What We Don’t Know
What we think we know is probably not true. If we are practicing medicine the same way next year as we are practicing this year, we clearly haven’t learned anything.
This is the principle on which I have built my practice and research career. It breeds a healthy skepticism of both “accepted” knowledge and “standard of care” practices. A few recent studies have reinforced this belief. Here they are:
- Ibuprofen and anti-inflammatories: Inflammation is the normal response to injury. When tissues are damaged, vessels are broken; pouring blood into surrounding tissues. Cells release chemical factors, recruit stem cells and other repair cells, and the process of tissue repair begins. Anti-inflammatory drugs inhibit prostaglandins, the inflammation mediators in all tissues. If you take anti-inflammatory drugs, you actually inhibit this healing process. While these drugs are potent pain relievers and reduce inflammation, reports of their negative effects are growing. Recently, ibuprofen has been linked to reducing testosterone production in men, causing infertility. All prostaglandin inhibitors—meaning all anti-inflammatory drugs—likely have the same effect. This is unfortunate because when I think about the things I want my injured and healing patients to have, increased testosterone is one of them. Testosterone builds muscle and enhances well-being. Inflammation reduction is an important part of therapy for many chronic diseases, such as inflammatory arthritis and cardiovascular disease (where inflammation in the walls of blood vessels may be a key contributor to abnormal clot formation and heart attacks). Yet, the side effects of the drugs we are using to reduce inflammation may, in some cases, be worse than the disease.
- Ice: We use cold therapy after surgery to reduce swelling and pain. It is highly effective and reduces the need for pain medications. Yet, all healing tissues require increased blood flow. Ice reduces blood flow. So, where is the trade-off? Should we be cycling heat with cold? When is one better than the other? This remains unknown.
- Cortisone: We know that cortisone powerfully shuts down inflammation by inhibiting cell metabolism. It shuts down the cells’ ability to recruit new cells to the site of inflammation and tissue repair. Cortisone causes long-term damage to cartilage, weakens tendons, and inhibits healing. Yet, it remains the number one injection ordered by physicians for painful joints. This is changing, however, with the introduction of stem cells.
- Stem cells: Stem cells are potent growth factor production engines. Unlike cortisone, they appear to do no harm. The factors they release are anti-inflammatory, antimicrobial, anabolic, and “professorial” in that they teach other cells what to do at the site of an injury. There are various types of stem cells in the body, some more specialized than others. Each injury profile is unique. A newly torn knee joint ACL is very different from a joint with chronic arthritis. Today, we inject generic stem cells and combinations of growth factors into joints without knowing which combinations are ideal for which tissues. Clearly, we can get more targeted in our therapies.
- Calcium, Vitamin D, and Bone: For decades, we have recommended that our patients use calcium and Vitamin D supplements to prevent hip fractures (everyone becomes more osteoporotic as they age, women faster than men). Yet, a review of randomized clinical trials involving 51,000 patients 50 years and older showed no significant association of calcium and/or Vitamin D treatment compared to placebo—regardless of dose, gender, fracture history, dietary calcium intake, or baseline Vitamin D concentration.
So, if some of these time-tested therapies—with megabillion dollars invested— are rife with uncertainty (and even possible harm), what are we to do?
The answer lies not just in practice, but in research. In this era where many medical school applicants claim to be interested in research and all patients carry a permanent identification number (their smartphone number), the opportunity now exists to assess and track all therapies that patients are given.
I believe every patient should have an “app” placed on his or her cell phone that enters them into a study for any therapy they are being administered or for any implant placed into their bodies. The app would ask the patient to enter data on the therapy’s effectiveness on a regular basis. By adding their patients’ information into outcomes trials, every doctor can now be a researcher—and the number of clinical trials and patient outcomes could number in the tens of millions, rather than just a few thousand. Though this platform does not yet exist, we’re working on it.
By using both rigorous scientific protocols and by crowdsourcing outcomes and complications, we could be better informed and make solid decisions based on huge databases. This would truly advance the art and science of medicine. Then, next year, we surely will know better.