Flip-Flops in medical advice.

I want to forward readers some clips I've taken from a review by Zuger of a recent book "Ending Medical Reversal" by Prasad and Cifu. After glancing through the following you might want to also have a look a this article by Span on the over-treatment of older patients.

Prasad and Cifu... 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...[they] 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 reversal 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 disproved treatments in the book’s appendix.

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.

“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.)