13 ms·

An epidemic of unnecessary and unhelpful medical treatments

245 points by greendesk 10y ago

deleted 10y ago
[deleted]
skolos 10y ago
>The 21st Century Cures Act—a rare bipartisan bill, pushed by more than 1,400 lobbyists and signed into law in December—lowers evidentiary standards for new uses of drugs and for marketing and approval of some medical devices. It shows again that we will not have sane healthcare system when there are thousands of lobbyist working to keep it insane.
- makomk 10y ago
  Not to mention all the "patient advocacy groups" funded by the pharmaceutical industry: https://theintercept.com/2016/12/01/new-report-exposes-patient-advocacy-groups-as-a-big-pharma-scam/ https://theintercept.com/2016/12/01/new-report-exposes-patie...
- Symmetry 10y ago
  Here's a semi-random blog post with a handful of examples[1]. Generally speaking European countries are much quicker to approve most drugs and tend to have better health outcomes on average even though you can point to individual disasters like Thalidomide. But on the other hand beta blockers were available in Europe about a decade before they were in the US and would have saved about 10,000 lives a year during that time. [1]http://www.advicegoddess.com/archives/2017/01/11/the_fda_protect.html http://www.advicegoddess.com/archives/2017/01/11/the_fda_pro...
  - maxerickson 10y ago
    The article discusses beta-blockers. The overall picture of beta-blockers is complex. For example, some beta-blockers have been shown clearly to reduce the chance of a stroke or heart attack in patients with heart failure. But the latest review of beta-blockers from the Cochrane Collaboration—an independent, international group of researchers that attempts to synthesize the best available research—reported that they “are not recommended as first line treatment for hypertension as compared to placebo due to their modest effect on stroke and no significant reduction in mortality or coronary heart disease.”
    - Symmetry 10y ago
      Well, that'll teach me to post in Hacker News without reading all parts of an article.
  - karlkatzke 10y ago
    Are you taking into account the recent studies of the effectiveness of beta blockers, which the OP article discusses? "the latest review of beta-blockers ... reported that they 'are not recommended as first line treatment for hypertension as compared to placebo due to their modest effect on stroke and no significant reduction in mortality or coronary heart disease.'"
- jerf 10y ago
  What the article is talking about and what that bill seems to address are two separate issues. Whether you have high or low evidentiary standards for a new treatment is, under our current system and almost any system I've ever seen proposed, independent from whether doctors will end up completely correctly using those new systems. Doctors already have that responsibility and are already failing in that responsibility for a variety of complicated reasons, apparently, but it's easy to construct "solutions" that make it even worse. How do you out-expert the very people you've trained to be experts in the first place? That may not be unsolvable but it surely isn't a trivial problem to be fixed with some regulation here and some pamphlets there. We've frequently discussed on HN the idea that sky-high evidentiary standards for new treatments may have passed the point where they are doing more harm than good. While I'm sure there are disagreeable details in the new bill, the broad strokes of the bill are things that the HN gestalt has at least been talking about for a while. It's not like it's a sudden out-of-the-blue idea that nobody's ever heard of before.
  - Hnrobert42 10y ago
    The term "sky-high" means the evidentiary standards are by definition harmful. One wouldn't describe them as sky-high if one thought they were reasonable. If one starts with the premise that existing standards are sky-high, then of course one will conclude they should be lowered.
    - jerf 10y ago
      I am obviously speaking about the end result of that debate and my personal opinion, which I won't try to hide. The debate itself was substantial, however, not merely word games.
- hinkley 10y ago
  It'll make a great pejorative some day. "No thanks, grandma. We don't want none of your 21st Century cures here."
- BurningFrog 10y ago
  How exactly does it show that? Because it was supported by many lobbyists? Or because it lowers evidentiary standards?
- kolinko 10y ago
  On the other hand, you had situations where people were smuggling drugs into the country for HIV treatment. Or you have drugs that we know are safe, and initial research shows a lot of promise, but are unavailable. A patient with a serious condition should not be denied a possible treatment, as long as it's proven that it won't hurt him.
taxicabjesus 10y ago
Sometimes medicine helps patients, sometimes the medical-industrial complex makes work for itself. I took a lot of medicaid patients to & from doctor appointments where nothing much was accomplished. > In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. In general, Brown says, “nobody that’s not having a heart attack needs a stent.” [...] Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure. [emphasis added] (This comment recycled from the earlier submission of the propublica version this story: https://news.ycombinator.com/item?id=13705761 https://news.ycombinator.com/item?id=13705761 )
fsloth 10y ago
Is this a correlating effect with the fact that a large number of published scientific results are botched? If researchers are not allowed to do good science they are no more progressive than the augur reading from the entrails of a fish.
- maxerickson 10y ago
  It isn't just poorly done research. In many cases it is simply difficult to design a study that can reasonably evaluate a treatment. The article discusses a cancer vaccine at length, pointing out that the ethics of providing known effective treatment basically obliterate the ability to evaluate the vaccine. It's concerning that the vaccine was approved despite the problems with the study, but they also can't have people agreeing to die in order to increase the statistical power of their results.
- crpatino 10y ago
  You make it sound like the entrails of the fish do not have anything to tell you...
maxerickson 10y ago
One interesting point made in the article is that an awful lot of the gains we have made in life expectancy have come from public health rather than medical advances. The article claims that the increase from the public health revolution in the late 1800s did more to increase life expectancy than antibiotics. Which makes sense, not getting sick is more effective than any treatment once you are sick. A sibling comment mentions that lobbyists worked to get the 21st Century Cures Act passed, but a potentially bigger issue with the act is that it transfers $3.5 billion of public health spending to medical research.
- funkymike 10y ago
  > but a potentially bigger issue with the act is that it transfers $3.5 billion of public health spending to medical research. I would like to see much more public funding going towards medical research, with the stipulation that the results must be open and cannot be patented. In mentioning this I just had an idea that I don't remember seeing before. I wonder if there should just be a sort of medical treatment lottery for pharma companies. They come up with a treatment, get a patent, and prove it works as normal. Instead of allowing the monopoly however, the FDA could buy out the patent and make it public domain. The pharma company gets a guaranteed and immediate profit (say 50% of the projected total profit over the life of the patent). Meanwhile any company can then produce the drug/device/etc. competing on the quality and price of the treatment, separate from the cost of the research that led to it.
  - maxerickson 10y ago
    There's nothing wrong with public funding of medical research. Taking funds away from public health to do medical research is highly questionable.
    - funkymike 10y ago
      I agree and I wasn't clear enough about that. Moving funds from areas that provide clear tangible results to research that might produce results seems wrong.
    - 10y ago
greendesk 10y ago
Is there a process or technology to avoid unnecessary medical treatment? The article mentions how one patient googled his condition and sought a second opinion. I imagine that this direction is common among patients. I am afraid that once I get old I will also be pushed to have unnecessary treatments.
- maxerickson 10y ago
  The ProPublica version of the article has a chart at the end showing an evaluation of the benefit vs risk of a treatment (search "A Different Way to Think About Medicine"): https://www.propublica.org/article/when-evidence-says-no-but-doctors-say-yes https://www.propublica.org/article/when-evidence-says-no-but... So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment.
  - randcraw 10y ago
    I think you're describing "Number Needed to Treat" (NNT, or 'How many patients need to be treated with a drug or procedure for one patient to get the hoped-for benefit?'), which is described briefly just before the graphic you mention. NNT is a great idea, but not as practically useful for individuals as for policymakers, IMHO. I suspect few primary care clinicians can discuss current and precise NNT figures. More likely they will rely on standard of care advice from the AMA or their subspecialty board that itself was shaped by NNTs.
    - maxerickson 10y ago
      No, I was specifically talking about the sort of framework used in the graphic, where the outcome of a treatment may be beneficial, benign or harmful. I'll repost my second paragraph too: So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment. Yes, it will be difficult for providers to have detailed information. They should still be open to discussing downsides and tradeoffs. It's a red flag if they hesitate to talk in terms of tradeoffs or to take the time to discuss the expected benefits and potential downsides.
jbob2000 10y ago
This is only a problem in the US (aka "list of countries with private healthcare"). In Canada, we are actively trying to prevent any medical procedure possible because of the huge expense. I just completed a huge app to educate and prevent diabetic foot amputations. It costs $70,000 to remove a foot and the government is really trying to cut down on these if they are preventable. Patient gets to keep their foot, government doesn't have to spend money - win win! In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics. Chop off more feet, I say!
- maxerickson 10y ago
  It would really hammer home your argument if you showed that outcomes for diabetes patients in the US were worse.
- graeham 10y ago
  There is different math for each system. In the USA: if riskFromTreatment <= riskFromNoTreatment: doTreatment In most public systems: if (treatmentCost <= someThresholdPerBenefit) && (riskFromTreatment <= riskFromNoTreatment): doTreatment In practice, treatment outcomes are pretty similar, but more treatments are preformed in the USA system. Being a for-profit system is one cause, but so is the litigation culture. Not doing every possible treatment and test can lead to the physician being accused of being negligent.
  - jbob2000 10y ago
    That's a bit of a strawman argument. In your math, you need to include the point that the article makes - that the American system always considers riskFromNoTreatment to be close to infinite. The risk is completely skewed on the American side, doctors are saying "EVERYTHING WILL KILL YOU TREAT IT NOW"!
    - nradov 10y ago
      That's an overbroad generalization. Not even close to all doctors constantly push for aggressive treatment of all medical conditions.
darkerside 10y ago
Does anyone know what the problem is that the 21st Century Cures Act is solving? The claim was made that treatments are being withheld pending FDA approval. Is it illegal to use FDA-unapproved drugs, or is it that insurance is not covering unproven treatments?
- burkaman 10y ago
  It's not illegal to take them, but yes I doubt insurance will cover unapproved treatments. Also, while it's not directly illegal for a doctor to prescribe an unapproved drug, I think it would open them up to malpractice lawsuits, and it just seems like a bad idea in general. Here's a doctor's blog post about this issue: http://thehealthcareblog.com/blog/2013/08/26/should-a-doctor-prescribe-drugs-that-are-unapproved-by-the-fda/ http://thehealthcareblog.com/blog/2013/08/26/should-a-doctor...
  - darkerside 10y ago
    That definitely seems different than "withholding" treatments as described in the article. If you want to use an unapproved drug, you can do so, it's just not going to be paid for by our shared insurance system. Makes total sense to me. I'm not arguing, just wondering what exactly is the problem that this act is trying to solve.
    - burkaman 10y ago
      The problem is mostly on the side of drug and medical device companies. They spend lots of money on research and development and they want an easier and faster return on their investment. There are also problems for patients, when someone hears about a promising new treatment for their serious condition, but it's going to take several years to get through FDA approval. > If you want to use an unapproved drug, you can do so This is not true in general. Where do you get it? A doctor won't prescribe it, you can't get it from a pharmacy without a prescription, you certainly can't just order it directly from the drug company. Sometimes it might be more easily available in another country, but that won't always be the case.
Gatsky 10y ago
The article gives an introductory example of a patient that was referred to two different cardiologists, both of whom wanted to do an angiogram. The article doesn't mention of course that the cardiologists get paid per angiogram performed. The remuneration per unit time for seeing the patient in clinic and carefully discussing the options and evidence is drastically less than just doing the angiogram. Some cardiologists will also have a target number of angiograms they need to perform every year specified by arrangements with the angiogram facility. So although it is widely known that doing angiograms and inserting stens in patients with stable coronary artery disease is a waste of time, perverse incentives in a fee for service model result in these outcomes. As such it isn't a good example of evidence-free medicine. In Australian public hospitals, the cardiologists are paid the same salary regardless of whether they do zero or 1000 angiograms a year. They are very happy not to do unnecessary angiograms in line with the current evidence. If anything, this introductory example shows that a health system needs to be set up to facilitate and encourage evidence-based practice. Otherwise this article rehashes many points about clinical trials and interpreting medical evidence, without a really coherent theme, except maybe to (yet again) criticise doctors. Things have improved in the last 10 - 15 years. Clinical trials come under more scrutiny, trial pre-registration has become more common (although not strictly enforced), health systems gather more and more data about patient outcomes outside of clinical trials and manipulative marketing practices by pharmaceutical companies have been curtailed drastically. In my opinion, the challenges for evidenced based medicine in the next decade are: 1. Getting some decent data about nutrition. There are really remarkably few useful things we can say about how nutrition relates to health. 2. Reducing unnecessary interventions towards the end of life in an ageing population. Healthcare and healthcare research is not well suited to de-escalating care. 3. Transitioning from a one-size-fits-all approach doing clinical trials in 1000s of undifferentiated patients, to collecting 1000s of data points about each individual patient (blood and metabolic variables, genome sequencing, immune profiling, microbiome etc) and using that data to get them healthy and keep them that way. Needless to say, the difficulties in doing this will make doing a randomised controlled trial look like a walk in the park. 4. Fighting pseudo-scientific diagnostic tests and treatments. Examples of this are everywhere - Theranos, gene therapy clinics in undisclosed locations in South America, quantified self services that have no proven health benefits, virtually every supplement ever sold, multivitamins... 5. Fighting the politicisation of health care. This is a very worrying trend that can easily render all our scientific efforts irrelevant - eg anti-vaxxers, far-right intolerance of harm minimisation measures like abortion and decriminalising drug use.
alkonaut 10y ago
Surprised every time I'm in the US and see commercials for drugs and procedures that are administered by doctors being directed towards patients with the ending "ask your doctor about xyz". I'm fairly sure this kind of thing ends up with patients asking/pressuring doctors for treatments they don't need.
- coldcode 10y ago
  I find these utterly idiotic: you are telling patients about side effects of some drug with pretty pictures and a pleasant voice but only a doctor can prescribe them and you would assume understand the side effects and contraindications. What is the point? Other than obviously make drug companies more money.
  - noxToken 10y ago
    That is the point. Drugs x, y, and z are all the market. They do the same thing with the same side-effects for the same cost. An ailment that the drug cures pops up in someone's life. When they go to the doctor, they can ask specifically for drug z, because they saw drug z in a commercial. If our drugs, for all intents and purposes, are the exact same, then there is no point in a doctor prescribing drug x or y when the patient specifically asked for drug z.
    - randcraw 10y ago
      Any two drugs are most definitely not the same unless one is a generic of the other. And even then, because different manufacturers package drugs differently, this can slightly affect a compound's delivery. Even when two drugs use the same mechanism of action (an agonist or antogist toward the same receptor active in the synthesis of a target protein), different generations of drugs often produce significantly different pharmacodynamic profiles of efficacy and toxicity that affect people differently. A good example are the diabetes drugs Actos vs Avandia -- same MoA (glitazones), but the latter has proven to be toxic. Fact is, no two drugs are the same, unless they both do nothing.
arafa 10y ago
Adding to this article (I'm not a medical professional and not giving advice), the same inferior medical outcomes are attributed to most, if not all forms of back surgery. Physical therapy outperforms most or all back surgery with much fewer side effects, etc. This is covered extensively in the book How Doctors Think (https://www.amazon.com/How-Doctors-Think-Jerome-Groopman/dp/0547053649/ref=mt_paperback?_encoding=UTF8&me= https://www.amazon.com/How-Doctors-Think-Jerome-Groopman/dp/...) as well as articles like this Ars Technica one: https://arstechnica.com/science/2017/02/doctors-lower-back-pain-is-like-a-cold-minor-annoying-and-temporary/ https://arstechnica.com/science/2017/02/doctors-lower-back-p.... You see the same with exercise outperforming anti-depressants in most cases, again with much fewer side effects. (For example: https://www.theatlantic.com/health/archive/2014/03/for-depression-prescribing-exercise-before-medication/284587/ https://www.theatlantic.com/health/archive/2014/03/for-depre...) The kicker is that doctors will often refuse these same treatments when offered, which is not a good reflection on their efficacy (again covered in How Doctors Think). This is not an indictment of modern medicine (which is often very effective on acute care), just a recognition of the limitations.
- seibelj 10y ago
  Exercise helped reduce my depression and anxiety, and I tried to cure it without medication for 2 years. Finally I gave in and went on a low dose of lexapro, in addition to my usual exercise and healthy diet, and I recovered within weeks. Completely changed my life. I know this is just my anecdote, but when natural remedies fail, don't be afraid of medicine.
  - tcj_phx 10y ago
    > but when natural remedies fail, don't be afraid of medicine. SSRIs frequently create their own problems. They are sometimes effective because of their effect on the neuroactive steroids: https://en.wikipedia.org/wiki/Neuroactive_steroid#Role_in_antidepressant_action https://en.wikipedia.org/wiki/Neuroactive_steroid#Role_in_an... Depressed people frequently have a metabolic problem, where they don't make enough ATP. This is caused by thyroid imbalances, poisoning with excess Omega-6 polyunsaturated oils, etc.
speeder 10y ago
Sadly, the problem is not just excessive treatment, but also lack of them, for the exact same reason: medics seemly hate science. Example: Thyroid disease diagnostic and treatment problems are so common, that there are organizations made solely to support thyroid patients, including having lawyers specialized in suing doctors to force them to start treatment... The reason for that, is that although there is plenty of research showing that the 80s blood tests are too conservative (they only show positive to people that are usually too damaged beyond any repair), many doctors insist in using solely those tests, and ignore symptoms and newer blood tests. This does have to do with pharmaceutic industry though, some of the organizations pushing for the 80s tests are all supported by pharma companies, and the same companies also have lobbists that try to get in the way of allowing research of treatments that would skip such companies, for example many patients only improve when using "alternative" but centuries old methods that were known to work for centuries, yet lobbists and pharma companies try to convince doctors and politicians that these ancient methods are "wrong because they are old", and don't allow even research to proceed properly, the leading manufacturer of thyroid medicine that works is in Thailand, because in most other countries their business is considered shady or sketchy. Same thing happen in psychiatry, problems that are popular in the public mind are overdiagnosed, specially when they have expensive medication, yet when the problems aren't popular, psychiatrists refuse to treat sufferers. I found a strange case with ADHD: kids are being pumped full of meds due to the fact that they keep disrupting classrooms and ADHD is a "popular" disease with kids, but all adults I know that are actual sufferers from ADHD to the point of disrupting their adult lives, struggle to find treatment, with the usual excuse from doctors being that the meds are "too dangerous" (then why give it to the kids by the boatload?) or that people in their 20s seeking meds must be some kind of junkie looking to boost academic performance, nevermind if non-academic symptoms are there too.
- M_Grey 10y ago
  These are the problems when arts and crafts with scientific elements are confused in the popular and professional imagination with science.
- nradov 10y ago
  Which specific thyroid organization sues doctors to force treatment? That seems highly unlikely. Refusal to provide treatment doesn't constitute malpractice.
e40 10y ago
Three months later, his cholesterol had improved markedly, he had lost 15 pounds, and the chest pain never returned. And it just goes to show you, that Dr. Brown might have saved the executive a stent procedure, but they are still promulgating the myth that cholesterol causes CHD. It's a side effect not the cause. There are plenty of people that have high cholesterol and don't have blocked arteries. <sigh>
- regardmore 10y ago
  It's not a mere side effect. If it were, treatment with anti-cholesterol drugs such as statins (the most used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such a clear cause-and-effect on reducing cardiovascular events and mortality. Since removing cholesterol from circulation reduces cardiovascular disease, you can view it as a cause and not as a mere marker of disease.
  - e40 10y ago
    If it were, treatment with anti-cholesterol drugs such as statins (the most used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such a clear cause-and-effect on reducing cardiovascular events and mortality. I've read that studies show it only has an effect for men > 50 yrs, but that the effect isn't due to reducing cholesterol. I have notice a huge increase in the last 10 years in the number of researchers reporting no causal link between cholesterol and CHD. On the first page of a Google search: https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2016-06-13-study-says-theres-no-link-between-cholesterol-and-heart-disease/ https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines... Evidence abounds that there is no link.
AnsemWise 10y ago
This is a very important issue. Doctors are over prescribing and jumping to unneeded surgeries. The question is, are they doing it out of fear of a malpractice lawsuit for denying a patient what they need or is it from kickbacks, incentives and the knowledge that the persons insurance will pay them? Just because something works doesn't mean it's not a broken system. Suprised that no one else has commented on this article.
- AnsemWise 10y ago
  > Suprised that no one else has commented on this article. Didn't refresh
WalterBright 10y ago
> Steven Galson [...] has called the strengthened approval process created in 1962 the FDA’s “biggest contribution to health.” Before that, he said, “many marketed drugs were ineffective for their labeled uses.” Sam Peltzman in "Regulation of Pharmaceutical Innovation" provides statistical evidence that the "safe and effective" 1962 Amendments reduced the development of new effective treatments as well as new ineffective ones, for a net decrease in positive results.
happy-go-lucky 10y ago
Speaking from my personal experience… My way of life dictates adequate exercise, healthy diet and normal sleep patterns. I come from a family of strict vegans. No, I’m not here to promote either veganism or non-veganism. I’m in my early 40’s and have been exercising since I was a teenager. My routine includes running, cycling, strengthening exercises, lifting light weights, and I do one or two of these a couple times a week. IMO, any and all physical activity is a form of exercise. Usually, my day starts in the early hours. And, as I’m getting older, my endurance levels have been getting significantly better now than during my schooldays, 20’s, or 30’s and with regard to my work I’m getting more productive, too. I also think that those who are not predisposed to any genetic conditions are in a league of their own. Even those who inherit a predisposition can benefit from delayed onset of a condition by practicing a healthy lifestyle. I’m not a medical professional, so my assumptions may or may not carry any weight. All I’m trying to do is keep such treatments as are being discussed here at bay and I will keep at it as long as I possibly can :)
woodandsteel 10y ago
This is an excellent and disturbing article. However, something very important was missed. Let me start by saying that I think that whenever we have a problem in this country, one of the things we should do is look at how other countries handle it to see if there is anything useful we could learn. That being the case, we need to know how other countries handle the over-treatment problem. Are there studies on this? Perhaps the authors could write a follow-up article.
un-devmox 10y ago
I have, according to my MRI, severe cervical stenosis. I also have carpal tunnel, which was diagnosed first. Based on my symptoms and the awful looking MRI, 4 highly regarded spine surgeons recommended a 2 level fusion right away. The 5th doctor, instead recommended carpal tunnel and ulnar nerve releases. My symptoms abated by 80+% and is something I can live with comfortably. None of the 4 other doctors even considered dealing with my carpal tunnel first, which, combined with stenosis causes what's called a 'double crush' scenario. Only one surgeon recommended the least invasive and risky procedure for me! Even though a fusion in the future is likely, for now the risk - reward for such a procedure does not warrant immediate action. I also think it's worth noting that that 5th doctor is the only female of the group. She was the only one that didn't seem gung-ho about the fusion. I'm not saying gender plays a role but...
- nommm-nommm 10y ago
  https://www.statnews.com/2016/12/19/patients-female-physicians-live-longer/ https://www.statnews.com/2016/12/19/patients-female-physicia... >Public health researchers at Harvard found that elderly patients were less likely to die or be readmitted to the hospital within 30 days if treated by female doctors rather than male. The study doesn’t explain why this happens, but prior studies have found that female doctors tend to spend more time with patients, communicate better, and follow clinical guidelines more often than their male colleagues.

245 points by greendesk 10y ago

deleted 10y ago

[deleted]

>The 21st Century Cures Act—a rare bipartisan bill, pushed by more than 1,400 lobbyists and signed into law in December—lowers evidentiary standards for new uses of drugs and for marketing and approval of some medical devices. It shows again that we will not have sane healthcare system when there are thousands of lobbyist working to keep it insane.

makomk 10y ago
Not to mention all the "patient advocacy groups" funded by the pharmaceutical industry: https://theintercept.com/2016/12/01/new-report-exposes-patient-advocacy-groups-as-a-big-pharma-scam/ https://theintercept.com/2016/12/01/new-report-exposes-patie...
Symmetry 10y ago
Here's a semi-random blog post with a handful of examples[1]. Generally speaking European countries are much quicker to approve most drugs and tend to have better health outcomes on average even though you can point to individual disasters like Thalidomide. But on the other hand beta blockers were available in Europe about a decade before they were in the US and would have saved about 10,000 lives a year during that time. [1]http://www.advicegoddess.com/archives/2017/01/11/the_fda_protect.html http://www.advicegoddess.com/archives/2017/01/11/the_fda_pro...
- maxerickson 10y ago
  The article discusses beta-blockers. The overall picture of beta-blockers is complex. For example, some beta-blockers have been shown clearly to reduce the chance of a stroke or heart attack in patients with heart failure. But the latest review of beta-blockers from the Cochrane Collaboration—an independent, international group of researchers that attempts to synthesize the best available research—reported that they “are not recommended as first line treatment for hypertension as compared to placebo due to their modest effect on stroke and no significant reduction in mortality or coronary heart disease.”
  - Symmetry 10y ago
    Well, that'll teach me to post in Hacker News without reading all parts of an article.
- karlkatzke 10y ago
  Are you taking into account the recent studies of the effectiveness of beta blockers, which the OP article discusses? "the latest review of beta-blockers ... reported that they 'are not recommended as first line treatment for hypertension as compared to placebo due to their modest effect on stroke and no significant reduction in mortality or coronary heart disease.'"
jerf 10y ago
What the article is talking about and what that bill seems to address are two separate issues. Whether you have high or low evidentiary standards for a new treatment is, under our current system and almost any system I've ever seen proposed, independent from whether doctors will end up completely correctly using those new systems. Doctors already have that responsibility and are already failing in that responsibility for a variety of complicated reasons, apparently, but it's easy to construct "solutions" that make it even worse. How do you out-expert the very people you've trained to be experts in the first place? That may not be unsolvable but it surely isn't a trivial problem to be fixed with some regulation here and some pamphlets there. We've frequently discussed on HN the idea that sky-high evidentiary standards for new treatments may have passed the point where they are doing more harm than good. While I'm sure there are disagreeable details in the new bill, the broad strokes of the bill are things that the HN gestalt has at least been talking about for a while. It's not like it's a sudden out-of-the-blue idea that nobody's ever heard of before.
- Hnrobert42 10y ago
  The term "sky-high" means the evidentiary standards are by definition harmful. One wouldn't describe them as sky-high if one thought they were reasonable. If one starts with the premise that existing standards are sky-high, then of course one will conclude they should be lowered.
  - jerf 10y ago
    I am obviously speaking about the end result of that debate and my personal opinion, which I won't try to hide. The debate itself was substantial, however, not merely word games.
hinkley 10y ago
It'll make a great pejorative some day. "No thanks, grandma. We don't want none of your 21st Century cures here."
BurningFrog 10y ago
How exactly does it show that? Because it was supported by many lobbyists? Or because it lowers evidentiary standards?
kolinko 10y ago
On the other hand, you had situations where people were smuggling drugs into the country for HIV treatment. Or you have drugs that we know are safe, and initial research shows a lot of promise, but are unavailable. A patient with a serious condition should not be denied a possible treatment, as long as it's proven that it won't hurt him.

taxicabjesus 10y ago

Sometimes medicine helps patients, sometimes the medical-industrial complex makes work for itself. I took a lot of medicaid patients to & from doctor appointments where nothing much was accomplished. > In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. In general, Brown says, “nobody that’s not having a heart attack needs a stent.” [...] Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure. [emphasis added] (This comment recycled from the earlier submission of the propublica version this story: https://news.ycombinator.com/item?id=13705761 https://news.ycombinator.com/item?id=13705761 )

fsloth 10y ago

Is this a correlating effect with the fact that a large number of published scientific results are botched? If researchers are not allowed to do good science they are no more progressive than the augur reading from the entrails of a fish.

maxerickson 10y ago
It isn't just poorly done research. In many cases it is simply difficult to design a study that can reasonably evaluate a treatment. The article discusses a cancer vaccine at length, pointing out that the ethics of providing known effective treatment basically obliterate the ability to evaluate the vaccine. It's concerning that the vaccine was approved despite the problems with the study, but they also can't have people agreeing to die in order to increase the statistical power of their results.
crpatino 10y ago
You make it sound like the entrails of the fish do not have anything to tell you...

maxerickson 10y ago

One interesting point made in the article is that an awful lot of the gains we have made in life expectancy have come from public health rather than medical advances. The article claims that the increase from the public health revolution in the late 1800s did more to increase life expectancy than antibiotics. Which makes sense, not getting sick is more effective than any treatment once you are sick. A sibling comment mentions that lobbyists worked to get the 21st Century Cures Act passed, but a potentially bigger issue with the act is that it transfers $3.5 billion of public health spending to medical research.

funkymike 10y ago
> but a potentially bigger issue with the act is that it transfers $3.5 billion of public health spending to medical research. I would like to see much more public funding going towards medical research, with the stipulation that the results must be open and cannot be patented. In mentioning this I just had an idea that I don't remember seeing before. I wonder if there should just be a sort of medical treatment lottery for pharma companies. They come up with a treatment, get a patent, and prove it works as normal. Instead of allowing the monopoly however, the FDA could buy out the patent and make it public domain. The pharma company gets a guaranteed and immediate profit (say 50% of the projected total profit over the life of the patent). Meanwhile any company can then produce the drug/device/etc. competing on the quality and price of the treatment, separate from the cost of the research that led to it.
- maxerickson 10y ago
  There's nothing wrong with public funding of medical research. Taking funds away from public health to do medical research is highly questionable.
  - funkymike 10y ago
    I agree and I wasn't clear enough about that. Moving funds from areas that provide clear tangible results to research that might produce results seems wrong.
  - 10y ago

greendesk 10y ago

Is there a process or technology to avoid unnecessary medical treatment? The article mentions how one patient googled his condition and sought a second opinion. I imagine that this direction is common among patients. I am afraid that once I get old I will also be pushed to have unnecessary treatments.

maxerickson 10y ago
The ProPublica version of the article has a chart at the end showing an evaluation of the benefit vs risk of a treatment (search "A Different Way to Think About Medicine"): https://www.propublica.org/article/when-evidence-says-no-but-doctors-say-yes https://www.propublica.org/article/when-evidence-says-no-but... So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment.
- randcraw 10y ago
  I think you're describing "Number Needed to Treat" (NNT, or 'How many patients need to be treated with a drug or procedure for one patient to get the hoped-for benefit?'), which is described briefly just before the graphic you mention. NNT is a great idea, but not as practically useful for individuals as for policymakers, IMHO. I suspect few primary care clinicians can discuss current and precise NNT figures. More likely they will rely on standard of care advice from the AMA or their subspecialty board that itself was shaped by NNTs.
  - maxerickson 10y ago
    No, I was specifically talking about the sort of framework used in the graphic, where the outcome of a treatment may be beneficial, benign or harmful. I'll repost my second paragraph too: So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment. Yes, it will be difficult for providers to have detailed information. They should still be open to discussing downsides and tradeoffs. It's a red flag if they hesitate to talk in terms of tradeoffs or to take the time to discuss the expected benefits and potential downsides.

jbob2000 10y ago

This is only a problem in the US (aka "list of countries with private healthcare"). In Canada, we are actively trying to prevent any medical procedure possible because of the huge expense. I just completed a huge app to educate and prevent diabetic foot amputations. It costs $70,000 to remove a foot and the government is really trying to cut down on these if they are preventable. Patient gets to keep their foot, government doesn't have to spend money - win win! In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics. Chop off more feet, I say!

maxerickson 10y ago
It would really hammer home your argument if you showed that outcomes for diabetes patients in the US were worse.
graeham 10y ago
There is different math for each system. In the USA: if riskFromTreatment <= riskFromNoTreatment: doTreatment In most public systems: if (treatmentCost <= someThresholdPerBenefit) && (riskFromTreatment <= riskFromNoTreatment): doTreatment In practice, treatment outcomes are pretty similar, but more treatments are preformed in the USA system. Being a for-profit system is one cause, but so is the litigation culture. Not doing every possible treatment and test can lead to the physician being accused of being negligent.
- jbob2000 10y ago
  That's a bit of a strawman argument. In your math, you need to include the point that the article makes - that the American system always considers riskFromNoTreatment to be close to infinite. The risk is completely skewed on the American side, doctors are saying "EVERYTHING WILL KILL YOU TREAT IT NOW"!
  - nradov 10y ago
    That's an overbroad generalization. Not even close to all doctors constantly push for aggressive treatment of all medical conditions.

darkerside 10y ago

Does anyone know what the problem is that the 21st Century Cures Act is solving? The claim was made that treatments are being withheld pending FDA approval. Is it illegal to use FDA-unapproved drugs, or is it that insurance is not covering unproven treatments?

burkaman 10y ago
It's not illegal to take them, but yes I doubt insurance will cover unapproved treatments. Also, while it's not directly illegal for a doctor to prescribe an unapproved drug, I think it would open them up to malpractice lawsuits, and it just seems like a bad idea in general. Here's a doctor's blog post about this issue: http://thehealthcareblog.com/blog/2013/08/26/should-a-doctor-prescribe-drugs-that-are-unapproved-by-the-fda/ http://thehealthcareblog.com/blog/2013/08/26/should-a-doctor...
- darkerside 10y ago
  That definitely seems different than "withholding" treatments as described in the article. If you want to use an unapproved drug, you can do so, it's just not going to be paid for by our shared insurance system. Makes total sense to me. I'm not arguing, just wondering what exactly is the problem that this act is trying to solve.
  - burkaman 10y ago
    The problem is mostly on the side of drug and medical device companies. They spend lots of money on research and development and they want an easier and faster return on their investment. There are also problems for patients, when someone hears about a promising new treatment for their serious condition, but it's going to take several years to get through FDA approval. > If you want to use an unapproved drug, you can do so This is not true in general. Where do you get it? A doctor won't prescribe it, you can't get it from a pharmacy without a prescription, you certainly can't just order it directly from the drug company. Sometimes it might be more easily available in another country, but that won't always be the case.

Gatsky 10y ago

The article gives an introductory example of a patient that was referred to two different cardiologists, both of whom wanted to do an angiogram. The article doesn't mention of course that the cardiologists get paid per angiogram performed. The remuneration per unit time for seeing the patient in clinic and carefully discussing the options and evidence is drastically less than just doing the angiogram. Some cardiologists will also have a target number of angiograms they need to perform every year specified by arrangements with the angiogram facility. So although it is widely known that doing angiograms and inserting stens in patients with stable coronary artery disease is a waste of time, perverse incentives in a fee for service model result in these outcomes. As such it isn't a good example of evidence-free medicine. In Australian public hospitals, the cardiologists are paid the same salary regardless of whether they do zero or 1000 angiograms a year. They are very happy not to do unnecessary angiograms in line with the current evidence. If anything, this introductory example shows that a health system needs to be set up to facilitate and encourage evidence-based practice. Otherwise this article rehashes many points about clinical trials and interpreting medical evidence, without a really coherent theme, except maybe to (yet again) criticise doctors. Things have improved in the last 10 - 15 years. Clinical trials come under more scrutiny, trial pre-registration has become more common (although not strictly enforced), health systems gather more and more data about patient outcomes outside of clinical trials and manipulative marketing practices by pharmaceutical companies have been curtailed drastically. In my opinion, the challenges for evidenced based medicine in the next decade are: 1. Getting some decent data about nutrition. There are really remarkably few useful things we can say about how nutrition relates to health. 2. Reducing unnecessary interventions towards the end of life in an ageing population. Healthcare and healthcare research is not well suited to de-escalating care. 3. Transitioning from a one-size-fits-all approach doing clinical trials in 1000s of undifferentiated patients, to collecting 1000s of data points about each individual patient (blood and metabolic variables, genome sequencing, immune profiling, microbiome etc) and using that data to get them healthy and keep them that way. Needless to say, the difficulties in doing this will make doing a randomised controlled trial look like a walk in the park. 4. Fighting pseudo-scientific diagnostic tests and treatments. Examples of this are everywhere - Theranos, gene therapy clinics in undisclosed locations in South America, quantified self services that have no proven health benefits, virtually every supplement ever sold, multivitamins... 5. Fighting the politicisation of health care. This is a very worrying trend that can easily render all our scientific efforts irrelevant - eg anti-vaxxers, far-right intolerance of harm minimisation measures like abortion and decriminalising drug use.

alkonaut 10y ago

Surprised every time I'm in the US and see commercials for drugs and procedures that are administered by doctors being directed towards patients with the ending "ask your doctor about xyz". I'm fairly sure this kind of thing ends up with patients asking/pressuring doctors for treatments they don't need.

coldcode 10y ago
I find these utterly idiotic: you are telling patients about side effects of some drug with pretty pictures and a pleasant voice but only a doctor can prescribe them and you would assume understand the side effects and contraindications. What is the point? Other than obviously make drug companies more money.
- noxToken 10y ago
  That is the point. Drugs x, y, and z are all the market. They do the same thing with the same side-effects for the same cost. An ailment that the drug cures pops up in someone's life. When they go to the doctor, they can ask specifically for drug z, because they saw drug z in a commercial. If our drugs, for all intents and purposes, are the exact same, then there is no point in a doctor prescribing drug x or y when the patient specifically asked for drug z.
  - randcraw 10y ago
    Any two drugs are most definitely not the same unless one is a generic of the other. And even then, because different manufacturers package drugs differently, this can slightly affect a compound's delivery. Even when two drugs use the same mechanism of action (an agonist or antogist toward the same receptor active in the synthesis of a target protein), different generations of drugs often produce significantly different pharmacodynamic profiles of efficacy and toxicity that affect people differently. A good example are the diabetes drugs Actos vs Avandia -- same MoA (glitazones), but the latter has proven to be toxic. Fact is, no two drugs are the same, unless they both do nothing.

arafa 10y ago

Adding to this article (I'm not a medical professional and not giving advice), the same inferior medical outcomes are attributed to most, if not all forms of back surgery. Physical therapy outperforms most or all back surgery with much fewer side effects, etc. This is covered extensively in the book How Doctors Think (https://www.amazon.com/How-Doctors-Think-Jerome-Groopman/dp/0547053649/ref=mt_paperback?_encoding=UTF8&me= https://www.amazon.com/How-Doctors-Think-Jerome-Groopman/dp/...) as well as articles like this Ars Technica one: https://arstechnica.com/science/2017/02/doctors-lower-back-pain-is-like-a-cold-minor-annoying-and-temporary/ https://arstechnica.com/science/2017/02/doctors-lower-back-p.... You see the same with exercise outperforming anti-depressants in most cases, again with much fewer side effects. (For example: https://www.theatlantic.com/health/archive/2014/03/for-depression-prescribing-exercise-before-medication/284587/ https://www.theatlantic.com/health/archive/2014/03/for-depre...) The kicker is that doctors will often refuse these same treatments when offered, which is not a good reflection on their efficacy (again covered in How Doctors Think). This is not an indictment of modern medicine (which is often very effective on acute care), just a recognition of the limitations.

seibelj 10y ago
Exercise helped reduce my depression and anxiety, and I tried to cure it without medication for 2 years. Finally I gave in and went on a low dose of lexapro, in addition to my usual exercise and healthy diet, and I recovered within weeks. Completely changed my life. I know this is just my anecdote, but when natural remedies fail, don't be afraid of medicine.
- tcj_phx 10y ago
  > but when natural remedies fail, don't be afraid of medicine. SSRIs frequently create their own problems. They are sometimes effective because of their effect on the neuroactive steroids: https://en.wikipedia.org/wiki/Neuroactive_steroid#Role_in_antidepressant_action https://en.wikipedia.org/wiki/Neuroactive_steroid#Role_in_an... Depressed people frequently have a metabolic problem, where they don't make enough ATP. This is caused by thyroid imbalances, poisoning with excess Omega-6 polyunsaturated oils, etc.

speeder 10y ago

Sadly, the problem is not just excessive treatment, but also lack of them, for the exact same reason: medics seemly hate science. Example: Thyroid disease diagnostic and treatment problems are so common, that there are organizations made solely to support thyroid patients, including having lawyers specialized in suing doctors to force them to start treatment... The reason for that, is that although there is plenty of research showing that the 80s blood tests are too conservative (they only show positive to people that are usually too damaged beyond any repair), many doctors insist in using solely those tests, and ignore symptoms and newer blood tests. This does have to do with pharmaceutic industry though, some of the organizations pushing for the 80s tests are all supported by pharma companies, and the same companies also have lobbists that try to get in the way of allowing research of treatments that would skip such companies, for example many patients only improve when using "alternative" but centuries old methods that were known to work for centuries, yet lobbists and pharma companies try to convince doctors and politicians that these ancient methods are "wrong because they are old", and don't allow even research to proceed properly, the leading manufacturer of thyroid medicine that works is in Thailand, because in most other countries their business is considered shady or sketchy. Same thing happen in psychiatry, problems that are popular in the public mind are overdiagnosed, specially when they have expensive medication, yet when the problems aren't popular, psychiatrists refuse to treat sufferers. I found a strange case with ADHD: kids are being pumped full of meds due to the fact that they keep disrupting classrooms and ADHD is a "popular" disease with kids, but all adults I know that are actual sufferers from ADHD to the point of disrupting their adult lives, struggle to find treatment, with the usual excuse from doctors being that the meds are "too dangerous" (then why give it to the kids by the boatload?) or that people in their 20s seeking meds must be some kind of junkie looking to boost academic performance, nevermind if non-academic symptoms are there too.

M_Grey 10y ago
These are the problems when arts and crafts with scientific elements are confused in the popular and professional imagination with science.
nradov 10y ago
Which specific thyroid organization sues doctors to force treatment? That seems highly unlikely. Refusal to provide treatment doesn't constitute malpractice.

e40 10y ago

Three months later, his cholesterol had improved markedly, he had lost 15 pounds, and the chest pain never returned. And it just goes to show you, that Dr. Brown might have saved the executive a stent procedure, but they are still promulgating the myth that cholesterol causes CHD. It's a side effect not the cause. There are plenty of people that have high cholesterol and don't have blocked arteries. <sigh>

regardmore 10y ago
It's not a mere side effect. If it were, treatment with anti-cholesterol drugs such as statins (the most used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such a clear cause-and-effect on reducing cardiovascular events and mortality. Since removing cholesterol from circulation reduces cardiovascular disease, you can view it as a cause and not as a mere marker of disease.
- e40 10y ago
  If it were, treatment with anti-cholesterol drugs such as statins (the most used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such a clear cause-and-effect on reducing cardiovascular events and mortality. I've read that studies show it only has an effect for men > 50 yrs, but that the effect isn't due to reducing cholesterol. I have notice a huge increase in the last 10 years in the number of researchers reporting no causal link between cholesterol and CHD. On the first page of a Google search: https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2016-06-13-study-says-theres-no-link-between-cholesterol-and-heart-disease/ https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines... Evidence abounds that there is no link.

AnsemWise 10y ago

This is a very important issue. Doctors are over prescribing and jumping to unneeded surgeries. The question is, are they doing it out of fear of a malpractice lawsuit for denying a patient what they need or is it from kickbacks, incentives and the knowledge that the persons insurance will pay them? Just because something works doesn't mean it's not a broken system. Suprised that no one else has commented on this article.

AnsemWise 10y ago
> Suprised that no one else has commented on this article. Didn't refresh

WalterBright 10y ago

> Steven Galson [...] has called the strengthened approval process created in 1962 the FDA’s “biggest contribution to health.” Before that, he said, “many marketed drugs were ineffective for their labeled uses.” Sam Peltzman in "Regulation of Pharmaceutical Innovation" provides statistical evidence that the "safe and effective" 1962 Amendments reduced the development of new effective treatments as well as new ineffective ones, for a net decrease in positive results.

happy-go-lucky 10y ago

Speaking from my personal experience… My way of life dictates adequate exercise, healthy diet and normal sleep patterns. I come from a family of strict vegans. No, I’m not here to promote either veganism or non-veganism. I’m in my early 40’s and have been exercising since I was a teenager. My routine includes running, cycling, strengthening exercises, lifting light weights, and I do one or two of these a couple times a week. IMO, any and all physical activity is a form of exercise. Usually, my day starts in the early hours. And, as I’m getting older, my endurance levels have been getting significantly better now than during my schooldays, 20’s, or 30’s and with regard to my work I’m getting more productive, too. I also think that those who are not predisposed to any genetic conditions are in a league of their own. Even those who inherit a predisposition can benefit from delayed onset of a condition by practicing a healthy lifestyle. I’m not a medical professional, so my assumptions may or may not carry any weight. All I’m trying to do is keep such treatments as are being discussed here at bay and I will keep at it as long as I possibly can :)

woodandsteel 10y ago

This is an excellent and disturbing article. However, something very important was missed. Let me start by saying that I think that whenever we have a problem in this country, one of the things we should do is look at how other countries handle it to see if there is anything useful we could learn. That being the case, we need to know how other countries handle the over-treatment problem. Are there studies on this? Perhaps the authors could write a follow-up article.

un-devmox 10y ago

I have, according to my MRI, severe cervical stenosis. I also have carpal tunnel, which was diagnosed first. Based on my symptoms and the awful looking MRI, 4 highly regarded spine surgeons recommended a 2 level fusion right away. The 5th doctor, instead recommended carpal tunnel and ulnar nerve releases. My symptoms abated by 80+% and is something I can live with comfortably. None of the 4 other doctors even considered dealing with my carpal tunnel first, which, combined with stenosis causes what's called a 'double crush' scenario. Only one surgeon recommended the least invasive and risky procedure for me! Even though a fusion in the future is likely, for now the risk - reward for such a procedure does not warrant immediate action. I also think it's worth noting that that 5th doctor is the only female of the group. She was the only one that didn't seem gung-ho about the fusion. I'm not saying gender plays a role but...

nommm-nommm 10y ago
https://www.statnews.com/2016/12/19/patients-female-physicians-live-longer/ https://www.statnews.com/2016/12/19/patients-female-physicia... >Public health researchers at Harvard found that elderly patients were less likely to die or be readmitted to the hospital within 30 days if treated by female doctors rather than male. The study doesn’t explain why this happens, but prior studies have found that female doctors tend to spend more time with patients, communicate better, and follow clinical guidelines more often than their male colleagues.