in the School of Public Health and Preventive Medicine at Monash University. She also serves as Coordinating Editor for the Cochrane Musculoskeletal, Back and Neck division and is Chair of the NHMRC Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network Centre of Research Excellence. In addition, she holds the title of the Monash-Warwick Honorary Professor in the Clinical Trials Unit of Warwick Medical School at Warwick University in the UK. Dr. Buchbinder is the author, with Ian Harris, MD, of Hippocrasy: How doctors are betraying their oath.

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