I don’t know how you all keep from going slightly bonkers over the endless reversal of opinion from “experts” in the world of medicine. In the last few days alone, medical journals/websites (and the newspapers nobody subscribes to anymore) have reported policy changes on issues that I personally was just beginning to wrap my head around.
For the third time in two years, the guidelines on mammogram frequency and Pap smears have changed. The PSA blood test for prostate cancer that was a great breakthrough several years ago, before entering the medical hall of shame for subjecting men to unnecessary surgeries, is now being partially resurrected. Bacon and sirloin strip steaks are apparently more dangerous to the average American than ISIS. And low-fat diets, once the answer to reversing heart disease and promoting weight loss, end up to be pretty useless.
I can only wonder what all this must be doing to your minds.
“Confusing” becomes an understatement
“Oh, screw it!” becomes the most rational thing you can think of as you “reach for a Lucky instead of a sweet.” That quote was actually a piece of medical advice from the 1940s, when doctors fully endorsed smoking not only for relaxation, but as a weight loss aid.
A patient of mine sent me the Ending Medical Reversal New York Times book review, which discusses exactly this flip-flopping and how to protect yourself from it. Prone as I am to impulse book purchases, I promptly downloaded it to my ereader (after the usual 60 minutes spent struggling with the process) and can now report that thus far it’s been worth the effort.
The authors point out that medical flip-flopping is very common, that roughly half the stuff a doctor learns in medical school turns out to be wrong a few years later, and that, as a result, patients have been subjected to cringingly bad advice, bad drugs, and bad surgeries (prefrontal lobotomy, anyone?).
They lay much of the blame for this on so-called evidence-based medicine, which is supposed to look objectively at data from clinical research, drug studies (the famous double-blind, placebo-controlled approach), surgical outcomes, etc, and reach scientifically based conclusions. What happens after a few years, though, is that someone new reevaluates the data, undertakes a new study, or uses any of several ways to reconsider a “fact.” And lo, a flip flop. Oops! Changed our minds.
Ending Medical Reversal offers suggestions to avoid being caught in a treatment (medical or surgical) whose veracity may well be reversed in a year or two. Essentially, their ideas boil down to common sense, topics we’ve discussed for years in these Health Tips:
- Take care of yourself so you can avoid the health care system as much as possible. This is especially important in our current era of for-profit corporate medicine. More and more studies are emerging that show under the direction of nonphysician medical executives doctors are being encouraged to order what are turning out to unnecessary diagnostic tests, making referrals to unnecessary specialists, and scheduling unnecessary surgical procedures. I commented on this trend in two recent Health Tips, one on cowboy doctors and another on worrisome mammograms.
- Do your homework on any new diagnostic test (especially invasive ones) or treatment (medical or surgical) that’s being offered. Get second or even third opinions. Learn to challenge and ask questions like “What can I do to avoid taking this medication?” and “Do I really need this surgery or is there a simpler option?” One key question that should be asked by both doctors and patients about any treatment: “Does the desired end point (the perfect blood pressure, the really low Hemoglobin A1c, the pristine Pap smear, the effect of this gruesomely expensive medication) really matter?”
- Find a physician you can work with. Again, surveys among physicians show that most newly minted doctors go to work at corporate-owned medical systems and, being obedient wage earners, do too much in terms of tests, drugs, and referrals. You need to find someone who will listen to your concerns and not begin with a treatment that may turn out to be useless or even dangerous in the long run.
- Don’t be shy about speaking up. Perhaps say to your doc, “I want to make sure I’m going to be comfortable with what I choose. Do you really see a risk in trying lifestyle changes and alternative therapies first, before we move to the Big Guns?”
Appendix of flip-flopping
Ending Medical Reversal concludes with an appendix listing more than a 100 instances in which medicine has changed its mind. For me, it’s really the tip of the iceberg. When I look at the forgotten therapies from old medical journals or long-vanished drugs from previous editions of the Physicians’ Desk Reference, I think “How many people were seriously hurt by this over-reliance on ‘science’”?
- Tonsillectomy done so routinely it was almost a rite of passage (in my childhood).
- Removing adenoids from kids with stuffy noses (adenoids are lymphatic tissue at the back of the nasal passages, and they disappear during adolescence).
- Inserting ear tubes into children with ear infections lasting longer than three months (turned out to cause hearing loss with learning disabilities).
- Low-calcium diet for preventing kidney stones (actually increased the risk of stones).
- Arthroscopy for arthritis of the knee (ineffective, no better than placebo).
- Radical mastectomy–breast, nodes, and chest wall muscles–for breast cancer (this was the major surgical treatment in the 20th century, only recently found to be no better than far less aggressive surgery).
- Antibiotics for symptomfree bacteria in urine (no benefit).
- Aggressive treatment for atrial fibrillation (meds plus cardiac electroversion–no benefit).
- Hormone treatment for menopausal women (this one has been a ping pong ball, currently cited as helpful for symptom relief only).
- Encasing bedding in plastic covers for people allergic to dust mites (no benefit).
- Radiation therapy for breast cancer in women over 70 (no benefit).
- Surgery for torn knee ligaments (most would heal by themselves).
- Surgery for torn shoulder/rotator cuff (most would heal by themselves).
“Evidence-based” fibro treatment
I have some familiarity with the history of so-called evidence-based treatment for fibromyalgia, the chronic muscle pain condition affecting mainly middle-aged women. Fibromyalgia is a clinical diagnosis, made by listening to the patient and performing a physical exam. There are no positive test results to be had, a fact that to this day many physicians have difficulty grasping.
Initially the rheumatologists to whom fibro patients were referred routinely diagnosed them as neurotic and sent them on for psychiatric evaluation. When psychiatrists reported the fibro patient fine except for pain, the patient would be referred to an orthopedic surgeon in the hope there was something to be fixed.
After xrays and MRIs, especially of the upper (cervical) spine, the radiologist would report some arthritis. Though we all have some spine arthritis in our 50s, surgeons saw this as “evidence” of a pain source and often performed a major back surgery called cervical laminectomy, which turned out to be totally useless. Probably thousands of women underwent this procedure until the fibro flip-flop occurred and doctors realized it wasn’t a surgical problem after all.
(After hearing this, you can likely guess the sad fate of many women whose fibro made its first appearance as chronic pelvic pain.)
And on and on…and on.
Be skeptical, and be well,
David Edelberg, MD