Des Spence highlighted the rather selective way statistics are used to support promotion of drug treatments to prevent disease. In particular, he has focussed on the heavy promotion of statins to control cholesterol levels in the blood. Several doctors have written in to the BMJ in response to this article.
Malcolm Kendrick, who has written The Great Cholesterol Con, says (in referring to the statistic that to prevent one death a year you have to treat 700 people)
let us assume that you do gain one entire extra year of life for every 700 years of taking a statin. Then, clearly, if you treat for 700 years you will create one added life year.
Using this (overoptimistic) figure means that if you treated someone for 30 years you can expect to provide them with 30/700 added years of life. This is 15.64 days, or, a shade over two weeks.
In short, if a 50 year old man asked you how much longer he could expect to live if he took a statin for 30 years you can inform him “just over two weeks—max.”
(it’s also worth watching his exploration of what DOES cause heart disease – here it is……………it’s for a medical audience so is pretty technical!)
Peter Davies asks for inclusion of statistics of relevance to the patient who will actually be taking the medicine –
Any trial generates four summary numbers: relative risk reduction, absolute risk reduction, number needed to treat, and personal probability of benefit.
Each number is useful and gives some information, but no one number gives us the whole truth about the information. Using one figure on its own, particularly the relative risk reduction above all others, is very risky.
Each figure takes a different viewpoint on the evidence. The relative risk reduction is a public health (area wide) prediction.
The absolute risk reduction puts the starting risk back into the frame.
The number needed to treat measures the workload needed to achieve the relative risk reduction. It’s the beginning of health economics.
The personal probability of benefit answers the patient’s question, “What’s in this for me?”
Peter Davies has written an excellent piece in the studentBMJ about this problem with interpreting the value of “evidence”, with this excellent conclusion –
Acknowledging the various perspectives on data will lead us away from simple statements such as “this works” and “the evidence shows” towards more specific statements of what works for whom and when. It leads us away from guidelines and back to intelligent negotiation, to distinguish treatment of an established disease from treatment for reducing the risk of a disease, whether as primary or secondary prevention. The gradual reclassification of risk factors as diseases, “risk factoritis,” has lead to confusion over applying evidence derived from populations to individual patients who may not need or want our help.
The parties involved all need to admit that they know part of the truth, but never the whole truth—whether about the evidence, the patient, or the disease. The next time anyone tells you that “the evidence shows that this treatment works,” ask, “From what perspective does this seem to work?” If they do not understand your question, then they do not fully understand the evidence.
It’s good to see this discussion in a mainstream medical journal. There are some hard questions about the direction of medicine which need to be asked. The reliance on medication for a “healthier” life is one of them.
Heroes Not Zombies 
Wow, Doc; I’m a pretty smart girl, but you lost me on this one. I understood most of the first video…I think… but the bit I’m taking away from this post are the very last lines:
There are some hard questions about the direction of medicine which need to be asked. The reliance on medication for a “healthier” life is one of them.
I think, maybe, we need to define our terms. What is “healthy,” really, and why do we feel so desperately that we need outside influences to help us attain it?
I know, it’s one of those discussions about statistics. I have a real love-hate relationship with statistics. I mean maths interests me, and I have that same fascination with numbers that all men have (remember the scene from that lovely Scottish movie “Gregory’s Girl”? I must see if I can find a clip!)
But somehow, with statistics I’m always wary, always thinking there’s been some jiggery-pokery (is that a Scottish term?)
But I’m glad you hone in one what I think IS the take home message here – and that’s the one asking about what direction medicine should take. You are so right to focus on the question of what we mean by “healthy” – I’ve done a LOT of reading and thinking about this one and the best I’ve come up with so far is what I set out in my permanent “AdaptCreateEngage” page (one of the tabs in my banner)
I am very interested in any other views about this though. What do you think “healthy” is?
here it is mrschilli – the VERY clip I was looking for! http://www.youtube.com/watch?v=kXRSlJbPNp0
I believe, Doc, that “jiggery-pokery” IS a Scottish term, and I’m adding it to my vocabulary RIGHT THIS VERY SECOND. I can lay claim to it as I come from a long and nearly unbroken line of Scots.
I’ve been thinking, for the last two days, of what “healthy” is. I feel as though I’m only circling around the answer, though. The closest I’ve been able to come is a sort of equilibrium; “healthy” for me – my body, my spirit, my mind – may look very different than “healthy” looks for you.
I can have all my physical systems working just fine – food’s digesting, blood’s moving, lungs are breathing – but if my mind is ill-at-ease or my spirit is disturbed, I won’t tell you that I’m “healthy.” Same goes in the opposite direction; I could be a veritable snot factory, but I’ll feel LESS ill if my spirits are up and my mind is untroubled.
I think a lot of it is choice, really. Not only is my line a long litany of Scots, one would also think, to look at it, that I come from a genetic cesspool. With only one exception – that being my father’s brother, who is two years older – there’s not been a man on my father’s side of the family who’s lived past 60 (and my father, who turns 59 in August, likely won’t break that trend). When I go to a new doctor and fill out the family history, the only thing I DON’T check off is Alzheimer’s disease, and that’s only because no one in my family lives long enough to get it. Cancer, diabetes, lung and heart disease, mental illnesses (bipolar disorder and paranoia), ulcers, cholesterol problems, arthritis… you name it, SOMEONE in my family’s got it. Everyone’s sick… except me. Sure, I’ve got some low back thing, and I catch a couple of colds a year, but overall, I’m remarkably healthy given my predisposition to chronic illness.
Why is that? Well, for starters, I didn’t start smoking when I was nine. I eat an okay diet (though I suspect I think more highly of it than a nutritionist would). I’m not profoundly overweight (my body seems to have found a weight it likes; it doesn’t care a fig that the charts all say that, for my height, I should weigh about 20 pounds less. I say I have cast-iron bones and leave it at that). All my blood chemistry tests come back fine.
The difference between me and my biological relatives, I think, is that I think of myself as a whole person. I’m not just my blood panel or my resting heart rate. I’m my relationships and my aspirations and my joys and my frustrations and my outlook and my attitude.
Am I making ANY sense?!
Oh yes! You are making a LOT of sense! I completely agree with two fundamentals of your idea – first that for everyone health is different. This is very important. Health is an experience and experiences are influenced by so many things – not least being personal values. With different values we consider different aspects of our being when thinking about how healthy we are. This leads on to your second fundamental – that health is a holistic concept. You mention one of the commonest frameworks that people use – the triad of body, mind and spirit. This works well for everyone I think and everyone has a tendency to consider one of those three aspects more important than the others.
You ARE more than your DNA. Additionally, ALL of your relatives spent most of their lives in different economic, social and cultural environments from you – and that all matters! I’m sure your way of thinking (holistically) will indeed create a difference between you and your relatives if they don’t think the same way. It allows you a much greater range of choices.
Good morning from snowy Canada….(but there are signs of spring in the far western part near the Pacific Ocean).
Since I was a teenager, I have been interested in the nature of reality, metaphysics and philosophy, and health and healing. And spent most of my adult life reading, taking workshops from various teachers and studying and applying these concepts.
And what I have now determined and experimented upon my personal lab of one, is embedded in both of your writings- that your THINKING, your THOUGHTS, create your experience,
(not just fleeting thoughts, but ones that you hold with emotion and even say with words).
….and then the Law of Attraction draws to you those experiences, people, things that match exactly your thoughts…..
And so health is the reality of someone whose thoughts tend to turn toward wellness rather than the fear or worry of illness.
Something like:” I am always sick. I don’t want to be sick. I am afraid of getting all the diseases my family members get”- well, the words that are created upon is “sick”… not the NOT part. And so sickness is drawn towards you.
When one is sick or fears getting sick, the thought that will draw healing is : ” I desire wellness, complete and absolute wellness” or something upon those lines.
What I have been observed, is that we live in a world of contrast. That contrast will show us what we don’t want, which will increase our desire for what we DO want.
So mrshili, your family’s poor health, has shown you what you do not want, and has increased your desire to stay healthy and live past the age of 60…
The law of attraction works in all areas of your life- health, finances, relationships etc. What you primarily focus upon, will be drawn unto you in time.
Life is meant to be a wonderful adventure of creating, continually creating desires and the delicious expectancy of their manifesting. And it will never end……….
Health for me is the incredible feeling of a life current running through me, and excitement for what the day will bring, and a deep and certain knowing that I am good. On my kitchen wall I have put up ” You are good, Be happy”. Simple! yes, but the wonderful things that turn up are a wonder to behold.
Oh, MAN, Doc! You opened up the CHOICES can! I’ll try to restrain myself….
I very often come off as an airy-faerie nutjob when I talk about stuff like this, so I’ll try to put it in a way that honors the fact that I’m really a very intelligent, well-grounded woman. I’m likely to fail spectacularly, and I hope you still respect me when this is all done.
On the topic of choice, I have a lot of opinions. The one that feels most authentic to me – the one that seems to hum with the truth – is that we’re here for some very specific reasons.
In the Northeast US (I can’t speak for anywhere else, as I’ve never really BEEN anywhere else) there’s a bumper sticker that’s pretty popular. It says “We are spiritual beings having a human experience.” I buy this – it’s not on my car, mind you, but the sentiment rings true for me.
My thinking is this; sometime, before we came to this existence, we decided that we had something to learn. What that something is is different for everyone, I think, and we’re all on different parts of the same path, but we all come here looking to experience things to help us learn whatever it is we came here for.
Let’s take me, for example. I was emotionally abused as a child and, for the longest time, I couldn’t figure out how it was that *I* ended up with THOSE parents. I thought nothing like them. I could feel them crushing my spirit and my self-esteem and the way I saw the world. Later, after I’d been essentially rescued by an adoptive family, I came to recognize that my biological parents gave me an incredible gift. I had come here to learn, I think, perseverance and confidence; to truly believe in myself and what I was, regardless of what others told me I was. Somewhere, before I was born, I stated that I wanted to learn this, and the beings who became my parents agreed to behave in ways that would teach me those lessons.
The reason this feels genuine for me is that SO many things have made sense to me once I looked at them in that light – that I CHOSE to have these things happen so that I could grow and change and evolve. Another reason this feels true is that, once I figured out a big take-away lesson, I stopped having those kinds of experiences. There are, for example, no abusive people in my life anymore.
My biological mother would not even BEGIN to entertain the idea that she chose her physical conditions so that she could learn something from them. I really do believe that we choose to take on certain ailments or diseases or handicaps so that we can be put in situations where we can learn from them – whether our illnesses bring us in contact with people we need in our lives or get us in touch with our inner courage or empathy or stamina.
Again, am I making any sense?
Wow! GaleG and mrschilli, I really appreciate you both sharing your thoughts this way.
“Life is meant to be a wonderful adventure of creating, continually creating desires and the delicious expectancy of their manifesting.” – a lovely phrase, GaleG. I do agree. I think the process of life is a process of creation. Sure, there is a lot of destruction to encounter too, but a healthy life is a growing, developing, creative one. And this phrase of yours “Health for me is the incredible feeling of a life current running through me, and excitement for what the day will bring,” really reminds me of Csíkszentmihályi’s concept of “flow” (google it if you don’t know it – wikipedia has a very good article on it). This idea really works for me. Life is dynamic. It’s about flow. Without flow, there’s stasis, and stasis leads to decay and death. Long may your life current flow strong, GaleG!
Mrschilli, you have no problems making sense. You don’t only make sense, you are really interesting and thought-provoking. What you’ve just described here is your way of understanding your life. That’s precious. An awful lot of people don’t even stop to consider – that’s one of the key themes of this blog – be a hero, not a zombie! You are the hero of your own story, and you create that story consciously. That story, and the sense you make of it, is unique. Sometimes I think people are only prepared to say something makes sense if it makes the same sense that they make of things! (oops, that was a clumsy sentence!) What I mean is I think there are many ways to make sense of things. In fact, that’s a big thing in my work. I love trying to see the way other people are experiencing the world and how they are trying to make sense of it. I always ask patients “what sense do you make of this then?” after they’ve told me the story of their illness.
I too think choice is a very, very important feature. It’s a distinguishing characteristic between hero-life and zombie-life. I take on board Viktor Frankl’s comments about what’s important in life is the “stand” we take in the face of life’s events. All kinds of things happen, but the effect of what happens, is influenced (some say even determined) by the responses we make.
Funnily enough I’ve just posted a piece about teaching and learning which refers to William Glasser’s choice theories. Is that work familiar to you, mrschilli? It’s new to me but looks interesting.
Thank you again, both of you, for sharing the way you see and experience the world. I think that’s a wonderful thing to do.
Doc, I’ve not had this much fun in a long time! Thanks for offering this kind of conversation, and for giving me a reason to organize all my crazy thinking into coherent sentences! You’re my new favorite place to be (well, you and Doc. Bibey….).
[…] February 14, 2008 by bobleckridge Prescribing statins (lipid lowering drugs) prophylactically to try to reduce heart attacks has become big, big business. Just one drug, Lipitor, made by Pfizer, made $12.7 BILLION of sales last year alone. Health Insurance companies in the US, and the national GP contract in the UK reward doctors for putting patients with “high” cholesterol onto statins to produce lower blood levels in those patients. But does this do any good? […]