Below, a guest-post by Nortin M. Hadler, M.D., Professor of Medicine and Microbiology/Immunology at UNC Chapel Hill’s School of Medicine.Dr. Hadler is also an Attending Rheumatologist at UNC Hospitals, and author of The Last Well Person: How to stay well despite the health care system, Worried Sick, A prescription for health in an overtreated America and Stabbed in the Back, Confronting back pain in an overtreated society.
I don’t buy lottery tickets. True, someone will win, and likely a mind boggling windfall. That someone may be one in a million, but someone will win. It is so unlikely to be that someone, maybe there’s a magical force at play, maybe a gambler’s gryphon or a good fairy. Many reasonable Americans must believe in the gambler’s gryphon. Some have premonitions, a sense that the gryphon will fend for them in the deepest reaches of improbability where the power ball hides. None of this is irrational behavior. All understand the probabilities and many get a kick out of the possibilities.
Many states have deemed the purchase of lottery tickets legitimate if not moral, usually because some portion of the proceeds is to go to the common good…and someone wins. My choice not to play the lottery is simply my choice; it is not a reproach to those who play. However, the psychology of the lottery has been so well inculcated that it commonly makes sense to apply it to another challenging win-lose exercise, betting on our health. It drives the “I know the chance is slim, Doc, but let’s go for it” response when we or our loved ones are sick. It also drives our choice of a health insurance plan. In the case of the lottery, we know what we’re doing. In the case of winning good health, we are all too often bamboozled. Let me explain:
The decision to undergo treatment revolves around our understanding that meaningful benefit is a more likely outcome than an adverse effect of the treatment. That’s a rational basis for a clinical decision. Next, we weigh the value we ascribe to the benefit against our fear about harmful effects. If we felt desperate we might want the treatment even if the likelihood of benefit was quite remote, as long as we valued the possibility of benefit more than the specter of harm. That, too, is rational. It is informed medical decision making.
How are we to be informed? There are many inputs coming from our social network, the media, and marketing. There is often a physician on whose opinion we might rely simply because she is an authority figure – so called eminence based medicine. In the case of pharmaceuticals, most of us assume that the Food and Drug Administration has responsibility for assuring that there is scientific evidence for a degree of benefit that outstrips the scientific evidence regarding the likelihood of harm. In fact the Kefauver-Harris Amendment to the laws regulating the Food and Drug Administration in 1962 mandated the demonstration of such efficacy before pharmaceuticals could be licensed. If we or our physician wishes, summary statements of the science that swayed the FDA are available as are collections of complementary science. We can rest assured that every licensed drug has a degree of efficacy that is at least comparable to other drugs designed for the same purpose – and harmful effects that have been considered to be a small price to pay for the likelihood of benefit.
That’s where our lottery mentality gets us in trouble. We are made to understand what we might lose if we don’t take the drug, but seldom do we question how likely it is that we will gain something if we do. We are lulled into the notion that someone is winning or the drug would not be licensed. Don’t you want to know how many people need to be treated to benefit one? And is the benefit important to that one person or does it seem trivial? Would you buy a lottery ticket if the jackpot was trivial? You’d be surprised how many drugs need to be taken by 100 people or more to benefit one person, and you’d be surprised at how often the benefit is not meaningful. For example, how rational is the decision to lower your cholesterol or your blood sugar if either is deemed “high”?
Treating high cholesterol: Let’s assume you are a perfectly well middle-aged man who learns that his cholesterol is above the level some committee defined as normal. Now you’re worried. You have a “risk factor” for heart disease, stroke and death before your time. Naturally you feel relieved that your doctor can pummel your cholesterol below the upper limits of normal if you take her favorite statin drug. Few can refuse. Even fewer pause to wonder whether the result of doing so is meaningful to them. It turns out that if I treat 100 men with a statin and 100 with a placebo, after 5 years 96 would be alive in both groups. Of the 4 who died in each group, 2 died of a heart attack. I wonder if these men would be as worried by their “high cholesterol” if they knew that their risk of death was 2% in 5 years with or without treatment. Of the 96 still alive and taking a statin, 4 had survived a heart attack. Of the 96 still alive on placebo, 6 had survived a heart attack. So if 100 men swallow a statin every day for 5 years, 2 might be spared the experience of a non-fatal heart attack. That is a surprisingly meager “win” for swallowing 1,800 pills.
Here’s where the lottery mentality leads us astray. The odds of winning a lottery are orders of magnitude less than 2%, yet many go for the win and someone will win. But the 2% reduction in risk on a statin does not guarantee anyone will win. In a randomized controlled trial 2% is right on the cusp of unbelievably small. Such small differences often do not reproduce when the trial is repeated. That means you do almost as well on the placebo and maybe as well. That’s like winning the lottery without buying the ticket. When the effect size is very small on a randomized controlled drug trial, the thinking should not be “someone wins” but maybe I would win without the risks of taking the drug.
I won’t even let anyone check my cholesterol, or PSA for that matter. I never submit to screening unless the test is accurate, the disease is important, and something important can be done about it.
Treating high blood sugar: Oral hypoglycemics are prescribed to lower blood sugar in people whose blood sugar qualifies as “Type 2 diabetes”. All of these drugs lower the blood sugar or they would not have been licensed. So if I were to treat 100 people, I will lower the blood sugar (or its modern measure, Hemoglobin A1c) to some degree in all 100. The assumption on the part of the FDA was that this must be a good thing to do, an assumption that is widely held by physician and patient alike even today. I say even today, because the flaw in this reasoning was revealed by 3 long-term, large trials of lowering the blood sugar of people with Type 2 diabetes. Nothing meaningful was accomplished; no one was spared a heart attack, renal failure, stroke, amputation, death before their time, or any other of the feared outcomes associated with Type 2 diabetes . For some of the brands of oral hypoglycemics, there seems to be an increased incidence of these feared outcomes. In 40 years of practice, I’ve never prescribed an oral hypoglycemic drug. I’m waiting for the demonstration of meaningful benefit. I’m waiting for the FDA to demand as much.
I’m also waiting for a trial that shows that stents do something for my patients (such as spare them a heart attack, chest pain, death before their time) and not just do something to their coronary arteries. The three randomized controlled trials have all failed to show any meaningful benefit of stenting over medical treatment alone regardless of how quickly people are rushed to the stent-placer . And why don’t we ask if a cancer chemotherapy regimen or cancer surgery offers something meaningful. Sometimes there is a science in the affirmative. Often times the intervention might do something to the tumor such as shrink it but nothing meaningful for the patient. I would want to know that before signing the “permission” slip. And if a few of the treated patients happen to live longer, I would want to know my chances of being so lucky without the treatment.
Where is the Power Ball hiding?
It’s bad enough that Americans all too often are allowed (encouraged) to approach medical decisions with a lottery mentality. We are also asked to choose the lottery we want to play in. Those of us who have health insurance generally choose our coverage from a menu of plan options. Those who have no health insurance will be faced with similar choices should any of the many proposals in Congress prove lawful. How do we choose?
The menu of possibilities includes varying co-pay choices, deductibles, coverage caps and choice of doctors. Rational choosing is nearly impossible. It’s a lottery. For example, if you are well you might be tempted
to go without insurance, or opt for the plan that entails the lowest payroll deduction, usually with a high deductible. If you stay well, you win. But should you require an appendectomy or surgery for the fracture you suffered playing sports you could very well be faced with over $10,000 in bills. You lose.
I understand that the citizenry of most states consider playing the state lottery a morally defensible exercise. Turning health care into a lottery is morally indefensible.