Undoing dogmas in medicine

So far, we’ve shown that some of the false assumptions on which many science-led sectors are based can be very deeply rooted, making them extremely difficult to expel. If we continue to look at medicine as an example, it is often quoted that it takes 17 years for research evidence to reach clinical practice, such is the hold these institutionalised dogmas have on the discipline. One man very familiar with this is Ian Roberts, from the London School of Hygiene & Tropical Medicine, who’s been looking at the potential benefits of a drug that can cut the risk of bleeding during surgery.

Chris - Ian, welcome to the programme. What put you on the trail of this in the first place?

Ian - Tranexamic acid is a drug that was invented the year I was born, which is about 60 years ago. It was widely used to reduce bleeding after tooth extraction and heavy menstrual periods. And then surgeons started using it because it reduces surgical bleeding and the need for blood transfusion. And it really, really does work. There have now been over a hundred thousand patients in randomised trials; without any shadow of doubt tranexamic acid reduces bleeding in surgery by about 25% and reduces the need for blood transfusion by about a third to a quarter.

Chris - So what's not to like, Ian.

Ian - I don't know. There's a remarkable reluctance of doctors, surgeons, anaesthetists to use it. In fact, we've just started a collaborative campaign with the Royal College of Surgeons, the Royal College of Anaesthetists, the Royal College of Physicians, all these eminent Royal colleges to try to encourage doctors to consider the use of tranexamic acid in all patients having inpatient surgery. And also patients should ask for it too.

Chris - Stepping back a section, usually physicians are loathe to do something because there is a perceived risk that something bad will happen if they depart from established dogma. That's what this programme ultimately is all about, isn't it? So what are people worried about then if they were to use this? What sounds like the blood clotting equivalent of aspirin - it is wonderful for health in all ways - what are they concerned about.

Ian - Drugs that reduce bleeding sometimes increase the risk of unwanted clotting causing heart attacks and strokes and things. And so they've got this kind of mechanistic sort of expectation, but it's just not born out by the large scale randomised trials. It's a sort of belief that's not completely unreasonable, but trying to shift that belief with evidence, which is I think what it's time we did, is the hard thing.

Chris - It sounds to me a bit chicken and egg here, where there's this perception of risk and so people find it difficult to then do the studies that would prove that there isn't any risk and because they don't have the evidence, they don't act on it. And it goes round like a self-fulfilling prophecy.

Ian - Well, except that we have the evidence with people have been doing randomised trials of tranexamic acid in surgery for about, I don't know, 50 years. And now we've got lots of evidence. There was another big trial published in the New England Medical Journal a couple of months ago. And it was just the same, highly significant reduction in the risk of bleeding, major bleeding, potentially life threatening bleeding, and no increase in the risk of thromboembolic events. We have a job being rational in a way.

Chris - Do you think this sort of thinking infests medicine comprehensively, or is it just something about surgery?

Ian - Medicine is like this huge super tanker that changes course very, very slowly because it's all about habits. Doctors might say they are up to date with the evidence and they think of every individual patient that's in front of them, but actually a lot of it is habits and, "patients like this, I normally manage like this." And so changing habits is quite difficult. With the surgical issue, the opportunity to change habits is that there's a bit of a crisis at the moment. So there's a blood shortage in the NHS. I think it's partly due to COVID and summer holidays and all of that. But blood stocks currently are really low; they're halfway where they should be. And if they get any lower, they'll have to possibly postpone elective surgery and that's a real disaster for patients. So I hope that surgeons and anaesthetists are going to respond to this crisis and start using tranexamic acid in surgery to reduce unnecessary blood use.

Chris - It certainly sounds like you're making a strong point. One has to wonder though, to what extent we are actually shooting ourselves in the foot with this sort of mentality. Because on the one hand we are very risk averse because we don't want to do harm because if we do harm because we depart from established guidelines, then the authorities come down on us like a ton of bricks. On the other hand, we could potentially be costing lives through inaction because of this sort of anonymity. So how do we break the cycle? And what would you say to Joanna who we just heard from about the fact that she's lobbying saying serotonin and depression are not linked in the way that we've been taught dogmatically for years, we need to rethink.

Ian - It's almost like sins of omission and sins of commission. So patients can die because we don't do something and that's not weighted as seriously as if patients died because we did something. I don't know if that's the way humans are hardwired. All I can think of to do is to keep on trying to present the evidence in different ways, emotionally appealing ways. I've learned over the years that humans aren't really rational. We're sort of a fizzing ball of emotion. So you've got to tap into people's emotions if you want to get practice change.

Chris - I mean, taking a contemporary example just to finish the Covid vaccines, for example, which broke the mould in terms of how they got invented, how quickly they got through trials and things, and the technology they were founded upon. People have been working on those mRNA technologies for decades in some cases. And no one had got close to making a vaccine, which now Pfizer and Moderna are fighting over who owns what, because they're regarded as the biggest breakthrough in infectious diseases in cancer in the last two decades.

Ian - I think that's a sort of example of the point that I'm trying to make: the NHS seems like a very slowly moving super tanker, but during the COVID crisis, it just suddenly got very nimble and started changing direction very quickly. I got redeployed back to the intensive care unit at the Royal London hospital, and I was just amazed how quickly they could change things when there's a crisis. People can respond really rapidly. So to some extent, I think in order to change the thing you're trying to do, trying to implement, has to be the solution to some crisis.

Chris - Yeah. I'd rather not have a COVID crisis every day of the week though, but I would like to see a faster pace of change. Ian, thanks very much for joining us to talk about the dogma in medical practice and changing medical practice. That's Ian Roberts, he's at the London School of Hygiene and Tropical Medicine.