There’s No Such Thing as a Free Med
In this guest post from Prof. Fenyves, he discusses the idea of a risk tax. That means there could be downsides to giving a medical product that we only learn of down the road— and we should include this in our decision making today. I think all great physicians think about this, but we don’t discuss it enough. Prof Fenyves puts it into words nicely.
Vinay Prasad MD MPH
When suggesting a medical treatment, doctors often proffer the justification “it can’t hurt.” I believe “it can’t hurt” is fundamentally false, and should never be accepted as the sole reason for a medical intervention. A better adage to guide medical decisions is “there’s no such thing as a free lunch.”
Balancing risks and benefits is a basic part of life. In all domains, we are forced to weigh pros and cons, to accept trade-offs.
The balancing of risks and benefits is of course essential in healthcare too, but there is an added complication: While most of the benefits of a medical intervention are known upfront, discovering all of the risks can take years or decades.
Consequently, when considering medical treatments, especially newer treatments, I believe that doctors should apply a “risk tax” to account for the harms that will often materialize.
As an illustration of these ideas, consider the following medical vignette: A 52-year-old man walks into his doctor’s office in April 1988, wearing, I assume, a jean jacket and Z. Cavarichi pants. He just returned from a trip to Mexico, his first vacation since suffering a heart attack one year ago. While away, he picked up a stomach bug, and although his diarrhea is now improving, the doctor suggests a course of the antibiotic ciprofloxacin, because “it can’t hurt.”
Two weeks later, the man returns to see his doctor. Although his diarrhea is better, he now complains of sharp pains in the back of his ankles. The doctor writes a prescription for ibuprofen 600 mg, and instructs the man to take one pill three times a day for the next week. Two weeks later, the man suffers his second heart attack.
The doctors among you already got the punchline. Ciprofloxacin is an incredibly effective and versatile antibiotic, but over the last two decades we have learned that it is associated with a rather high frequency of complications, including tendon pain and even tendon rupture.
Ibuprofen (AKA Motrin and Advil) is an NSAID which can effectively treat a wide variety of aches and pains. But over the last two decades, we have learned that NSAIDs can bring a variety of harms, including an increased risk of heart attack.
It is not surprising that these medications were found to have associated risks. After all, there is no such thing as a free lunch. But what is noteworthy is just how long it took the medical community to uncover these risks. How many people needed to pop a few Advil before we learned they were assuming an increased risk of cardiovascular disease?
To be clear, I say this not as a criticism of the medical community, but as a rationale for medical conservatism. In medicine, we are always playing with fire, wielding potent tools that can bring tremendous benefits, but must be handled with care, lest we get burned.
This approach to balancing risks and harms has informed how I have evaluated medical interventions throughout the Covid pandemic. In the United States, we have recommended bivalent booster vaccines to young healthy people, and have doled out Paxlovid to low-risk vaccinated patients. Both of these interventions lack evidence of benefit, and the maximum potential benefits are small. While there might be no benefit, there always might be risk of harm (both known and unimagined), and doctors should scrupulously follow our first dictum to do no harm.
Of course, every rule has its exception, and perhaps one example of something that “can’t hurt” in medicine is placebo. A placebo is an inert substance that harnesses our body’s ability to moderate our subjective experience of pain and suffering. A placebo can modestly reduce our discomfort for a period of time, without the need for a “true” medication. Since a placebo lacks active ingredients, it cannot directly cause us harm.
Still, one can imagine some rare cases where the use of a placebo might hurt us: A cancer diagnosis is delayed, because the telltale discomfort is dulled, preventing a timely doctor visit. Or a sprained ankle is worsened, because the protective pain is reduced, encouraging a premature jog. Discomfort is a message from our body to slow down and search for problems, and by allowing us to ignore this message, placebos might occasionally bring harm. Still, I would say placebo is the closest thing to a free lunch that medicine has to offer.
Returning to active drugs, I will close with the medication that has most informed my approach to balancing benefits and risks: Antibiotics.
The development of modern antibiotics was an absolute miracle, saving untold numbers of lives from infections that were previously untreatable. But as antibiotics became more and more widely available, they began to be used for less and less severe infections, including infections for which they offer no benefit, such as the common cold.
The widespread use of antibiotics lead to an unanticipated problem: resistance. Bacteria evolved mechanisms to survive antibiotics, reducing the treatment’s effectiveness. With time, doctors learned that they must use antibiotics more judiciously in order to preserve the medications’ utility.
Then came another unexpected realization that antibiotics might negatively impact our microbiome. The microbiome is the very large and diverse collection of beneficial bacteria that cover our skin and line our intestinal tracts, living in a symbiotic relationship with our body. The microbiome protects us from more pathogenic organisms, helps train our immune system, provides us with necessary nutrients, and aids in our digestion of food.
Although scientists have been aware of the microbiome for some time, the medical community was largely ignorant of the system until around 2010. So, for over half a century, doctors had been prescribing antibiotics without being aware that they were affecting a basic system of the body. While the consequences of antibiotics interacting with our microbiome are unclear, scientists have hypothesized that this has been a factor contributing to our increasing rates of allergic and autoimmune disease.
Due to the problem of resistance and interactions with the microbiome, I exercise more caution when prescribing antibiotics. I am less likely to use antibiotics for milder or improving infections, more likely to first try a course of watchful waiting. And I try to leave a smaller “antibiotic footprint,” favoring shorter courses, lower doses and less broad-spectrum therapeutics.
More generally, the history of antibiotics should remind us to exercise medical humility. The human body is complex, our understanding is incomplete, and our interventions can have unexpected consequences that only come to light years later. When the benefits are small and uncertain, we should proceed with caution.
Paul J. Fenyves, MD is a board certified doctor of internal medicine. He provides primary care with Weill Cornell Medicine, where he is the Associate Director, Digital Care and Innovation for Primary Care.