The wrong forty percent

Continuing yesterday's train of thought... Perhaps it's too simplistic to describe medical knowledge as a rapidly expanding universe. The amount of knowledge we know about the body isn't just expanding - it's evolving every day.They tell you when you become an MD that at least 40% of what you learned in medical school is wrong - the trouble is, you don't know which 40%.

TV newscasters love studies. How many times in the past year have you heard variations on the following teaser while the credits roll for Must See TV: "A new study reveals that *** can prevent ***." First eggs were anathema, then they were okay for a once-a-week brunch. Hormone replacement therapy was the solution to hot flashes, then it was the treatment that could cause cancer. The best example? One word: Vioxx.

No wonder they say the American people have lost faith in their health care professionals. Reguarly, the media exposes doctors as flip-floppers, scientific suckers, so many lemmings who follow the lead of conventional wisdom - sometimes dragging their patients off the cliff. The reason, as always, is multifactorial. Part of it has to do with the institution of medical research, which has spawned a veritable industry of medical scientists, all vying for publications and academic prestige. The cult of the study has breached the traditional wall between the bench and the bedside through the rise of "evidence-based medicine" - in which doctors base their day to day decisions not on their anecdotal experiences, but on the results of carefully planned clinical trials. The trouble with evidence based medicine is that 1) it's nearly impossible to design a truly unbiased trial and 2) many clinical trials are incorrectly extrapolated from one population (say the millions of men in the national VA system) to another (say, women in suburban LA).

The back and forth, the ambiguity is also partly due to the proverbial battle of the noble and pure family doctor against the dark side of pharmaceuticals and for-profit HMOs. As long as two forces exist in opposition, they will try to manufacture statistics to support their value system.

It's no wonder that so many physicians revolt against the madness by placing their heads in the ground and doing what their experiences and their gut tell them to do. I'm studying for the American Board of Surgery In-Service Training Exam (ABSITE) today, trying to look up the answers for the questions I got wrong last year. And I despair, because medicine is not a multiple choice test. One book contradicts another, one "fact" goes under when a study debunks it.

What do we really know? What can we really tell our patients except that we will try our best, there are no guarantees, and there's always another path to take if this one works?