Fantasies and folliws in medicine

Petr Skrabanek

Petr Skrabanek, a professor of public health at Trinity college Dublin and Lancet editorialist, was one of the great iconoclasts In the beginning of Fantasies and Follies in Medicine he announces that he suffers from scepticaemia, a generalised condition to which a course at medical school will invariably confer lifelong immunity. He examined poor thinking in medical science, had fun with doctors’ authority, and as a result this superb book seem to have been slightly neglected by the profession.
Fantasies and Follies begins with a chapter on placebos, and he slides into a disquisition on what doctors do. They are not scientists. And here we have the delicate subject of uto suggestions. The placebo effect works: the physician’s belief in the effects of his treatment and the patient’s faith in his physician exert a mutually reinforcing effect which nearly “always results in an improvement and sometimes in a cure.” But as a rule discussions of the placebo effect concentrate the gullibility of patients and ignore that of physicians. He quotes Platt wryly observing that the frequency with which placebos are used is an inverse relation to the combined intelligence of physician and patient.. He then asks: if therapy is beneficial why should scientists, envious of the results, accuse doctors of using placebos. But the magic only works, like the monarchy, if no light is let in upon the practice. Which is maybe why his books ought to be unread after all.
He writes: since much of the success of medicine depends on the placebo effect it is puzzling that medical textbooks have little to say on the subject. But surely, as he must know, it is not puzzling at all. Sir Douglas Black, he writes, a past president of he RCP, estimated that only 10 percent of diseases were significantly influenced by modern treatment. Or Sir George Pickering, who said that in 90 percent of patients seen by a general practitioner the effects of the outcome are unknown or there is no specific remedy to the symptoms. Though doctors prescribe drugs with active compounds, it has been estimated that up to half of modern-day prescriptions have any effect on the diseases for which they have been ordered: positive results are a folie a deux affecting doctors and patients alike.
He spells out the difference between science, which is inherently anarchic and subversive of authority, and the practice of medicine. And here he quotes Oxford academic Iain Chalmers, discussing the various authoritarian strategies to prevent inquiry into the placebo effect: “It is because the scientific method actively fosters uncertainty that it must invariably be subversive of authority. If these authorities are to be successful propagandists for their diverse practices and causes then they, unlike scientists, need the self confident certainty that they know what is good and bad. Searching questions about how they know are only unsettling, they serve to complicate the simple messages which are such an important component of their work.”
In chapter two his project becomes clearer: his enemy is not authority in medicine, but poor thinking in science. If the desire to take medicine is what distinguishes men from animals, man’s need for explanations of his raisons d’etre to explain why we are born and die are even more characteristic.. Doctors and healers since time immemorial have flourished because neither they nor their patients tare able to distinguished between association, cause and effect. He compares irrational polypharmacy of the modern age with blood letting of the past, and laments that “learning from experience means nothing more than learning to make the same mistakes with increasing confidence”.
Any layman reading science papers should take a primer in his expose of the fallacies of logical reasoning before believing the latest media scare – journalists especially. In Dublin, writes Skrabanek, the density of television aerials was strongly associated with infant mortality, not because television was lethal to infants but because density of aerials reflected poor housing, overcrowding and misery. In the personal relationship between physician and patient where a a situation arises that the patient feels better, cause and effect may not matter, but when faulty causational logic is applied to science you have junk science.
Skrabanek, who died in 1994, was accused in the medical press of taking payments as a consultant to Phillip Morris, a factor probably contributing to his obscurity today. One section of his book deals with how relative risk is misinterpreted. His example might be out of date, but the principle still holds: in 1995, the committee on safety of medicines wrote to all British GPs informing them that taking newer contraceptive pills doubled the risks of thrombosis. In the next few months abortion rates increased by 10 percent; with an unquantifiable number of unwanted pregnancies carried to term. Yet the absolute risk, beyond earlier contraceptives, seems to have been about 10-15 per 100,000 woman years of use, the increased mortality rate would be one per 1 million woman years, As he writes: “Life itself is a sexually transmitted disease with 100 percent fatality, and living it to the full means balancing reasonable and unreasonable risk.” It is probably attitudes like that, and the principle of relative risk carried over to lung cancer, that endeared him to the tobacco industry.
But his distinction between medicine and science surely still holds true: just recently the researcher John Ioannides published a paper which has since become rather well known “Why most Published research findings are false”, which operates in Skrabanek territory. In essays published elsewhere, Skrabanek takes issue with the near random play if epidemiological associations: supposed findings that do not reflect links with the outside world but are constructed by epidemiologists’ methods of examining data and reporting results.
Despite the cloud of tobacco industry associations, I intuit that Skrabanek was essentially just sceptic: Bohemia from where he escaped to Ireland after the Prague spring has one he strongest traditions of freedom and dissenting thought in Europe: surrounded and over-run by authoritarian empires, whether Prussian, Habsburg, Nazi or Communist, the Czechs much more than other Slav peoples sought refuse in scepticism, doubt – and in humour. If answering from the grave, Skrabenek would no doubt say he wrote in the tradition of Vaclav Havel. Havel opposed communism, whereas Skrabanek cast his eye over the nature of medical authority, careful to distinguish its merits from its demerits.
He was a jazz lover, chess player and bon viveur, loved by generations of Trinity students, his greatest love his Czech wife, who escaped from Prague with him.
His books remain available for download on Trinity College’s website.