Tuesday, September 19, 2006

Journal: Tough luck

In the NYT today, an essay about medicine and luck (or chance, or what you will). The gist: medical science may have improved your chances of a positive outcome, but there's still plenty of room for failure, and the occasional lucky break. Snip:
Luck seems to have become particularly anathema in an era of evidence-based medicine, in which physicians and patients are encouraged to learn the latest relevant data to guide decisions. Dr. Peter A. Ubel, a University of Michigan internist and author of "You're Stronger Than You Think," believes that his patients prefer biological explanations of why they are sick, rather than hearing that they have bad genes or bad luck. But given the biological variability within given diseases, like cancer, and the fact that variable genetic makeup leads different individuals to respond differently to diseases and therapies, even better scientific knowledge will not eliminate the role played by luck. Chance, the British physician R. J. Epstein wrote in the Quarterly Journal of Medicine, ensures different outcomes within given sick populations.

I would guess that MS patients, as a group, probably understand this idea better than others. It starts with that consult with the neurologist where he show you some blurry little patches on the MRI, and tells you that you might have MS, or you might be fine, but it's impossible to say at that point. It continues with every new tingle, tremor, tic, every new symptom or disability. And every new drug you get: studies indicate that subjects who took the drug were 30% less likely to have new exacerbations/were 25% more likely to remember where they put the car keys/were 12% less likely to punch the bus driver/were 66% groovier/were 72% more likely to fit into their jeans/were 17% less likely to miss a mortgage payment/were 59% less likely to chew off their own feet.

Then there's the subset of those of us with pain. We are exquisitely conscious of our rising and (mostly) falling fortunes. We fill shoeboxes with drugs that didn't work, or stopped working, or that we tried because our insurance companies wouldn't pay for the drug the doctor prescribed until we tried the half-dozen cheaper alternatives. Anyone need Neurontin? I have buckets of the stuff, plus a bunch of pills with names that end in -amine, and some Lyrica that will probably be left over when I switch back to one of the losers to give it another try.

Nobody needs to explain to us that medicine is partly science and partly art. We are the canvas upon which medicine doodles: Drug not working for you? Try playing around with the dose. If that doesn't work, we'll try something else, something we're studying, something off-label, and feel free to play around with that, too. If that doesn't work, put all your meds into a blender with some yogurt, some orange juice, a banana, and some honey, and make a smoothie. Feel free to play around with that.

When it still hurts, the artsy side of medicine -- the side that we haven't had good luck with -- looks to us like Jackson Pollack, or de Kooning. Art? we scoff to ourselves. Shit, a four-year-old could have come up with that.

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