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from: Atul Gawande
to: Natalie Angier

Risky Business

Posted Tuesday, April 16, 2002, at 3:17 PM ET

Who are these people?

Natalie,

It seems hard to object to enrolling more kids in experiments if all it means is testing out ways of getting "at risk" kids to do less drugs, have less sex, drop out of schools less often, be nicer to their parents. And whether we call this at-riskness a "condition" doesn't matter much as long as we don't get carried away. The key question is what we're using these labels (or more to the point, these kids) to justify doing. Experiments with counseling or even certain medications to get obese children to lose weight are one thing. But we'd better think pretty hard before doing randomized trials of stomach-stapling operations on 10-year-olds.

We're in a bind in medicine, though. The group we're most concerned about inflicting untested remedies on is children. Yet, as a result, they are one of the two groups whose treatments are the MOST untested. Drugs, for example, absolutely must be tested in adults before the FDA will approve them. But drugs are very rarely tested in either children or pregnant women—we're all understandably too skittish about the potential for harm to require it. The paradoxical result, though, is that doctors are commonly prescribing drugs to kids (and pregnant women) with only the crudest information about the proper dosage, effectiveness, and potential for harm.

You asked earlier if we are less likely to use experimental or innovative procedures on kids. I think the answer is that we're MORE likely to do so. My son, now 6, had to have cardiac surgery a few years ago, and the cardiac surgeon proposed using a relatively new synthetic material in reconstructing his aorta. There were no randomized trials comparing it to the usual stuff used. And we certainly didn't know how that new material would hold up 75 years down the road. All we had was a theory suggesting that it could be better. But we went with it. What else did we have to go on? If doing more experiments can help answer questions like these better, I'm inclined to think that's good, even if a bit scary.

Now, on the matter of these embargoes the science journals use to keep you from saying what you already know is big news this week, I find I'm of two minds. On the one hand, I agree, the whole business seems awfully suspicious and hypocritical. If the journals want to keep the lid on hot science news, why hand out press releases at all? There's a fundamentally patronizing notion behind it all that the lay press needs a few days to "digest" the latest genetics or physics or medical advancement and report on it responsibly. And I'm not convinced that the quality of reporting really improves just because reporters aren't allowed to mention Dolly on Tuesday, when they find out about her, but must wait until Thursday. On the other hand, the process of vetting science through journals that keep tight control on what's branded "good" science has allowed a far greater degree of public confidence in what is found than we would otherwise have. Every once in awhile, a breakthrough is reported by press conference rather than through a journal. Such breakthroughs frequently get big-time press. But they almost always fail to pan out. Cold fusion is just one example that jumps to mind. I still think, however, that people should understand the little game that goes on.

Speaking of breaking embargoes, though, how's that cooking piece coming?

Atul

the breakfast table
entries
1234567891011121314151617
from: Atul Gawande
to: Natalie Angier

Risky Business

Posted Tuesday, April 16, 2002, at 3:17 PM ET
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Natalie Angier is a science writer for the New York Times and the author of Woman: An Intimate Geography. Atul Gawande, a surgical resident in Boston, is a staff writer on medicine for The New Yorker and author of the new book Complications: A Surgeon's Notes on an Imperfect Science.
Illustration by Mark Alan Stamaty.
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