Personal Responsibility in Medical Choices

Dr. Harriet Hall has published a personal attack on Mish Shedlock regarding his recent personal experience with prostate cancer.  Apparently, the original post was even more mocking and disrespectful than it is now.

An economic analyst, Mike “Mish” Shedlock, wrote a blog post to describe how he beat prostate cancer. When laymen and patients write about cancer, they are likely to get some things wrong. Mish’s story is full of typical misunderstandings and misinterpretations.

He interpreted his experience in his own way and did his own research into the medical literature, something he was not qualified to do. Prostate cancer is a very complex subject, and understanding the implications of published studies for treating patients can be difficult even for experts. In typical Dunning-Kruger fashion, he rejected the advice of his doctors, thinking he could do better.

Why would Mr. Shedlock do that? (Side note:  I find Dr. Hall’s reference to Mr. Shedlock as “Mish” throughout the article to be condescending.)  Does he really think he’s smarter than all his doctors?  That explanation doesn’t make sense.  If he really thought that, he would go find different doctors.  He is a thinking man.

Mr. Shedlock’s beliefs and actions about medicine are sure to be impacted by his wife’s battle against ALS, which ended in 2012.  This is personal to him, but even without this experience, however it changed his view of the medical system, his actions are not unreasonable.

Doctors today often practice with ongoing conflicts of interest, for both medications and medical procedures.  The government is supposed to set up a database so that the public can at least have visibility to some of these conflicts, but it has been delayed.  Mr. Shedlock, on the other hand, is required to disclose all conflicts to all of his clients.

Doctors often do not agree on the best course of action.  This is seen right in this example.  It’s why people get second and third opinions.  For lots of things, but also for medicine.

Doctors do not always present all the options.  Again, it’s seen right in this example.  It is the responsibility of the patient to get as much information as possible, and using multiple sources for that information seems sensible to me.  I don’t see how anyone can disagree with that.

Dr. Hall disagrees with Mr. Shedlock’s chosen course of treatment (“After 60 hours of research, he settled on a cocktail of the ten “most promising things” that he thought would help fight his cancer.”).  The main objection is that there is not enough clinical evidence that the supplements he used would have a positive effect.  Unless and until one of the big single payer systems (UK, Canada) sponsors FDA-style double blind studies, this evidence will never exist.  Because money.  Supplements, food, lifestyle changes, basically anything that people can do for their own health that does not involve paying big pharma a lot of money, these things will never be studied with the rigor of FDA approved drugs and devices.  Doctors in today’s litigious society reasonably will err on the side of recommending NO, with this kind of data availability.

A related point is that doctors are not always up to date on the latest research.  The NIH website lists this as part of a treatment for heart disease:

Follow a Healthy Diet

A healthy diet is an important part of a healthy lifestyle. A healthy diet includes a variety of vegetables and fruits. These foods can be fresh, canned, frozen, or dried. A good rule is to try to fill half of your plate with vegetables and fruits.

A healthy diet also includes whole grains, fat-free or low-fat dairy products, and protein foods, such as lean meats, poultry without skin, seafood, processed soy products, nuts, seeds, beans, and peas.

Choose and prepare foods with little sodium (salt). Too much salt can raise your risk for high blood pressure. Studies show that following the Dietary Approaches to Stop Hypertension (DASH) eating plan can lower blood pressure.

Try to avoid foods and drinks that are high in added sugars. For example, drink water instead of sugary drinks, like soda.

Also, try to limit the amount of solid fats and refined grains that you eat. Solid fats are saturated fat and trans fatty acids. Refined grains come from processing whole grains, which results in a loss of nutrients (such as dietary fiber).

Are all these recommendations in line with the latest research?  No.  But they are a current consensus, and a treatment path that would easily be defended in court.  (In the financial advisory industry, this is known as “career risk.” That is, if you recommend the same thing that a majority of advisors recommend, you will not be blamed if it doesn’t work out, even if you didn’t really believe in it.  Of course, mistakes in finances only cost money.)

  • Salt intake NOT related to heart disease related death.  Yeah, one study.  But if you have a patient who loves salt, why would you deny the quality of life for what may not be any benefit?  This is an example of where the interests of the patients and the interests of the doctors diverge.
  • All of the information on fats is outdated.  Read The Big Fat Surprise.  Here’s a study from 2014.
  • “Processed soy products” are not of any special benefit.

Dr. Hall made her recommendation on Mr. Shedlock’s treatment at the end of the article:

There was no need to do PSA screening tests in the first place.

But then, oddly:

Mish thinks he “beat cancer” with his cocktail of diet supplements; we can’t rule out that possibility, but I think it is highly unlikely. I don’t think his cocktail made a bit of difference. I think he fooled himself. The cocktail fed him false hope, gave him a false sense of control, and provided the virtuous feeling that he was “doing something” rather than passively waiting for what the future would bring.

Fortunately he is still under the care of his regular doctor, who tolerated his experimentation and continued to monitor his condition. The negative biopsy doesn’t mean that his cancer is gone. If it isn’t, we can hope that it won’t progress; and we can hope that if it does, he will get the appropriate treatment.

I would submit that if Mr. Shedlock was healed by a placebo effect, then good for him.  Or maybe one or more of his supplements did help.  There is no way to know.

It must be incredibly annoying/embarrassing  to have your patients ask you questions about things they find on the internet that you are not familiar with.  Even worse, things that you are familiar with and find wrong to the point of harm, like anti-vaxxers.  Doctors of today, however, are going to have to deal with this reality.  It sounds like Mr. Shedlock’s doctors were willing to work with him so that all parties were satisfied, although not necessarily in total agreement with, the treatment plan.

In the end, it’s the patient’s life.

 

 

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