Why Doctors Still Offer Treatments That May Not Help - The New York Times
benzonit at GMAIL.COM
Tue Aug 27 20:44:21 UTC 2019
This article as well as the extensive literature on "therapeutic nihilism"
and "slow adopters" as well as pressure to "get with the guidelines" should
give us all pause. I remember the halcyon days of many of these
now-disproven methods. (Benjamin Rush was a hugely influential proponent of
bloodletting. (Search RL North 2000 NCBI.)
Read on SlowMedicine.
On Tue, Aug 27, 2019 at 3:09 PM David L Meyers <dm0015 at comcast.net> wrote:
> Not specifically diagnosis related but an important observation…
> David L Meyers, MD FACEP
> Society to Improve Diagnosis in Medicine
> Listserv Moderator/Board member
> Save the Dates: Diagnostic Error in Medicine Conference (DEM2019),
> November 10-13, 2019 at Hyatt Regency Washington, DC (Capitol Hill)
> Why Doctors Still Offer Treatments That May Not Help
> By Austin Frakt <https://www.nytimes.com/by/austin-frakt>
> Aug. 26, 2019
> [image: A leech basin and other bloodletting instruments, taken by
> Meriwether Lewis and William Clark on their expedition to the West in 1803,
> as seen at an exhibit at the College of Physicians of Philadelphia.]
> A leech basin and other bloodletting instruments, taken by Meriwether
> Lewis and William Clark on their expedition to the West in 1803, as seen at
> an exhibit at the College of Physicians of Philadelphia.Associated
> Press/Mark Stehle
> When your doctor gives you health advice, and your insurer pays for the
> recommended treatment, you probably presume it’s based on solid evidence.
> But a great deal
> of clinical practice that’s covered by private insurers and public programs
> The British Medical Journal sifted through
> the evidence for thousands of medical treatments to assess which are
> beneficial and which aren’t. According to the analysis, there is evidence
> of some benefit for just over 40 percent of them. Only 3 percent are
> ineffective or harmful; a further 6 percent are unlikely to be helpful. But
> a whopping 50 percent are of unknown effectiveness. We haven’t done the
> Sometimes uncertain and experimental treatments are warranted; patients
> may even welcome them. When there is no known cure for a fatal or severely
> debilitating health condition, trying something uncertain — as evidence
> is gathered
> — is a reasonable approach, provided the patient is informed and consents.
> “We have lots of effective treatments, many of which were originally
> experimental,” said Dr. Jason H. Wasfy, an assistant professor of medicine
> at Harvard Medical School and a cardiologist at Massachusetts General
> Hospital. “But not every experimental treatment ends up effective, and many
> aren’t better than existing alternatives. It’s important to collect and
> analyze the evidence so we can stop doing things that don’t work to
> minimize patient harm.”
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> policy and everyday life.
> In many cases, routinely delivered treatments aren’t rigorously tested for
> years. Benefits are assumed, harms ignored.
> This might have killed George Washington
> At 67 years old and a few months shy of three years after his presidency,
> Washington reportedly awoke short of breath, with a sore throat, and soon
> developed a fever. Over the next 12 hours, doctors drained 40 percent
> <https://www.nejm.org/doi/full/10.1056/NEJM199912093412413> of his blood,
> among other questionable treatments. Then he died.
> Washington surely had a serious illness. Theories include croup,
> diphtheria, pneumonia and acute bacterial epiglottitis. Whatever it was,
> bloodletting did little but cause additional misery, and most likely
> hastened his death.
> Though the procedure was common at the time for a variety of ailments, its
> benefits were based on theory, not rigorous evidence. In the era of modern
> medicine, this may strike some as primitive and ignorant.
> Yet, hundreds of years later, the same thing still happens (though
> fortunately not with bloodletting).
> In the late 1970s, some doctors thought they had found a way to treat
> breast cancer patients with what would otherwise be lethal doses of
> chemotherapy. The approach involved harvesting bone marrow stem cells from
> the patients before treatment and reintroducing them afterward.
> Fueled by encouraging comments from doctors
> <https://www.bmj.com/content/324/7345/1088.short>, the 1980s news media
> reported higher chemotherapy doses
> as the means to survival. Yet there was no compelling evidence that bone
> marrow transplants protected patients.
> But, told they would, many patients fought insurers in court to get them.
> Under pressure from Congress, in 1994 all health plans for federal workers
> were required to cover the treatment. Yet not a single randomized trial had
> been done.
> Finally, in 1995
> the first randomized trial was published, with impressive results: Half of
> women who received bone marrow transplants had no subsequent evidence of a
> tumor, compared with just 4 percent in the control group. But these results
> didn’t hold up, with four subsequent clinical trials contradicting them.
> The approach was recognized for what it was: ineffective at best, lethal at
> Wishful thinking that runs ahead of or goes against research findings is behind
> today’s opioid epidemic
> too. Despite a lack of solid evidence, for years many believed that modern
> opioid medications were not addictive. It’s now abundantly clear they are.
> But the damage is done.
> There are countless other examples of common treatments and medical advice
> provided without good evidence: magnesium supplements
> for leg cramps; oxygen therapy
> <https://www.nejm.org/doi/full/10.1056/NEJMoa1706222> for acute
> myocardial infarction; IV saline
> <https://www.medscape.com/viewarticle/876521> for certain kidney disease
> patients; the avoidance of peanuts
> to prevent allergies in children; many knee
> and spine
> operations; tight blood sugar control
> <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530321/> in critically ill
> patients; clear liquid diets
> <https://www.ncbi.nlm.nih.gov/pubmed/26460222> before colonoscopies; bed
> rest <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226811/> to prevent
> preterm birth; the prescribing
> of unnecessary
> medications, to list <https://www.medscape.com/viewarticle/876521> just a
> few. In some of these cases, there is even evidence of harm.
> It is not uncommon for newer evidence to contradict what had been standard
> practice. A study
> by an Oregon Health & Science University School of Medicine physician,
> Vinay Prasad, and colleagues examined 363 articles in the New England
> Journal of Medicine from 2001 to 2010 that addressed an existing medical
> practice. Forty percent of the articles found the existing practice to be
> ineffective or harmful.
> Some of these reversals are well known. For example, three articles
> contradicted hormone replacement therapy for postmenopausal women
> Another three reported increased risk of heart attacks and strokes from the
> painkiller Vioxx
> Looked at one way, medical reversals like these reflect a failure; we
> didn’t gather enough evidence before a practice became commonplace. But in
> another way, they were at least a partial success: Science eventually
> caught up with practice. That doesn’t always happen.
> “Only a fraction of unproven medical practice is reassessed,” said Dr.
> Prasad, who is co-author of a book on medical reversals
> along with Adam Cifu, a University of Chicago physician.
> Dr. Prasad’s work is part of a growing movement to identify harmful and
> wasteful care <https://www.ncbi.nlm.nih.gov/pubmed/23163685?dopt=Abstract>
> and purge it from health care systems. The American Board of Internal
> Medicine’s Choosing Wisely campaign <https://www.choosingwisely.org/>
> identifies five practices in each of dozens of clinical specialties that
> lack evidence, cause harm, or for which better approaches exist. The
> organization that assessed the value of treatments in England has
> identified more than 800 practices
> <https://www.bmj.com/content/343/bmj.d4519.long> that officials there
> feel should not be delivered.
> It’s an uphill battle. Even when we learn something doesn’t make us
> better, it’s hard to get the system to stop doing it. It takes years
> <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241518/> or even decades
> to reverse medical convention. Some practitioners cling
> <https://jamanetwork.com/journals/jama/fullarticle/209653> to weak
> evidence of effectiveness even when strong evidence of lack of
> effectiveness exists.
> This is not unique to clinical medicine. It exists in health policy, too
> Much of what we do lacks evidence; and even when evidence mounts that a
> policy is ineffective, our political system often caters to invested
> stakeholders who benefit from it.
> An honest assessment of the state of science behind clinical practice and
> health policy is humbling. Though many things we do and pay for are
> effective, there is a lot we don’t know. That’s inevitable. What isn’t
> inevitable — and where the real problems lie — is assuming, without
> evidence, that something works.
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