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When I posted recently on my approach to lipids in pediatrics, I got into a debate with one of my commenters regarding the merits of statin therapy.  I am never against having a dogma challenged, and lipid lowering through statin therapy is quickly becoming a medical dogma.  If a dogma cannot be challenged, it is no longer scientific.

One of the misconceptions of the general public about science is that we use science to come to definitive answers.  The process of science is to draw a conclusion through a finite number of observations to allow us to predict the behavior of things.  We use our senses and use tools to aid our senses in finding as much information about an object, process, or circumstance as possible and use reasoning to draw conclusions.  There is nothing definitive about the conclusions, they are simply based upon previous observations.

Once we get a good idea of the behavior of an object, then we can apply that knowledge to test the theory on new situations.  For example, if we observe that people with high LDL cholesterol have more heart attacks than those with low LDL cholesterol, then we can do several tests:

• We can look at a group of people with differing LDL levels and put them in groups ahead of time and see which ones get heart attacks.
• We can see if lowering the cholesterol with a medication will decrease the rate of heart attacks.

Once something has been shown to be effective, it must be repeated for it to be deemed reliable (repeated by someone other than the person who originally did the test).  This has been done many times with statin medications, showing reductions in heart attacks and stroke in most trials.

So, if this is shown, does this mean that all patients with high LDL should be put on statins?  Not so fast.  There are several other things to consider:

• Studies are usually first done on high-risk groups, because it is easier to see a statistically significant result in these populations.  For example, the first statin trials were done in people who had known coronary heart disease.  These people have a very high rate of future heart attacks, and so a reduction in that rate would become readily apparent.  So, you cannot generalize outside of the group studied – i.e. based on the original studies, you couldn’t say all people should take a statin, but simply those who have had a previous heart attack.
• What we really care about is if  a person dies or not, not necessarily what  they die from.  That is why all studies of this sort should look at all-cause mortality, as medications can cause harm in one area while they help in another.

So when do we stop putting an asterisk behind evidence and begin to accept it without significant doubt?  Where is the point that quality is measured based on how they live up to the scientific evidence?

While I can’t keep track of all of medicine (and since I am Med/Peds, I have a lot to keep up with), I do try to keep up with the best evidence guidelines, such as those I linked to previously by the AHRQ and also those of the AAP, ACP, and AAFP.

While it may be possible that all of these organizations are in the pocket of big Pharma and other high-dollar organizations, I have to think that any huge conspiracy to throw the wool over all of our eyes would have been made public pretty quickly.

So what do I think is "nearly dogma?"

• All children should be immunized.
• High blood pressure is bad and should be treated aggressively.
• People with a history of coronary heart disease should be taking aspirin if possible.
• All people who have had a heart attack or a stroke should be on a statin, if possible.  Their LDL should be below 100 if possible.
• All diabetics should keep their sugars in control, blood pressure down, and cholesterol low.
• Women over 50 should have yearly mammograms.
• Sexually active women should have pap smears every 1-3 years (depending on risk).
• People at high-risk (over age 65, diabetics, asthmatics, COPD) should have flu shots.

The evidence for these is rock-solid, in my opinion.  They are not perfect, but clearly are worth doing.  When high-risk people ask me if they should get a flu shot, I tell them that if they get it, it is more likely that they will be alive in a year than if they don’t. 

I know there are people who will challenge each one of these statements.  I expect comments that will do so.  As I stated at the start of this post, it is perfectly fine to question these things.  It is perfectly fine to question the round-earth theory as well.  Gravity may be the exception to the rule – it may only apply in this segment of the universe.  We don’t know.  On these issues I won’t spend too much time defending because I think this has been done before.

It is harder to defend a position than to attack it.  To defend a position, you must counter every argument.  To attack, you need but one decent argument.  Do not mistake people questioning Immunizations, Statins, or Mammograms with the discrediting of those things.  Calling them into question is simply science at work.  The truth won’t be decided by the press, public opinion, or some stupid doctor blogger.  The truth will be in the facts.  If we seek out the body of evidence on these subjects, we will be much more likely to be right in the end.

Doubt is fine.  Doubt is the normal questioning of dogma.  Doubt is a normal part of the scientific process.  Without doubt we will surely fall into error.  But don’t make doubt out to be more than it is.  Criticism of a position is always easier than holding one.  As a physician, I must make decisions based on the best evidence and hold tight enough to the evidence I think is best.  I may be wrong, but my realistic goal is not to be right all the time, it is simply to be reasonable in my decisions.