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    Wednesday, July 1, 2009

    PART I OF III Believing in Medical Treatments That Don’t Work

    Dr. David H. Newman writes* about how medical ideology often gets in the way of evidence-based medicine." Dr. Newman contends that "the practice of medicine contains countless examples of elegant medical theories that belie the best available evidence." For instance, despite "recent press reports detailing the dangers of cough syrup for children" that "have noted that cough syrup doesn't work," the use of these cough remedies "is common." Dr. Newman claimed that although "treatment based on ideology is alluring," the "uncomfortable truth is that many expensive, invasive interventions are of little or no benefit."

    Another example is in the early throes of a heart attack, caused by an abruptly clotted artery, the stunned heart often beats quickly and forcefully. For decades doctors have administered “beta-blockers” as a remedy, to reduce consumption of limited oxygen supplies by calming and slowing the straining heart. Giving these drugs in the early stages of a heart attack represents elegant medical ideology.

    But it doesn’t work.

    Studies show that the early administration of beta-blockers to heart attack victims does not save lives, and occasionally causes dangerous heart failure. While two studies support the use of beta-blockers after heart attack, there are 26 studies that found no survival benefit to administering beta-blockers early on. Moreover, in 2005, the largest, best study of the drugs showed that beta-blockers in the vulnerable, early hours of heart attacks did not save lives, but did cause a definite increase in heart failure.

    Remarkably, the medical community has continued to strongly recommend immediate beta-blocker treatment. Why? Because according to the theory of the straining heart, the treatment makes sense. It should work, even though it doesn’t. Ideology trumps evidence.

    The practice of medicine contains countless examples of elegant medical theories that belie the best available evidence.

    He noted that "the administration's plan for reform includes identifying healthcare measures that work, and those that don't," but "to place evidence above ideology, researchers and analysts must be trained in critical analysis, have no conflicts of interest and be a diverse group." And, "perhaps most importantly, we as doctors and patients must be open to evidence," he concluded.


    • Patients with ear infections are more likely to be harmed by antibiotics than helped. While the pills may cause a small decrease in symptoms (for which ear drops work better), the infections typically recede within days regardless of treatment. The same is true for bronchitis, sinusitis, and sore throats. Unnecessary antibiotics are still given to more than one in seven Americans each year for these conditions alone, at a cost of more than $2 billion and tens of thousands of serious adverse medication effects requiring treatment.

    • Back surgeries to relieve pain are, in the majority of cases, no better than nonsurgical treatment. Yet doctors perform 600,000 of these surgeries each year, at a cost of over $20 billion.

    • More than a half million Americans per year undergo arthroscopic surgery to correct osteoarthritis of the knee, at a cost of $3 billion. Despite this, studies show the surgery to be no better than sham knee surgery, in which surgeons “pretend” to do surgery while the patient is under light anesthesia. It is also no better than much cheaper, and much less invasive, physical therapy.

    Treatment based on ideology is alluring. Surgeries to repair the knee should work. A syrup to reduce cough should help. Calming the straining heart should save lives. But the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.

    The critical question that looms for health care reform, asks Dr. Newman, is whether patients, doctors and experts are prepared to set aside ideology in the face of data.

    Can we abide by the evidence when it tells us that antibiotics don’t clear ear infections or help strep throats?
    Can we stop asking for, and writing, these prescriptions?
    Can we stop performing, and asking for, knee and back surgeries?
    Can we handle what the evidence reveals?
    Are we ready for the truth?

    Somewhere along the line, theory trumped reality. Administering a medicine or performing a surgery became more important than its effect.

    New York Times (4/2/09) Well blog
    Evidence-based medicine is an important advance, although it can be a double-edged sword. When the evidence base applies, we should use it, and it reasonable for Medicare and other payers to insist on it. It is critical, however, to appreciate that there will always be patients for whom there is no evidence. They may so differ demographically from study participants from which the guidelines derive that it is doubtful as to whether guidelines are relevant. Or they may have conditions, such as rare diseases, for which there is no evidence band likely never will be. We must avoid the trap of those patients being shut out of care for lack of evidence.

    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    * Tune in tomorrow for Part II of IV, Believing in Treatments that don't work

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