"Medical Reversal" -- It Sounds So Innocent...
(April 24, 2020)
Last time we met, I was holding forth on the ideas of relative and absolute risk. The central concept was this -- that although you are twice as likely to be killed and eaten by your cat than squashed by a meteorite ("relative risk"), that should not be something that you worry about because the chances of either happening are absurdly low ("absolute risk"). (I know that there are people who will tell me that cat murder is far more common than this. You people there, stop trying to stir up trouble.)
Then I discussed those ideas in regard to medical procedures -- that "relative risk" and "absolute risk" are both concepts can be used for propaganda purposes. You can use either one to scare someone away from receiving a treatment, or conversely manipulate them into going forward with it.
Although people tend to assume that even if a medical procedure doesn't fix a problem there's no harm done, that is not true. If you back off just a bit and really look at it, you can see how risky surgery and medications can be. That's not to talk anyone out of doing these things when those treatments are appropriate, and I genuinely mean that. It is amazing what conventional medical procedures can accomplish.
But all medical procedures are not alike. One that doesn't work doesn't mean just that you're back where you started. It can cost you a lot of money, pain, and compromise your future health and even kill you. (Remember that medical error is the third leading cause of death in the U.S.). And if you are in that place after undergoing a treatment that wouldn't have helped you in the first place, well, that's just wrong.
This is not something that just happens once in a while. One very important area of difference between treatments in current use is that FEWER THAN HALF OF THEM have been run through double-blind trials. One that hasn't been so tested is automatically at least a little iffy, especially if there are alternatives that have been so tested.
You probably know that a double-blind trial is where both real and fake treatments are administered to a group of people, and neither the test subjects nor their doctors know whether they're being given a real treatment or a placebo. But these are not done ONLY to see if something really works or not. They are also done to see IF A NEW TREATMENT WORKS AS WELL AS EXISTING TREATMENTS FOR THE SAME THING. Because if you have a new way of treating something if the old way is just as good, or better, so what? Why fool with it?
Double blind trials can be hard to do. Plus they are expensive, and someone who has an investment in a new treatment can't really be trusted to do them properly. So once a treatment makes it into common use, further testing is often ignored or given short shrift even if questions arise. What happens THEN is an awful lot of people end up being treated with the "latest and greatest" treatment that either doesn't help them at all, helps them less than something cheaper or easier on their body would have, or actually harms them.
When the science of medicine finally zeroes in on one of these embarrassments and identifies it as such, it is called a "medical reversal". (You knew I'd get to the point eventually, didn't you?) And you would think that at that point the procedure would be abandoned. But in the real world, that is not what happens.
An article published in June 2019 found that there were over 400 of these treatments still in common use despite good evidence that they should be abandoned. Cardiovascular disease, critical care and preventative medicine were the fields with the biggest number of dubious treatments. Medications accounted for about a third of the reversals, and procedures for about a fifth of them. The article found that it was very hard to get doctors to abandon using procedures they were used to. It also found that medical companies of various sorts fund about half of all clinical trials generally (for their own products), but fewer than 10% of reversal studies (which might put their products out of action).
So both at the level of the individual doctor who's used to doing things a certain way and who doesn't want to admit that maybe s/he hasn't really been helping people like they thought, the reluctance of specialty advisory boards to admit that they've screwed up, and the shrieks of financial pain from whoever is selling the new treatment, substandard care marches onward indefinitely.
Here are three examples of treatments in current use that don't do what they are supposed to do.
--Epidural injections to relieve the pain of lumbar stenosis -- no evidence for efficacy. (I believe the same thing has been found for neck pain.)
--Stents inserted into the heart specifically for the purpose of relieving cardiac pain -- no evidence that that works either.
--Arthroscopic knee surgeries are mostly useless to relieve future pain or prevent or delay future surgery.
Also, diuretics tend to be the most helpful type of medication to reduce blood pressure, and they are often overlooked in favor of shinier new medications. Five years after this determination was made, a number of doctors' offices were surveyed and it was found that the study was mostly being ignored. This was a decade or so ago, so it may no longer be true. But it still serves as a useful example.
Here's the takeaway from all this. There are a LOT of outdated, useless, dangerous and expensive medical practices out there, and because of their prevalence it is almost certain that some time or another in your life, one will be recommended to you. And you should not do it, no matter how terrific your doctor swears it is.
Next time I'm going to steer you to a few resources where you can look up any treatment that someone recommends to you. This is serious business. If you take vitamin C to prevent a cold and it doesn't work, the worse that happens is you get a bit of diarrhea and are out a few bucks. If a stent surgery goes awry, that's a horse of an entirely different color. You need to be on top of this stuff, and hopefully I will be able to help a little with that next time.
--dr. diane holmes
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