New York Times: Why Doctors Still Offer Treatments That May Not Help

31 August, 2019

https://www.nytimes.com/2019/08/26/upshot/why-doctors-still-offer-treatm...

'When your doctor gives you health advice, and your insurer pays for the recommended treatment, you probably presume it's based on solid evidence.

But a great deal [https://www.nytimes.com/2019/07/01/health/medical-myths-doctors.html?mod... of clinical practice that's covered by private insurers and public programs isn't.

The British Medical Journal sifted through [https://theincidentaleconomist.com/wordpress/half-of-medical-treatments-... the evidence for thousands of medical treatments to assess which are beneficial and which aren't. According to the analysis, there is evidence of some benefit for just over 40 percent of them. Only 3 percent are ineffective or harmful; a further 6 percent are unlikely to be helpful. But a whopping 50 percent are of unknown effectiveness. We haven't done the studies.

Sometimes uncertain and experimental treatments are warranted; patients may even welcome them. When there is no known cure for a fatal or severely debilitating health condition, trying something uncertain as evidence is

gathered [https://www.nytimes.com/2019/07/29/upshot/medicare-for-all-coverage-ques... — is a reasonable approach, provided the ppatient is informed and consents.

"We have lots of effective treatments, many of which were originally experimental," said Dr. Jason H. Wasfy, an assistant professor of medicine at Harvard Medical School and a cardiologist at Massachusetts General Hospital. "But not every experimental treatment ends up effective, and many aren't better than existing alternatives. It's important to collect and analyze the evidence so we can stop doing things that don't work to minimize patient harm."

In many cases, routinely delivered treatments aren't rigorously tested for years. Benefits are assumed, harms ignored.

This might have killed George Washington [https://www.pbs.org/newshour/health/dec-14-1799-excruciating-final-hours....

At 67 years old and a few months shy of three years after his presidency, Washington reportedly awoke short of breath, with a sore throat, and soon developed a fever. Over the next 12 hours, doctors drained 40 percent [https://www.nejm.org/doi/full/10.1056/NEJM199912093412413] of his blood, among other questionable treatments. Then he died.

Washington surely had a serious illness. Theories include croup, diphtheria, pneumonia and acute bacterial epiglottitis. Whatever it was, bloodletting did little but cause additional misery, and most likely hastened his death.

Though the procedure was common at the time for a variety of ailments, its benefits were based on theory, not rigorous evidence. In the era of modern medicine, this may strike some as primitive and ignorant.

Yet, hundreds of years later, the same thing still happens (though fortunately not with bloodletting).

In the late 1970s, some doctors thought they had found a way to treat breast cancer patients with what would otherwise be lethal doses of chemotherapy. The approach involved harvesting bone marrow stem cells from the patients before treatment and reintroducing them afterward.

Fueled by encouraging comments from doctors [https://www.bmj.com/content/324/7345/1088.short], the 1980s news media reported higher chemotherapy doses

[https://www.nytimes.com/1988/04/24/magazine/breat-cancer-anguish-mystery... as the means to survival. Yet there was no compelling evidence that bone marrow transplants protected patients.

But, told they would, many patients fought insurers in court to get them. Under pressure from Congress, in 1994 all health plans for federal workers were required to cover the treatment. Yet not a single randomized trial had been done.

Finally, in 1995

[https://theincidentaleconomist.com/wordpress/the-rise-and-fall-of-bone-m..., the first randomized trial was published, with impressive results: Half of women who received bone marrow transplants had no subsequent evidence of a tumor, compared with just 4 percent in the control group. But these results didn't hold up, with four subsequent clinical trials contradicting them. The approach was recognized for what it was: ineffective at best, lethal at worst.

Wishful thinking that runs ahead of or goes against research findings is behind today's opioid epidemic

[https://www.nytimes.com/2014/12/23/upshot/painkiller-abuse-a-cyclical-ch..., too. Despite a lack of solid evidence, for years many believed that modern opioid medications were not addictive. It's now abundantly clear they are. But the damage is done.

There are countless other examples of common treatments and medical advice provided without good evidence: magnesium supplements https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2603490 for leg cramps; oxygen therapy

[https://www.nejm.org/doi/full/10.1056/NEJMoa1706222] for acute myocardial infarction; IV saline [https://www.medscape.com/viewarticle/876521] for certain kidney disease patients; the avoidance of peanuts [https://www.nytimes.com/2016/04/26/upshot/avoiding-peanuts-to-avoid-an-a... to prevent allergies in children; many knee

[https://theincidentaleconomist.com/wordpress/healthcare-triage-news-knee... and spine

[https://www.nytimes.com/2019/01/24/health/spinal-fracture-treatment.html... operations; tight blood sugar control [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530321/] in critically ill patients; clear liquid diets [https://www.ncbi.nlm.nih.gov/pubmed/26460222]

before colonoscopies; bed rest [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226811/] to prevent preterm birth; the prescribing [https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2528287]

of unnecessary [https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.ht...

medications, to list <https://www.medscape.com/viewarticle/876521] just a few. In some of these cases, there is even evidence of harm.

[The rest of the article is freely availablehere: https://www.nytimes.com/2019/08/26/upshot/why-doctors-still-offer-treatm... ]

HIFA profile: Eileen McGinn is a Consultant in USA. qedeileen AT aol.com