What if we are wrong? Such a simple question, but one that seems all but absent in modern medicine. Patients, particularly women, routinely present with chronic, treatment refractory, undiagnosed or misdiagnosed conditions. More often than not, the persistence of the symptoms is disregarded as being somehow caused by the patient herself. If the tests come back negative and the symptoms persist, then it is not the tests that are insensitive or incorrect but the patient. If the medication prescribed does not work or elicits ill-understood side effects, then somehow the patient is at fault. If the patient stops taking the medication because of said side-effects, then they are labeled non-compliant and difficult. The patient is always at fault. It is never the test, the disease model, or the treatment.
What if we are wrong? What if the tests to diagnose a particular condition are based on incorrect or incomplete disease models? What if a medication universally prescribed for a given condition doesn’t work or creates adverse reactions in certain populations of people? What if the side-effects listed are incomplete? Is it so difficult to admit that gold standards evolve or that medical science is fluid? Certainly, if a patient is presenting with a constellation of symptoms that create suffering and those symptoms do not remit with a given medication or medications and/or do not appear on the available diagnostic tests, why is it so difficult to consider that either the medication doesn’t work, the diagnostic was insufficient, or the diagnosis itself was incorrect? Why is it that we assume it must be a mental health issue or somehow the patient is causing the symptoms herself?
Here, one doctor tells how he learned that he was wrong about diabetes and metabolic disorder. He gleaned this not from a book or from his training and not from listening to his patients, but when he, a previously healthy young man, developed a metabolic syndrome that led to obesity and type 2 diabetes. It was by his own personal crisis that he began to question the model of diabetes and its relationship with obesity. Dr. Peter Attia asks:
What if we are wrong?
What if we are wrong, indeed. There are so many areas of medicine where we may be wrong; where we are likely wrong, but where no one is asking the question.
We congratulate Dr. Attia for his discovery, but why does it take a personal crisis for a physician to question the status quo? Why is there such fealty to particular disease classifications or disease models even when there is evidence to the contrary? Is it the nature of modern medicine to lay down guidelines and be done or is it simply human nature to resist the notion that we can be wrong? Maybe a combination of both; I don’t know the answer, but I do know that if one is certain of everything there can be no room for learning or discovery.
On the other hand, if we begin with the notion that humans, and thus, the structures humans create are fallible – that we do not know or understand everything – and if we add to that humility a dose empathy, perhaps then we can begin healing patients rather than managing them.
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This post was published originally on Hormones Matter in July 2013.
Pride seems to be at the root of much of my 40+ years of bad experiences with doctors. Even when they are proven wrong, they don’t admit it, and seldom apologize. Dr Attia’s genuine humbleness is refreshing. I count only one very humble doctor in my past who was worth more than all the others combined. Rare indeed! Yes, women are treated vastly different than men overall. I remember many of the insensitive, rude, impolite, and yes, cruel things said to me and my husband to/about me and our children. Doctors without true compassion serve only themselves. But then again, western medicine is not about healing.
What indeed if we are wrong? I watched the excellent presentation of Dr. Peter Attia with rising interest as he questioned the existing status quo. Perhaps I can add some remarks to help him in his search for truth. Some years ago I suddenly developed insomnia, mistakenly seen as a trivial kind of problem that is easily solved. I had some laboratory tests and was horrified to see the hallmarks of sugar ingestion. One of the tests clearly showed vitamin B1 deficiency. This test, known as the red cell transketolase, is insufficiently known. My blood triglycerides were elevated and there were inflammatory markers. My sugar ingestion had been modest, but I removed it completely from my diet. I performed serial laboratory studies and it took six months for them to return to normal. I lost 11 pounds in weight without thinking about it. One day, after these tests had become normal, and thinking that it would be of no consequence, I consumed two cookies and a sweet roll. To my surprise I was unable to sleep that night and returned for a repeat of the laboratory tests the following day. Blood triglycerides were again elevated and the vitamin B test had slightly worsened. I concluded that my insomnia was a symptom given to me in a kind of natural code that had to be interpreted for its essential meaning. Pursuing information on the well-known relationship between vitamin B1 metabolism and sugar I read a book by John Yudkin, a Professor of Nutrition at a major London hospital with the title of “Sweet and Dangerous”[1]. This book, published in 1973, reported that cardiovascular disease and many other diseases could be attributed to sugar. Here are two extracts from the book: first, “There is no physiological requirement for sugar. It now amounts to about 1/5 of the total calories consumed in the wealthier countries”: second, “If only a fraction of what is already known about the effects of sugar were to be revealed in relation to any of the material used as a food additive, that material would promptly be banned”.
Although we have known for a long time that sugar can overwhelm the capacity of vitamin B to process it, recent research has shown that vitamin B1 is also required for fat oxidation [2]. It also has a role in protein metabolism, making the ingestion of empty calories a dangerous part of our diet [3]. We have now also good reason to believe that supplementary thiamine can relieve the complications of diabetes[4].
1. John Yudkin. Sweet and Dangerous, 1973.
2. Casteels M, Snieckers M, Fraccasia P, Mannaerts GP, Van Veldhoven PP: The role of 2-hydroxyacyl–CoA lyase, a thiamin pyrophosphate-dependent enzyme, in the peroxisomal metabolism of 3-methyl branched fatty acids and 2-hydroxy straight chain fatty acids Biochem Soc Trans 35(5):876-880, 2007.
3. Lonsdale D. Thiamine and magnesium deficiencies: keys to disease. Med Hypoth 2015;84:129-134.
4. Thornalley P J. The potential role of thiamine (vitamin B1) in diabetic complications. Curr Diabetes Rev 2005; 1 (3): 287-298.
Wonderful article, completely to the point. Thinking out loud should be encouraged and more people should exposed to constructive observation. Persuasive without verbal agression. Well expressed. Cheers