15 ms·

The proportion of medical procedures unsupported by evidence may be nearly half

126 points by lnguyen 9y ago

tcj_phx 9y ago
If science advances one funeral at a time, what can be done about institutions that insist on bing wrong? The American Heart Association has a lot to answer for. Sometimes doctors do good work, sometimes their training leaves much to be desired.
- Y_Y 9y ago
  The irony being that worse medicine should lead to more funerals, and hence better medicine.
  - firethief 9y ago
    In the long run, worse medicine can only lead to fewer funerals (at least, until the life extension singularity).
- kiliantics 9y ago
  > their training leaves much to be desired As someone who teaches pre-med students, I can attest to this! When I see their performance in my class and realise they are trying to become doctors and surgeons, I shudder to imagine being treated by them. I think easily 80% don't show enough competence at that point to have my trust in their abilities. I teach them a required experimental physics class and believe doctors should have a scientific mentality when it comes to treatment but very few come out appreciating the scientific method and how to approach empirical problems. I fear many will just end up treating patients with a cookie-cutter approach and cashing in.
  - ams6110 9y ago
    Isn't it the case that every common diagnosis has an established "reasonable and prudent" treatment? It seems to me that the main skill of a doctor is making the correct diagnosis. Once that's done, treatment (at least in the vast majority of cases) is going to be perfunctory. And even the diagnosis itself is going to be, in most cases, the "most likely" condition that explains the patient's symptoms.
    - tcj_phx 9y ago
      Sometimes a diagnosis is useful, sometimes it's a useless (harmful) simplification. People are always more complex than their diagnosis. Specialists have a stranglehold on medicine: https://www.nytimes.com/2017/06/03/opinion/sunday/the-specialists-stranglehold-on-medicine.html https://www.nytimes.com/2017/06/03/opinion/sunday/the-specia...
  - deleted 9y ago
    [deleted]
bob_theslob646 9y ago
>As surgeon and health care researcher Atul Gawande observes, “Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.” I am not trying to defend doctors but the article left out a little detail that messes up the entire system. Malpractice Insurance In the United States, if God forbid , they happen to not do a procedure or precautionary test, and the patient ends up affected or imparied in some way or form, R.I.P that doctor's insurance. Only in America can you sue to get that witchcraft money( apparently copious amounts of money brings someone back to life) when someone dies after surgery complications in that life saving procedure. Doctors/surgeons are not God, their is always a risk in surgery.
- restuijs 9y ago
  People should be able to sue. It's the only natural incentive for good practice. Otherwise there's no consequences for poor practice. On the other hand, people should also be able to lose those lawsuits, and should also be able to sue for unnecessary preventative procedure, and the basis of winning or losing should be based on empirical evidence pertaining to risk. Insurance isn't the problem, nor are malpractice lawsuits. It's the inherent risk in the field. Malpractice issues are greatly overstated in health care debates.
  - halestock 9y ago
    It's certainly not the only incentive for good behavior, and I don't think adding more lawsuits to the mix is the solution. The proper incentive is having a medical board which has the power to discipline, and can do so without acting on emotion or greed, which presumably is the source of many lawsuits.
  - bob_theslob646 9y ago
    "empirical evidence pertaining to risk." This is a good point, I concur. I agree doctors should be held accountable, but it is not the case in the U.S. This article does a great job explaining the issue about malpractice in the U.S. I have no idea whether malpractice is overblown, but I do know that it doesn't prevent bad doctors from practicing. (https://m.huffpost.com/us/entry/us_5a1f4595e4b0dff40be0362f https://m.huffpost.com/us/entry/us_5a1f4595e4b0dff40be0362f) >"Our current malpractice system doesn’t work. Why? Because 90 percent or more of malpractice cases don’t even go to court. And the amount of money – and it is vast – that is attached to this “medical malpractice settlement industry,” if you will, is divvied up in such a way that much of it doesn’t reach the patient. It goes to lawyers, it goes to the courts, and it goes to so-called experts who testify on behalf of the defendant or the plaintiff."
sandworm101 9y ago
>> Before being randomized to receive the operation or the sham... I know that people opt-in to such studies, but what exactly does a "sham" stenting procedure involve? I find it hard to believe that any hospital would insert something along a blood vessel and into a heart, or even just anesthetize a patient, for the purposes of staging a false surgery. These are commonplace but not risk-free procedures. What exactly does it take to convince someone that a piece of metal has been inserted into their heart? Are they presented with false x-rays and other records? Are they ever told the truth? How do they react when they learn that it has all been a sham?
- nonbel 9y ago
  Here is one example: >"In all patients, a research invasive physiological assessment of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) was done. After the administration of intracoronary nitrate, a pressure wire was placed in the distal vessel at least three vessel diameters beyond the most distal stentable stenosis. [...] In the placebo group, patients were kept sedated for at least 15 min on the catheter laboratory table and the coronary catheters were withdrawn with no intervention having been done. [...] After the follow-up assessments, study participation was complete, and patients and physicians were then unblinded to the treatment group allocation. Patients who had the placebo procedure had the opportunity to choose to undergo PCI after consultation with their physician." http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32714-9/abstract http://www.thelancet.com/journals/lancet/article/PIIS0140-67... So it looks like they did an exploratory surgery on the sham patients, then just left them laying sedated on the table.
- nerdponx 9y ago
  If I were facing a terminal illness, I'd probably volunteer. Talk is cheap, of course, but I like to think I'd have the guts for it.
- firethief 9y ago
  Don't knock sham procedures; they're at least as effective as more than half of current medical procedures, and at lower risk. I'm thinking of getting one done.
otp124 9y ago
After journal bias, conflicts of interests, and corruption, I now hold little remaining faith in the justice of “science”. It seems the “scientific method” I learned decades ago is inconvenient to publishers and consumers alike. (Also, I’ve had personal doctors push drugs on me when it was clear they were getting a kickback). It’s frustrating when people read headlines and claim ”science” in a conversation, when the root of the research is fraudulent and the observer has never attempted to verify. When I challenge their assumptions, they are incredulous that I would question “science”.
- maroonblazer 9y ago
  Let's not throw the baby out with the bathwater. There's still plenty of excellent science being done every day; it's just not being written about in outlets like vox.com. The solution to the problems you cite is more and better science.
  - joe_the_user 9y ago
    Even more, it's only now that we're seeing some people apply a rigorous scientific and statical lens to medicine as a whole, A good portion of that fifty or whatever percent of procedures that don't any backing evidence exist through being grandfathered-in from the medical tradition. Beyond the germ theory of disease, medicine circa 1900 was appalling in multiple ways. Medicine continually advances, at least in parts. Hopefully that advance can continue against the grain of multitude of problems we see.
- gingerbreadfias 9y ago
  I was going to post a comment that may or may not be along the same lines as what you're getting at. My impression, after working in the biomedical field, in clinical settings as well as in research settings, is that a lot of what happens is arrogant hubris, in part related to identification with the physical sciences in a biomedical context. I'm not saying those in the physical sciences are arrogant, what I mean is that there is a certain arrogance that people afforded to themselves by virtue of their privilege and monopoly, and it justifies itself along the lines of "I'm an expert in the physical sciences, which means that whatever reasoning I employ to justify something is sound, because it is based in what I perceive to be sound biological, chemical, physical theory." I guess what I mean is that, although I agree with you that most of what is published is nonsense, to put it politely, the problems start much earlier, in conflating "science" with "physical objects of study." Often they don't even get to the stage of systematically collecting data, because they don't see reason to question the truth of their hypotheses. It sounds reasonable, because they are smart, therefore it must be correct. When you get to the stage of shoddy data supporting these biases, it makes things even worse. It's survivorship bias at its worst. People assume that because they get into medical school, or in some cases, grad school in the biomedical sciences, that they got there because they're geniuses (rather than because of who they know, luck, etc.), and that means they're somehow above the need to empirically verify their hypotheses. People just don't understand that there are lots of good ideas that are just wrong.
trhway 9y ago
a joke either from Gray's Anatomy or something similar: The dean of med school at graduation ceremony - "Half of what we've taught you here will be proven wrong in 5 years. The problem is what we don't know which half. "
stcredzero 9y ago
I would hazard a guess that the overall proportion of business procedures unsupported by evidence is nearly half as well.
- jayd16 9y ago
  Are any? What kind of double blind business experiments have taken place?
  - stcredzero 9y ago
    You do realize that there are forms of "supported by evidence" which fall far short of double blind tests.
raverbashing 9y ago
Ok, so how installing a shunt on a blocked artery can possibly not work? (Not alleviating chest pain is "understandable", not reducing the risk of heart attacks makes no sense to me) This article makes some "hand waves" about how understanding of the disease was simplified https://www.vox.com/science-and-health/2017/11/3/16599072/stent-chest-pain-treatment-angina-not-effective https://www.vox.com/science-and-health/2017/11/3/16599072/st... but the fact is blocked arteries don't let blood flow.
- jayd16 9y ago
  Maybe they didn't need it in the first place, maybe the blockage is treated by the medication regemine and not surgery maybe it causes other complications so it's a wash, maybe just because it seems like the mechanism should 'just work' it doesn't.
- davak 9y ago
  Zillions of reasons. If you miss your meds, that stent can abruptly occlude and cause death. Maybe you open one large vessel but the downstream vessels are clogged—even microscopically. Place enough useless stents and you’ll hurt patients from dye, bleeding, infection, etc. On the other hand, studies of procedures are done on very narrow patient populations. Our patients often don’t fit into those perfect boxes. What’s “needless” is difficult. As long as folks get paid per procedure, it adds bias that favors doing instead of not doing.
- joshgel 9y ago
  So ya that's what all cardiologists thought. Many still think this. They may even be right. But we don't have EVIDENCE that this does anything to prevent death, heart attacks or even reduce chest pain. To be clear though, they aren't talking about ACUTELY closed arteries as in a heart attack or myocardial infarction, when there is a plaque rupture and a blood thrombus that develops to cut off blood supply suddenly. But rather, when blood flow, which has been slowly narrowing over years, starts causing chest pain on physical exertion, when the heart muscle distal to the narrowing is asking for more oxygen than the artery can supply. We put stents in a lot of these people, because we like to try to help them, but there isn't much evidence that it helps. It may help, but we haven't been able to prove it yet. Or it may help select people, but we don't know which people to select. But many will still keep getting these stents. Medicine is tricky.
rednerrus 9y ago
The first day of med school they tell you "50% of what we tell you isn't true, we don't know which 50%."
- rhinoceraptor 9y ago
  Except for the diet stuff, that is totally based on rock solid evidence, there's no possible way that they've been dead wrong for 50 years and are covering it up. Just because a high fat low carb diet improves every possible health marker doesn't mean it's healthy!

126 points by lnguyen 9y ago

If science advances one funeral at a time, what can be done about institutions that insist on bing wrong? The American Heart Association has a lot to answer for. Sometimes doctors do good work, sometimes their training leaves much to be desired.

Y_Y 9y ago
The irony being that worse medicine should lead to more funerals, and hence better medicine.
- firethief 9y ago
  In the long run, worse medicine can only lead to fewer funerals (at least, until the life extension singularity).
kiliantics 9y ago
> their training leaves much to be desired As someone who teaches pre-med students, I can attest to this! When I see their performance in my class and realise they are trying to become doctors and surgeons, I shudder to imagine being treated by them. I think easily 80% don't show enough competence at that point to have my trust in their abilities. I teach them a required experimental physics class and believe doctors should have a scientific mentality when it comes to treatment but very few come out appreciating the scientific method and how to approach empirical problems. I fear many will just end up treating patients with a cookie-cutter approach and cashing in.
- ams6110 9y ago
  Isn't it the case that every common diagnosis has an established "reasonable and prudent" treatment? It seems to me that the main skill of a doctor is making the correct diagnosis. Once that's done, treatment (at least in the vast majority of cases) is going to be perfunctory. And even the diagnosis itself is going to be, in most cases, the "most likely" condition that explains the patient's symptoms.
  - tcj_phx 9y ago
    Sometimes a diagnosis is useful, sometimes it's a useless (harmful) simplification. People are always more complex than their diagnosis. Specialists have a stranglehold on medicine: https://www.nytimes.com/2017/06/03/opinion/sunday/the-specialists-stranglehold-on-medicine.html https://www.nytimes.com/2017/06/03/opinion/sunday/the-specia...
- deleted 9y ago
  [deleted]

bob_theslob646 9y ago

>As surgeon and health care researcher Atul Gawande observes, “Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.” I am not trying to defend doctors but the article left out a little detail that messes up the entire system. Malpractice Insurance In the United States, if God forbid , they happen to not do a procedure or precautionary test, and the patient ends up affected or imparied in some way or form, R.I.P that doctor's insurance. Only in America can you sue to get that witchcraft money( apparently copious amounts of money brings someone back to life) when someone dies after surgery complications in that life saving procedure. Doctors/surgeons are not God, their is always a risk in surgery.

restuijs 9y ago
People should be able to sue. It's the only natural incentive for good practice. Otherwise there's no consequences for poor practice. On the other hand, people should also be able to lose those lawsuits, and should also be able to sue for unnecessary preventative procedure, and the basis of winning or losing should be based on empirical evidence pertaining to risk. Insurance isn't the problem, nor are malpractice lawsuits. It's the inherent risk in the field. Malpractice issues are greatly overstated in health care debates.
- halestock 9y ago
  It's certainly not the only incentive for good behavior, and I don't think adding more lawsuits to the mix is the solution. The proper incentive is having a medical board which has the power to discipline, and can do so without acting on emotion or greed, which presumably is the source of many lawsuits.
- bob_theslob646 9y ago
  "empirical evidence pertaining to risk." This is a good point, I concur. I agree doctors should be held accountable, but it is not the case in the U.S. This article does a great job explaining the issue about malpractice in the U.S. I have no idea whether malpractice is overblown, but I do know that it doesn't prevent bad doctors from practicing. (https://m.huffpost.com/us/entry/us_5a1f4595e4b0dff40be0362f https://m.huffpost.com/us/entry/us_5a1f4595e4b0dff40be0362f) >"Our current malpractice system doesn’t work. Why? Because 90 percent or more of malpractice cases don’t even go to court. And the amount of money – and it is vast – that is attached to this “medical malpractice settlement industry,” if you will, is divvied up in such a way that much of it doesn’t reach the patient. It goes to lawyers, it goes to the courts, and it goes to so-called experts who testify on behalf of the defendant or the plaintiff."

sandworm101 9y ago

>> Before being randomized to receive the operation or the sham... I know that people opt-in to such studies, but what exactly does a "sham" stenting procedure involve? I find it hard to believe that any hospital would insert something along a blood vessel and into a heart, or even just anesthetize a patient, for the purposes of staging a false surgery. These are commonplace but not risk-free procedures. What exactly does it take to convince someone that a piece of metal has been inserted into their heart? Are they presented with false x-rays and other records? Are they ever told the truth? How do they react when they learn that it has all been a sham?

nonbel 9y ago
Here is one example: >"In all patients, a research invasive physiological assessment of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) was done. After the administration of intracoronary nitrate, a pressure wire was placed in the distal vessel at least three vessel diameters beyond the most distal stentable stenosis. [...] In the placebo group, patients were kept sedated for at least 15 min on the catheter laboratory table and the coronary catheters were withdrawn with no intervention having been done. [...] After the follow-up assessments, study participation was complete, and patients and physicians were then unblinded to the treatment group allocation. Patients who had the placebo procedure had the opportunity to choose to undergo PCI after consultation with their physician." http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32714-9/abstract http://www.thelancet.com/journals/lancet/article/PIIS0140-67... So it looks like they did an exploratory surgery on the sham patients, then just left them laying sedated on the table.
nerdponx 9y ago
If I were facing a terminal illness, I'd probably volunteer. Talk is cheap, of course, but I like to think I'd have the guts for it.
firethief 9y ago
Don't knock sham procedures; they're at least as effective as more than half of current medical procedures, and at lower risk. I'm thinking of getting one done.

otp124 9y ago

After journal bias, conflicts of interests, and corruption, I now hold little remaining faith in the justice of “science”. It seems the “scientific method” I learned decades ago is inconvenient to publishers and consumers alike. (Also, I’ve had personal doctors push drugs on me when it was clear they were getting a kickback). It’s frustrating when people read headlines and claim ”science” in a conversation, when the root of the research is fraudulent and the observer has never attempted to verify. When I challenge their assumptions, they are incredulous that I would question “science”.

maroonblazer 9y ago
Let's not throw the baby out with the bathwater. There's still plenty of excellent science being done every day; it's just not being written about in outlets like vox.com. The solution to the problems you cite is more and better science.
- joe_the_user 9y ago
  Even more, it's only now that we're seeing some people apply a rigorous scientific and statical lens to medicine as a whole, A good portion of that fifty or whatever percent of procedures that don't any backing evidence exist through being grandfathered-in from the medical tradition. Beyond the germ theory of disease, medicine circa 1900 was appalling in multiple ways. Medicine continually advances, at least in parts. Hopefully that advance can continue against the grain of multitude of problems we see.
gingerbreadfias 9y ago
I was going to post a comment that may or may not be along the same lines as what you're getting at. My impression, after working in the biomedical field, in clinical settings as well as in research settings, is that a lot of what happens is arrogant hubris, in part related to identification with the physical sciences in a biomedical context. I'm not saying those in the physical sciences are arrogant, what I mean is that there is a certain arrogance that people afforded to themselves by virtue of their privilege and monopoly, and it justifies itself along the lines of "I'm an expert in the physical sciences, which means that whatever reasoning I employ to justify something is sound, because it is based in what I perceive to be sound biological, chemical, physical theory." I guess what I mean is that, although I agree with you that most of what is published is nonsense, to put it politely, the problems start much earlier, in conflating "science" with "physical objects of study." Often they don't even get to the stage of systematically collecting data, because they don't see reason to question the truth of their hypotheses. It sounds reasonable, because they are smart, therefore it must be correct. When you get to the stage of shoddy data supporting these biases, it makes things even worse. It's survivorship bias at its worst. People assume that because they get into medical school, or in some cases, grad school in the biomedical sciences, that they got there because they're geniuses (rather than because of who they know, luck, etc.), and that means they're somehow above the need to empirically verify their hypotheses. People just don't understand that there are lots of good ideas that are just wrong.

trhway 9y ago

a joke either from Gray's Anatomy or something similar: The dean of med school at graduation ceremony - "Half of what we've taught you here will be proven wrong in 5 years. The problem is what we don't know which half. "

stcredzero 9y ago

I would hazard a guess that the overall proportion of business procedures unsupported by evidence is nearly half as well.

jayd16 9y ago
Are any? What kind of double blind business experiments have taken place?
- stcredzero 9y ago
  You do realize that there are forms of "supported by evidence" which fall far short of double blind tests.

raverbashing 9y ago

Ok, so how installing a shunt on a blocked artery can possibly not work? (Not alleviating chest pain is "understandable", not reducing the risk of heart attacks makes no sense to me) This article makes some "hand waves" about how understanding of the disease was simplified https://www.vox.com/science-and-health/2017/11/3/16599072/stent-chest-pain-treatment-angina-not-effective https://www.vox.com/science-and-health/2017/11/3/16599072/st... but the fact is blocked arteries don't let blood flow.

jayd16 9y ago
Maybe they didn't need it in the first place, maybe the blockage is treated by the medication regemine and not surgery maybe it causes other complications so it's a wash, maybe just because it seems like the mechanism should 'just work' it doesn't.
davak 9y ago
Zillions of reasons. If you miss your meds, that stent can abruptly occlude and cause death. Maybe you open one large vessel but the downstream vessels are clogged—even microscopically. Place enough useless stents and you’ll hurt patients from dye, bleeding, infection, etc. On the other hand, studies of procedures are done on very narrow patient populations. Our patients often don’t fit into those perfect boxes. What’s “needless” is difficult. As long as folks get paid per procedure, it adds bias that favors doing instead of not doing.
joshgel 9y ago
So ya that's what all cardiologists thought. Many still think this. They may even be right. But we don't have EVIDENCE that this does anything to prevent death, heart attacks or even reduce chest pain. To be clear though, they aren't talking about ACUTELY closed arteries as in a heart attack or myocardial infarction, when there is a plaque rupture and a blood thrombus that develops to cut off blood supply suddenly. But rather, when blood flow, which has been slowly narrowing over years, starts causing chest pain on physical exertion, when the heart muscle distal to the narrowing is asking for more oxygen than the artery can supply. We put stents in a lot of these people, because we like to try to help them, but there isn't much evidence that it helps. It may help, but we haven't been able to prove it yet. Or it may help select people, but we don't know which people to select. But many will still keep getting these stents. Medicine is tricky.

rednerrus 9y ago

The first day of med school they tell you "50% of what we tell you isn't true, we don't know which 50%."

rhinoceraptor 9y ago
Except for the diet stuff, that is totally based on rock solid evidence, there's no possible way that they've been dead wrong for 50 years and are covering it up. Just because a high fat low carb diet improves every possible health marker doesn't mean it's healthy!