Doctors Still Offer Treatments That May Not Work.

This is an important article that arrived on my desk this am. You can create a free account with the NY Times to read this article. I have reproduced it here (full credit to NY Times for this essay).


https://www.nytimes.com/2019/08/26/upshot/why-doctors-still-offer-treatments-that-may-not-help.html


Evidence-based medicine has made progress since doctors’ infamous bloodletting of George Washington, but less than you might think.


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 isn’t.


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 studies.


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.”


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 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).


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).


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 and purge it from health care systems. The American Board of Internal Medicine’s Choosing Wisely campaign 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 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 or even decades to reverse medical convention. Some practitioners cling 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.


Finally, not from the NY Times, this image confirms that the health of our healthcare system may be even less advantageous to our health than this article indicates:




Stay Well - And avoid modern medicine to the extent you can




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Wisdom is better than strength. Nevertheless the poor man's wisdom is despised. And his words are not heard. Words of the wise, spoken quietly, should be heard. Rather than the shout of a ruler of fools. 

-Ecclesiastes 9:16-17

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