Saturday, August 3, 2019

Medical myths and reality

One of the few things I remember from my medical school 2nd year pharmacology lectures was the maxim: “When a new wonder drug comes out, use it immediately, because in a year it will not work as well.” This tongue-in-cheek witticism expressed very well the notion that many of the things that doctors do are as much based on hope and limited data as on solid evidence.
There has been a lot written in recent years about low-value care: medications, tests and procedures that offer little benefit at all or which offer no more benefit than a less expensive alternative. A program started by the American Board of Internal Medicine Foundation called Choosing Wisely attempted to identify low value care by polling specialty organizations for recommendations in their fields, but as I point out in Prescription for Bankruptcy, this got the expected result. The procedures that the organizations suggested should be stopped were for the most part procedures rarely done or done by someone other than the organizations’ members.
A recent careful review of randomized trials published in three prestigious medical journals found almost four hundred “reversals:” findings that countered conventional wisdom and current practices. Examples abound. Many patients with Alzheimer’s disease appear depressed, and it seemed logical to treat them with standard antidepressants that work for non-demented patients, but a large trial found no benefit in the Alzheimer’s population. The American Cancer Society has recommended that women 40-49 get a mammogram every 1-2 years but a very large study found no benefit. When patients are admitted to hospital with congestive heart failure, catheters are still often inserted into the pulmonary artery to measure pressures and guide therapy even though trials going back 15 years found that use of these catheters increased complication rates and had no decreased mortality benefit. Lumbar spinal stenosis is a common cause of back pain, particularly in older patients. When severe, surgery can help, but for most patients, steroid injections are recommended despite a trial published five years ago showing no help of these injections. When an athlete suffers a torn meniscus in the knee, they are usually offered arthroscopic surgery as the quickest way back to full activity. This procedure is also widely used for the much commoner situation of a middle-aged or older patient with osteoarthritis and a torn meniscus on MRI even though a careful trial found no benefit of arthroscopy over physical therapy.
[Those who want the full details are directed to https://doi.org/10.7554/eLife.45183]
To get the best care at a reasonable cost, we need to rely more on science and less on “that’s what I do.”

Prescription for Bankruptcy. Buy the book on Amazon

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