Believing In Medical Treatments That Don't Work 467
Hugh Pickens writes "David H. Newman, M.D. has an interesting article in the NY Times where he discusses common medical treatments that aren't supported by the best available evidence. For example, doctors have administered 'beta-blockers' for decades to heart attack victims, although studies show that the early administration of beta-blockers does not save lives; patients with ear infections are more likely to be harmed by antibiotics than helped — the infections typically recede within days regardless of treatment and the same is true for bronchitis, sinusitis, and sore throats; no cough remedies have ever been proven better than a placebo. Back surgeries to relieve pain are, in the majority of cases, no better than nonsurgical treatment, and knee surgery is no better than sham knee surgery where surgeons 'pretend' to do surgery while the patient is under light anesthesia. Newman says that treatment based on ideology is alluring, '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 Obama administration's plan for reform includes identifying health care measures that work and those that don't, and there are signs of hope for evidence-based medicine: earlier this year hospital administrators were informed by the Centers for Medicare and Medicaid Services that beta-blocker treatment will be retired as a government indicator of quality care, beginning April 1, 2009. 'After years of advocacy that cemented immediate beta-blockers in the treatment protocols of virtually every hospital in the country,' writes Newman, 'the agency has demonstrated that minds can be changed.'"
Re:And next up (Score:2, Informative)
A Nit To Pick (Score:4, Informative)
Prescription cough syrups may be useful.The linked article regarding cough syrups only covered over-the-counter cough medications. Prescription cough syrups that contain codeine or hydrocodone seem to work really well but are liable to abuse.
Symptoms versus infection (Score:5, Informative)
Cough syrups *do* work. ...BUT...
They don't combat the infection. They alleviate the symptoms.
They don't kill the bug which is causing the cough, they only make the patient cough less (and thus sleep better, feel more comfortable).
So if you count the days spent being sick, a cough syrup won't make any difference. On the other hand if you look which makes happier the patient, one should prescribe the cough syrup anyway. (Same goes for lots of other ailment : most of the treatment prescribed by doctors for common illnesses are only to make the symptoms more bearable, not to kill the bug faster).
There's a saying here among doctors telling that a "cold" last one week without treatment and 7 days with treatment.
I am more astonished about the prescription of antibiotics. Here around in Europe, there have been large campaign to make the public aware that most common infections (bronchitis, sinusitis, sore throats, ear infections, etc...) are due to viruses and thus there's no point in insisting until the doctor prescribes antibiotics.
I would have expected that the same reduction in use of antibiotics would have happened in the US too.
Disclaimer : Although IAAMD, I happen to work in research for the last few years so other medical /.ers should have better knowledge than me.
Re:And next up (Score:3, Informative)
Re:And next up (Score:1, Informative)
True, but if there is a choice between an operation that extends life and one that increases quality, which does the provider pay for?
That isn't really how QALY works. Loath though I am to suggest Wikipedia, their explanation [wikipedia.org] is reasonably good.
Re:You have too much optimism (Score:5, Informative)
You do realize I hope that carcinogenic and toxic chemicals are present in great quantities in the natural environment too? For example the human bloodstream naturally contains small amounts of formaldehyde. It is hard to imagine how it would be possible to eliminate exposure to these materials when they are present in every plant or animal through their natural metabolisms.
Sperm count studies that claim reductions in sperm count over time are very questionable. There have been a number of publications [google.com] in the literature that claim sloppy investigative practices are the reason for this perception. And it definitely has not been world-wide. The data vary greatly by region.
As far as immune system affects of nuclear testing - there is no evidence of such effects even in areas directly downwind of radiation hotspots like Hanford. The only studies showing such affects are in populations exposed to far greater doses, i.e. Nagasaki survivors or children exposed in the Chernobyl accident.
Re:And next up (Score:5, Informative)
So who decides, the patient or family, or BIG government?
Under our current system, insurance companies decide. It seems disingenuous to imply that patients have the choice and that the current system(private insurance companies) pays for every treatment than anyone could ever want/need. There are plenty of people who have been denied claims. I also don't understand why you can't still have private insurance if there is national health care. Did the advent of Blue Cross/Blue Shield make it impossible to get Aetna?
Re:And next up (Score:4, Informative)
Not to mention the risks. Cancer treatments can kill people, and surgery is always dangerous. Elderly people are the most likely to die from such treatments.
Re:And next up (Score:5, Informative)
I can testify that knee surgery is sometimes a wonderful cure. I suffered terrible pain for years and two new artificial knees are better than the originals in many ways and they never,ever hurt at all.
The knee surgery being referred to is the kind where they don't replace anything, just dinkering around in there - I believe. They aren't arguing that artificial knees don't work.
Re:And next up (Score:3, Informative)
That's where quality adjusted life years comes in. You look at years of life weighted by quality of life for each option and choose the greater. It's an attempt to codify the idea that most people would rather live 2 more healthy years than 4 years wracked in pain.
Re:And next up (Score:5, Informative)
From your nic, I assume ze jsi cech. I'm not sure where you live, but try the health care here in the US. When my kid broke his arm, my insurance refused to pay for the doctor, as it was "elective surgery", the doctor was not one of our preferred providers, and we did not get prequalified.
I guess we could have set his arm ourselves, or perhaps let it heal crooked....
For this we were billed $7,000....
One of my relatives is a doctor in the CR. As everywhere, there are good doctors, and bad doctors. All in all, the care I've received in the CR and Japan rivals that in the US, at a much lower cost.
Re:Placebo testimony (Score:3, Informative)
OK, now you have to do this for the half dozen other reasons you would typically do arthroscopic surgery of the knee for. Then figure out how to do a sham knee replacement.
Now, do you see why we don't know jack.....
And a shameless plug, even though I have nothing in particular to do with them: The Cochrane Collaboration [cochrane.org] - an attempt to answers these questions by studying the extant literature. Read it and weep.
Re:And next up (Score:3, Informative)
If there's government insurance and private insurance, will I be allowed to opt out of government healthcare (and not be required to pay taxes to support the government healthcare) if I purchase private healthcare?
The only proposal currently on the table is requiring that everyone have insurance. There's no discussion of what insurance you have to have, tho one might argue that there ought to be minimums, e.g., you can't get insurance that doesn't provide for catastrophic care, no matter how stupid you are.
The benefit of requiring everyone to have insurance is that doctors are legally required to render aid if withholding such aid would lead to death, permanent harm, etc. That costs doctors and hospitals, and those costs are passed right along to those who are insured.
Now, the other stupid thing about the US health system is that they (we?) pay more as a country than the rest of the world, for considerably worse care. Where is all that extra money going? Some can be explained by all of the uninsured people who get more or less no early or preventative care (since they can't pay for it), waiting until they might actually die before doctors & hospitals are obliged to intervene.
But the reality is that most of the useless money is going to insurance companies in the form of profits. And that's not likely to change any time soon, since all of the health care reform discussion is simply about requiring everyone to purchase insurange.
Re:And next up (Score:3, Informative)
I would not be surprised if this article were wrong about that conclusion. The article is definitely wrong about the conclusion regarding sinus infections.
Ever since I was a kid, I've been prone to sinus infections. Every couple of years, I'll have one. They have never---and I do mean never---gone away on their own. I've left them for well over a week just to see. Never happens. By contrast, when I take antibiotics, whether that is after four days of symptoms or eight, the symptoms decrease dramatically within just a few hours after the start of the first round. Even if the infection would have gone away after a few more days (and I'm not convinced it would have), taking an antibiotic still means you get three or four days of your life back, and that alone is sufficient reason to consider such treatment.
Further, the doctor's view is dangerous. Doctors don't prescribe antibiotics for strep throat because of the symptoms. They prescribe antibiotics for strep throat because if left untreated, strep infections can turn into scarlet fever (which can cause kidney damage) or rheumatic fever (which has a 2-5% mortality rate). Failing to prescribe antibiotics if strep is suspected is madness.
Even in the case of sinus/ear infections, his few is dangerous. My ear infections have gotten painfully close to rupturing my ear drum. If I did not take antibiotics, there is a very good chance that I would have hearing damage today. As a musician, that would be a bad thing.
Now if you want examples of bad medicine, take a look at statin drugs. Heart doctors notoriously prescribe these to people with even moderate cholesterol levels to bring their levels down. While clinical studies do show that in patients with severely elevated cholesterol, heart attack risk can be reduced by some statins, other statins have been shown to increase the risk of heart attacks and strokes [timesonline.co.uk].
Also, the side effects are much more common than they lead you to believe and are severe and debilitating. Both my grandparents have experienced textbook adverse reactions to statin drugs (peripheral neuropathy in both, sleep issues in one, confusion/anxiety/cognitive disruption in one). These side effects are very real.
Worse yet, studies show that these drugs don't reduce overall deaths because for every death they prevent from heart disease or strokes, you get an increase in deaths from other causes, including cancer. So basically it reduces quality of life while failing to actually increase the typical length of life....
Re:And next up (Score:4, Informative)
Actually, the doctors order all the tests because if they don't, and the patient happens to have some disease that would've been detected by that test, they'll get sued for malpractice, and their malpractice insurance rates will go up, and/or they could lose their license to practice. Having universal health insurance wouldn't stop this, it would actually make it worse since the doctors would know the tests would be paid for. (Unless you put some bureaucrat in charge of deciding which tests are necessary, taking that decision out of the hands of the doctor who sees you.)
The only other ways to stop it are to tighten up the requirements to file a malpractice suit (which would make the lawyers unhappy), or for the government to provided some sort of universal malpractice insurance. But then you'd get the same arguments being raised for/against universal health insurance, but applied to rich doctors instead of poor people (e.g. bad doctors being allowed to continue practice). Personally I think getting people's opinions on both is a great way to detect whether they truly want to fix the health care system, or if they just have an agenda they want to push and have picked health care as their vehicle.
Re:it is about money. (Score:3, Informative)
While lots of the things you say have a ring of truth to them, I think your suggestion is a horrible one. It's too simple. I know people in their nineties who are intellectually fine, want to live, but their bones are fragile. You would say that these people don't get a broken hip mended? no way! But if you were to ask if they wanted a heart transplant, they'd probably turn it down, saying it's their time to go and there's younger people who need a chance to grow old. It's not about the surgery, it's about the cost, and not just the simple cost - about the emotional cost to them and those around them, about the opportunity cost to others. Now people that are brain dead, or dying of everything all at once, at some point there needs to be a decision to give up. But who makes that decision? I wouldn't put it in your hands, after what you've said.
Medical ethics is hard. That's why you need bastards like Doctor Gregory House.