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.'"
good news (Score:1, Insightful)
Re:And next up (Score:5, Insightful)
Isn't it Japan that was looking to fine people for being overweight, since it would cost the government more for health care? And don't they stop treating cancer patients in some European countries if they're too old?
While the idea of universal free happy healthy health care sounds sugary sweet, there are some dire consequences of handing our individual health to governmental control.
Medicine is a psudoscience? (Score:1, Insightful)
If you think of pseudoscience as a practice that looks like science, but suffers from an ideologically motivated disconnect between evidence and conclusion, medicine suddenly seem to fit the bill.
Re:And next up (Score:5, Insightful)
There is a pretend-independent government committee called NICE (yup) which decides which treatments are to be made available through the free-at-the-point-of-delivery government health service, the NHS.
They do indeed make heavy use of QALYs, "Quality-Adjusted LifeYears" in much this way.
Although the way NICE works in specific instances has led to a lot of very justified criticism, there seems to be no realistic alternative to something like this if you have a tax-financed system that the sick don't pay for directly. There just isn't enough money to do everything possible for every patient.
I don't know the right answer. I work for the NHS (as a retinal specialist too!) and have had endless grief getting funding for some treatments for my patients; on the other hand, I've worked in systems where the first question you have to ask is not "what does this patient need?" but "what can this patient afford?" and I prefer the former despite all its problems and stupidities.
Re:Medicine is a psudoscience? (Score:4, Insightful)
Medicine is more like some unknown mixture of actual science and cargo-cult pseudoscience, both using the same tools and terminologies.
Separating the two is a nontrivial problem.
Re:And next up (Score:5, Insightful)
I often see very elderly (and often demented) patients receiving very expensive treatment of eye conditions. do they need the treatment - sure, to preserve their sight. Does the treatment improve their quality of life - maybe. So who decides, the patient or family, or BIG government?
This isn't about BIG government telling you you can't take homeopathic remedies, or OTC cough medicine, or sit under a pyramid. This is about government funding research that reveals snake oil as snake oil. If the $8 bottle of robitussin is no more effective than lemon tea, what reasonable consumer would buy the robo? Hooray, I say, for a government that encourages open and honest markets.
Re:Goes to show. (Score:5, Insightful)
The human body is pretty darn good at healing itself. There is absolutely no replacement for a decent diet, moderate exercise, and a positive attitude. The last factor alone has been repeatedly shown to boost immune system health over a variety of drug-based treatments.
While I agree that a lot of our respective societies health issues are preventable, I am 26 years old, can run a marathon, and rarely ever touch red meat and I call shenanigans on the idea that diet and exercise are a cure-all! I have 140/85 blood pressure (high) despite doing cardio work 5 days a week and eating right. I have knee problems when it's cold, back problems all the time, and suffer from bronchitis every winter from exercise in the cold. Sometimes I feel like a healthy lifestyle is making me fall apart.
However, my qualm is more with more with scientologists, and that various left field christian sects that refuse to immunize their kids or see doctors. Modern medicine is useful. Really. It is. There is more than diet, exercise, and positive thinking.
Re:Goes to show. (Score:4, Insightful)
There's merit in what you say, but on the other hand, I'll take antibiotics when I have an infection. I'll go in for any recommended cancer screenings, and if they find something, I'll be glad for the best medical treatment I can get, because I don't want to rely on diet, exercise, and attitude to fix that.
There is no replacement for diet, exercise, and a positive attitude, but those things also aren't a complete replacement for medical treatment.
Re:And next up (Score:5, Insightful)
Although the way NICE works in specific instances has led to a lot of very justified criticism, there seems to be no realistic alternative to something like this if you have a tax-financed system that the sick don't pay for directly. There just isn't enough money to do everything possible for every patient.
Who says it has to be tax-financed?
In the USA, much health care is funded by insurance companies that essentially serve the function of averaging medical expenditure among a group of people. The net result of this is that an individual with insurance has every incentive to spend as much as the insurance while let them, because the costs will distribute to all policy holders. When everyone does this, insurance policy costs keep going up. The insurance companies, trying to get costs back down, have incentive only to pay as little as possible, not prioritize approved treatments by QALYs or any other similar metric.
Then, due to all that, you end up with people who are uninsured or otherwise unable to afford health care ending up with emergency conditions, receiving expensive treatment, and being forced into bankruptcy. This also drives up cost (as the hospitals are forced to absorb the cost of treatment) and harms society (a financially ruined citizen accomplishes less and pays less tax).
And thus, we come to this, the worst of all possible worlds.
patients are just customers (Score:5, Insightful)
I'm sure doctors are performing some treatments that aren't warranted. However, I assure you that patients want treatment. I work in the medical field, and the psychology of medicine is weird. Parents want antibiotics for their children, and they don't really care about research that says the antibiotics aren't necessary or may even cause harm. Everyone wants a pill for what they have, and they want it now. I've seen people demand x-rays for their pinkie toe, even though the doc told them outright that it wouldn't make a bit of difference. If the doc doesn't order the x-ray (or fork over the pills), the patient is unhappy, and unhappy patients are vastly more likely to sue.
I've had a woman bring her kid to the ER with an cold and tell me in the triage room "I can't get in to see the pediatrician till Wednesday, and by then she'll get well on her own." I'm not making this up---she was rushing to make sure her kid got seen by a doctor, because she knew the kid would get well if she waited too long. She wasn't a drooling idiot, but part of her mental checklist of being a good parent included "If kid is sick, see doctor." If docs don't hand out antibiotics for every earache and sore throat, the patient will just come back tomorrow or the next day and complain "I'm still sick." If the second doc gives them pills, they'll tell everyone they know about the first doc, who is obviously an idiot who didn't have the intelligence to see how direly ill they were. "I needed antibiotics, and he didn't give me anything!"
So all told, I don't blame the docs too much. They are working against hypochondriac patients who demand a pill for everything. In a weird way, people want to be sick, or at least they want their routine aches and pains dignified with snazzy medical terms. I've actually had patients get mad at me when I told them that a contusion is just a bruise, and cephalgia is just a headache.
To paraphrase Heston... (Score:3, Insightful)
"You'll have to pry my Beta Blockers out of my cold, dead hands."
Point: when the government "retires" beta blockers --- based on strong evidence that they're ineffective --- you can expect objections having to do with 'patient choice' and how the government is telling doctors what to do. Merits be damned: this will be used as an example of why we can't afford government-subsidized health care.
It's no coincidence that the people who oppose "socialized medicine" are often the same ones who avoid evidence-based medicine in large-scale situations where it might be effective. It's also no coincidence that our health care costs more on average than many other nations, and yet our health outcomes are worse.
Re:And next up (Score:3, Insightful)
I work in a health-related field where a lot of practitioners are focused more on the dollars than the patient's best interest. Unfortunately, this is human nature. The only thing you can really do is try to find the ones that aren't just trying to sell you stuff.
I think government mandated standards can be harmful in some cases. Practitioners must have the flexibility to treat as they see fit, since not everyone fits the same mold and it's not always clear what's going to work. I've seen instances where insurance companies (who dictate treatment simply by refusing to pay) require certain treatments be tried before others - and savvy doctors turn it into a factory business forcing patients through treatment protocols en-mass even when it's obvious that treatment won't work.
There is a lot of perpetuated mythology regarding treatment protocols - people do things simply because it's always been done that way. There are also legal ramifications for the doctors - if something is considered to be the standard of care, you can (and will, in today's litigious society) be sued for NOT doing a particular treatment. It's an extremely complex set of issues.
The mark of a good doctor is one who puts your best interest first and any system we devise needs to encourage that.
Re:And next up (Score:5, Insightful)
And don't they stop treating cancer patients in some European countries if they're too old?
This is a fairly ubiquitous practice - most cancer treatments are nasty. Invasive surgery, chemotherapy and radiotherapy all potentially have significant negative impact on quality of life. If someone has the option of a certain number of relatively comfortable years, or a few additional years filled with serious complications, many doctors will recommend the latter option, and this is sometimes reflected in treatment options.
Re:Goes to show. (Score:3, Insightful)
I also utilize my UID when countering someone.
Re:And next up (Score:3, Insightful)
If an operation neither extends life nor increases quality of life, then what's the point in the operation?
True, but if there is a choice between an operation that extends life and one that increases quality, which does the provider pay for?
Placebo testimony (Score:3, Insightful)
According to TFA, you don't actually know that.
NICE does the job but people don't like it (Score:5, Insightful)
We need NICE because ethical drug companies are no longer ethical, and that in part reflects our demand for magical cures. The really serious problems we face - like TB and avian flu - are of little interest to drug companies because (in the first case) most people affected are poor and cannot afford expensive medicine and (in the second case) vaccines are usually a one or two off and do not represent a continuing revenue stream paid for by insurance. We cannot rely on insurance companies to control public health because their aim is to balance revenue and cost - they are not interested in controlling the diseases of the poor, and they do not want diseases cured to the extent that their revenue goes down. We as taxpayers need agencies like the NIH in the US and the NICE in the UK to advise and regulate in our interests, not those of shareholders only.
Re:And next up (Score:4, Insightful)
If an operation neither extends life nor increases quality of life, then what's the point in the operation?
True, but if there is a choice between an operation that extends life and one that increases quality, which does the provider pay for?
It depends on if the extended life years are Quality Life Years or just extended life. For example an operation that would keep the patient alive, but in a coma would have a low Quality, so it would be lower in priority than an operation that would give sight to a blind person - which while not changing the length of their life (ignoring any differences in life expectancy between the sighted and the blind) increases quality significantly.
Re:And next up (Score:5, Insightful)
As opposed to not having health care at all?
Having universal gov't health care doesn't stop the wealthy from buying more health care than anyone else; it provides health care for the 30% or so of Americans who have none.
It would also control some of the ridiculous cost spirals. Doctors have no idea how much treatment costs; I've asked how much a certain procedure might cost and I'm always met with a blank stare. All the doctors know is that they get a kickback from the lab/hospital/etc for ordering some test. They don't really care if it's necessary or useful.
I'm familiar with both Japanese and European health care systems. The Japanese system provides universal care to everyone. It's basic and no-frills, but it covers nearly all.
The European System (actually Czech Republic) is much the same way. Its focus is on quality of life; they are less likely to provide life-extending care if it means being tethered to a hospital bed. They'll tell you to go home, have some beer, and enjoy what life you have left. They might even send you to a spa or a hot-springs at state expense.
Re:That is because heath insurance (Score:4, Insightful)
I do not mind universal catastrophic health care, I do mind the idea of paying for every kook who thinks his tummy ache is an emergency.
Well the two might not be directly connected. It doesn't seem to me like giving universal catastrophic health care would encourage people to use the ER more, and in fact having better access to healthcare on a regular basis might decrease ER costs. Setting aside for a second the people who go to the ER for every tummy ache, what about those who do nothing about potentially serious issues until they actually become serious issues? Early detection can often save money, actually.
A local hospital in Atlanta (actually more than one) reports many cases of people calling 911 to get a ride downtown where by law they are required to be given a "ticket" to get home.
Well that's just a problem, and again doesn't really have a direct connection to universal healthcare. You can get in trouble (fines, I believe) for calling 911 unnecessarily. You have to figure there will be some abuse, that sometimes a person will get away with something like that. But if it's really all that rampant (the abuse the the ambulance service that you describe) then I would think they should investigate and arrest or fine people abusing the system.
Re:And next up (Score:5, Insightful)
O nm, its the same ones who already pay for almost all the amenities to the poor and/or lazy.
WOW that was a loaded sentence. First you call life saving medical care an amenity then you paint one third of the population as lazy all in one stroke.
Re:patients are just customers (Score:3, Insightful)
Just because people want medication that's harmful for their health doesn't mean doctors should do it.
Antibiotics are dangerous. They are dangerous for society as a whole, as they increase resistant strains, but they're also dangerous for each individual use. There is a non-zero risk of causing some sort of harm by using things that, after all, are designed to kill cells in your body. They're supposed to take out bacteria cells, but friendly fire is always happening. Although your body can stand to lose a lot of cells with no problem, there's always some risk, like a guy above who apparently suffered nerve damage, probably because an attack took out a nerve cell or two.
And hence it is unethical, period, to prescribe antibiotics when doctors know it's a viral infection. It is risking harm for no possible gain.
Doctors should just start prescribing high qualities of vitamins for viruses, if people really want something. People who have influenza and even the common cold often do not eat correctly, and lacking various vitamins has been demonstrated to vastly increase the time it takes to fight off infections, so there's a medical rationale there, and if the medical profession started promoting how they've discovered how to fight off some disease without using dangerous antibiotics, we'd all win.
Re:patients are just customers (Score:3, Insightful)
I inherited a subspecialty (cardiology) medical practice from an old-timer.
In the first year, I discharged between 50 and 100 patients from the practice (averaging between 1-2 per week), likely more.
A number of these patients refused to be discharged and would continue seeing me, even though I told them that their primary medical doctor could take care of their mild hypertension or "mitral prolapse syndrome" (which was usually just over-called bowing of a mitral valve leaflet).
I still discharge patients to their primaries whenever they are interested, but do put up with patients that want the yearly stress test to make sure that they are okay (even when I tell them that they can have a massive heart attack a week after a normal stress test).
*shrug*
Re:And next up (Score:2, Insightful)
Some medical practicioners don't really know! (Score:4, Insightful)
I dated a nurse's aide for about a year, and what always shocked me was how little she knew about the treatments she was suggesting. Every time I got a cold, she demanded we rush to the ER to get some penicillin.
Now, I'm not one of those assholes who thinks he knows everything, but I know that colds are caused by a virus, and penicillin doesn't work on viruses.
Since then, I've gone on the philosophy that just because someone who works in a hospital says something, doesn't mean it's gospel. I won't take it as *wrong*, but I'll take it with a grain of salt, like I do medical advice on the Internet.
Re:And next up (Score:4, Insightful)
You used a subtle, but clear distinction, that affirms the GP:
I will say that the article's use of "evidence-based medicine" is heartbreaking - implying evidence isn't currently used... which I don't believe.
Re:And next up (Score:5, Insightful)
Re:And next up (Score:3, Insightful)
It's true, but in terms of medical services, it had a few more consequences. If you're rich and you buy a car, I can still get a car. We are not about to run out of cars.
The same is not true of, for example, MRIs or surgery. We ARE frequently at the limit for how many surgeries can be performed. So if you are rich and you want an MRI someone else might not get one, or might have to wait longer.
In a service industry like medicine, where our resources are stretched fairly thin as it is, the concept of getting more because you're willing and able to pay for it can actually translate to someone else getting less.
Re:And next up (Score:5, Insightful)
Re:And next up (Score:1, Insightful)
In a service industry like medicine, where our resources are stretched fairly thin as it is, the concept of getting more because you're willing and able to pay for it can actually translate to someone else getting less.
Ideally the money flowing into the system would become capital, encouraging investment in new equipment and services.
Sadly, like many other fields, the business owners have forgotten what capitalism means, and have siphoned off their companies' capital to pad their own pockets. Besides, why spend 10 million dollars to build another MRI when you can claim time in your MRI is scarce and double the price?
Re:And next up (Score:5, Insightful)
And don't pretend the US isn't a socialist nation. I spent 5 years in the US. You guys have a national program that pays farmers to *not farm* to increase the price that the rest of the farmers get for their produce. You also just gave $700 billion in hand outs to failing corporations. You give national subsidies to the states for building the highway system, but tie social policy to it (the states have to implement a minimum drinking age of 21 to qualify for the funding).
The US still pays for the poorest people to get free medical care even though middle income people can't afford it. That's much worse than the Canadian system (having used both). In Canada, the people who run the health care system have to eat their own dog food. Their kids use the system that they run. Do you think the people who run the Medicare system in the US use that system?
Re:NICE does the job but people don't like it (Score:4, Insightful)
Welcome to what we call the "real world". In the real world, resources are limited. There isn't enough money to provide treatment to everyone who could benefit from it -- that means you have to deny some people treatment. Full stop.
NICE exists to make sure that the limited resources are spent on cost-effective treatments, not wasted on expensive and ineffective treatments.
Fine -- go private, then. Private patients can buy whatever treatments they like, and NICE can't do a thing to stop them.
NICE decisions only have any effect whatsoever on the treatments that are provided by the NHS. Treatments that are funded by the taxpayer. What the hell makes you think you're entitled to demand that we pay for whatever treatment you want? If you want something that's not on the menu, you can damn well pay for it yourself.
its usually the rich who are lazy.. (Score:5, Insightful)
Re:And next up (Score:3, Insightful)
Re:And next up (Score:3, Insightful)
Government healthcare doesn't necessarily need to swing the banhammer on nongovernment care in the country.
It *can* and *is* set up that way in many areas, but it's not an inherent feature to the concept.
Government covering a solid minimum for everybody, and letting rich people buy more/quicker healthcare - makes sense (is still fair to everyone, and doesn't do as much to irritate rich people who want to utilize their wealth in this manner)
Re:good news (Score:4, Insightful)
And do you know what one of the complaints against Bush's No Child Left Behind was?
That it required pedagogical methods to be scientifically proven [1].
Teachers didn't like that because then they couldn't use anecdote-based or other methods that they would prefer than methods that were "scientifically proven".
Expect similar complaints from the doctors (after all, if they were really scientists, they would've gone into research; there's a reason they chose the career that they chose), and yes, the "O admin" believes in the scientific method just as much as the Bush administration did—it's just the left-wing distortions in the media that made you think somehow Bush stood against scientific progress (remember last year, Bush proposed a relatively generous science budget, but it never got past the Democratic congress).
[1] From Department of Education website [ed.gov], "It only funds curricula and teaching methods that are scientifically proven to work."
Re:Ear infections TYPICALLY recede in a few days? (Score:1, Insightful)
So wait a week, and if it's still there, then see about treating it as something serious.
Still have to Operate within the system. (Score:0, Insightful)
Unless the broken-arm is an actual *life-threatening -emergency*...
Why didn't you work within the system of your health insurance. I'm sure you could have negated to perform the operation immediately; determine an in-network dr / emergency room; Call your insurance and tell them you're going to the emergency room and then go.
In a real life-threatening emergency get the best care available at whatever's closest.
But you still have to work the system. I'd much rather fight w/ my health insurance than fight with the federal government over "reasonable and customary" treatments.