Not So Quickly Darling: The Rush To Big Changes In Treatment After Small Amounts Of New Scientific Data

When I was in college, I spent a semester living with a family in Dijon, France. No one in the family spoke any English, except an elderly aunt who knew a few phrases. She worked hard to cure me of my American habits, particularly the way I ate. At almost every meal, she would tell me “not so quickly darling,” presumably referring to my tendency to eat faster than was considered appropriate for a Frenchman (you must imagine the order being given with a thick French accent). I am not certain that the eating skills training I got in France have resulted in my eating more slowly these days, but I will never forget my French aunt’s efforts to civilize me.

What’s Your Point Dr. Goldstein?

Recently there have been a number of news reports about two medical studies. The first was about a month ago and showed that patients with established heart disease seemed to develop more heart blood vessel damage on a combination of cholesterol-lowering drugs than on a single drug, despite the combination treatment resulting in a lower cholesterol than the single drug. The other study looked at the development of heart disease in patients with type 2 diabetes and found that patients with the “best” blood sugar control developed more heart disease than those with only “ok” blood sugar control. I don’t want to get deep into the details, but blood sugar control was assessed by measurements of hemoglobin A1c, a well-established test that is an index of average blood glucose levels over the preceding 3-4 months. The study design was to push for normal blood sugar levels in one group of patients but just slightly higher than normal in the second group- a level currently recommend by most expert groups.

The results of these two studies were more or less completely unexpected by the experts who, for the most part, seemed to be scratching their heads but were unwilling to make immediate sweeping recommendations for changes in the treatment guidelines for heart disease and type 2 diabetes patients.

Enter The News Media

One reason most experts were unwilling to change treatment guidelines based on the studies was that the data were inconclusive and puzzling. The cholesterol study was rather small and didn’t look at any “hard” endpoints (e.g., heart attacks, deaths), just lab test numbers and radiologic data. The diabetes study was fairly good sized but the number of events (heat attacks, deaths) were relatively small. Yet the media and a small number of medical “experts” bombarded us with the news that the studies had “turned conventional medical thinking on its head,” and that current therapies for diabetes and heart disease are being rethought. I have had these studies (actually the news reports about the studies) quoted to me by many of my patients the past few weeks. It’s driving me nearly crazy.

Not So Quickly Darling

I do not believe that the two studies in question (I’m not even going to give you the references to the studies unless you beg me to, since I present the studies only to make a point) ) provide enough information that would compel physicians to change their approach to managing either hyperlipidemia or diabetes mellitus. More and more I see the medical profession “jumping” to conclusions based on this or that medical report which often turns out to be of dubious value. It’s not always that the data are invalid but that the conclusions by the study authors and/or the medical community are incorrect. We need to slow it down some; we shouldn’t ignore new and potentially important scientific findings but rather, try to understand the study design, its conclusions, and whether more data are needed to establish the validity and general applicability of the findings. Just because we hear about something on CNN or NPR or read about it in the New York Times or the Wall Street Journal, doesn’t mean it is true.

Medical science is full of examples of study results that at first glance seemed to be “bombshells,” but later turned out to be duds. Even the opposite is true- studies that failed to show something or other but which were later disproven (this is the case with the hemoglobin A1c test- one of these days I’ll discuss its interesting history).

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