Medical Flip-Flopping

I don’t know how you all keep from going slightly bonkers over the endless reversal of opinion from the “experts” in the world of medicine. Over the last few years, 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.

In 2015 alone, for example, for the third time in two years the guidelines on mammogram frequency and Pap smears changed. The PSA blood test for prostate cancer that had been a great breakthrough, before entering the medical hall of shame for subjecting men to unnecessary surgeries, was partially resurrected. Bacon and rib eyes were apparently more dangerous to the average American than ISIS. And low-fat diets, once the answer to reversing heart disease and promoting weight loss, ended up being pretty useless.

More recently:
• Gluten sensitivity, which physicians were taught in medical school existed only in the form of celiac disease, was considered quite rare. No matter how hard a patient would try to convince her gastroenterologist that gluten made her ill, if a celiac test were negative she’d be reassured she could eat all the gluten she wanted. Literally, “it’s all in your imagination.” Now these same gastroenterologists accept that a majority of patients who report symptoms with gluten have non-celiac gluten sensitivity.

• Until two years ago, the CDC (Centers for Disease Control) said that tick-borne illnesses, especially Lyme, were rare, no more than 30,000 new cases per year. And then someone at the CDC took a second look and raised that number by a factor of ten to 300,000 new cases per year.

• “Some alcohol is good for you” vs. “alcohol is terrible” is almost like watching a ping pong game. This week in The Lancet it’s “No level of alcohol consumption improves health.” Any alcohol (any!) will affect your health and lifespan. Read this too for a fuller take.

• On the other hand, the federal government courted the alcohol industry to fund research to prove that some alcohol is good for you.

I can only wonder what all this must be doing to your minds.

“Confusing” is 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 New York Times book review for Ending Medical Reversal, 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 and can report that it was worth the purchase.

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.

Common sense applies
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 showing that, under the direction of non­physician medical executives, doctors are being encouraged to order what are turning out to be unnecessary diagnostic tests, making referrals to unnecessary specialists, and scheduling unnecessary surgical procedures. I commented on this trend in two 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?”

Not long ago I had an anesthesiologist as a patient. Warning him he didn’t have to answer my question if he felt uncomfortable, I asked him what percent of surgeries he participated in were probably medically unnecessary. He wasn’t at all hesitant when he replied, “Oh, probably half.”

     • 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 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’”?

Some examples:
– 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 symptom ­free 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).

And on and on…and on.

Be skeptical, and be well,
David Edelberg, MD