“Ending Medical Reversal” is a subtly subversive book in need of a considerably snappier title. “OOPS!” perhaps, or “Are You Kidding Me?”
This last was the reaction of a diabetic patient described by the authors who, after years spent dutifully following the most Spartan of diets to keep his blood sugar in check, just learned he needn’t have bothered. The goal his doctor (and doctors everywhere) were routinely setting for their patients had just been proved by a new study to be far too stringent.
All that broiled fish, all those unbuttered green beans, all that willpower, all for nothing. Oops.
This kind of medical whiplash is increasingly common and every bit as scary and damaging as the physical kind. What was good for you yesterday is useless or even bad for you today (and may be good for you again tomorrow; who knows). Medical gospel is rewritten daily on the evening news.
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The incremental progress of ordinary science is one thing, as individual treatments are progressively replaced by better variants. We all happily accept that kind of revision. But medical reversal, the authors’ sober term for sudden flip-flops in standards of care, unnerves and demoralizes everyone, doctors no less than their patients.
Dr. Vinayak K. Prasad and Dr. Adam S. Cifu, of Oregon Health & Science University and the University of Chicago, respectively, have set themselves the task of figuring out how often modern medicine reverses itself, analyzing why it happens, and suggesting ways to make it stop. If this short list of objectives explodes into a breathless and somewhat unwieldy critique of all of Western medicine, you still have to appreciate both their ambition and their argument.
An old saw has long held that 50 percent of everything a student learns in medical school is wrong. Actual calculations suggest that number is not too far off base — Prasad and Cifu extrapolate from past reversals to conclude that about 40 percent of what we consider state-of-the-art health care is likely to turn out to be unhelpful or actually harmful.
Recent official flip-flops include habits of treating everything from lead poisoning to blood clots, from kidney stones to heart attacks. One concerned an extremely common orthopedic procedure, the surgical repair of the meniscus in the knee, which turns out to be no more effective than physical therapy alone. The interested reader can plow through almost 150 disproven treatments in the book’s appendix.
Some of the glitches that allowed these flawed approaches to enter and persist in medical practice will be familiar. Adequate scientific study is often prohibitively complicated and expensive, forcing us to rely on less definitive work. Financial interests tend to distort scientific results.
More surprising, though, is an odd paradox: Often it is the treatments that make the most theoretical sense that fail.
The single thing that all the abandoned drugs and treatments on the authors’ list have in common is that they are all reasonable, logical and scientifically appealing. Every one of them should work.
The authors write that we know enough about human physiology — all the little molecules scooting around in our bodies at the behest of those dictators, our genes — that we are now able to come up with elaborate, well-defended notions of how to help them all along. But “the human body is so complicated, and our understanding of it so superficial, that what we believe should work often does not.”
What could make more sense, after all, than finding some cancers early, fixing a piece of torn cartilage, closing a hole in the heart and propping open blood vessels that have become perilously narrow? And yet not one of these helpful interventions has been shown to make a difference in the health or survival of patients who obediently line up to have them done.
As Prasad and Cifu point out, it all forces a careful, critical look at the scientific paradigm that rules medicine these days.
Basic science still lays the foundation for medical training in most schools. Long before students meet actual patients, they learn the minutiae of the theory behind the practice. In fact, that part of their training is generally far more rigorous and methodical than training in patient care, which can be remarkably slipshod.
“Often the study of the study of how therapies should work is much more extensive and comes before the study of whether therapies do work,” the authors write. Thus a medical culture based on “should work” rather than “does work” is condemned to constantly correct itself when the science is finally evaluated for outcomes that matter.
To fix this constant backtracking would require nothing less than a revolution in how doctors are trained, with an emphasis on the proven and practical rather than the theoretical. (It would also require a second revolution in how doctors practice, with less prestige and remuneration for coming up with new ideas and more for validating old ones.)
Until the revolution comes, how can the average patient avoid becoming a victim of medical whiplash? It’s not easy, particularly since common sense often won’t help distinguish good treatment from bad.
Prasad and Cifu offer a five-step plan, including pointers for determining if a given treatment is really able to do what you want it to do, and advice on finding a like-minded doctor who won’t object to a certain amount of back-seat driving. Of course, there are no guarantees that their tips will endure forever, but they probably have a longer shelf life than most medical advice.
‘Ending Medical Reversal: Improving Outcomes, Saving Lives’ by Dr. Vinayak K. Prasad. and Dr. Adam S. Cifu; Johns Hopkins University Press ($24.95)