4 ms·

I suppose if you end up reversing an established thing, you'd better have a damn good reason why you were doing that thing in the first place. Why give any tre

by J-dawg 7y ago

I suppose if you end up reversing an established thing, you'd better have a damn good reason why you were doing that thing in the first place. Why give any treatment that hasn't been through a randomised trial? (Unless, of course, you are giving it as part of a trial)

the_af 7y ago
I'm not sure I understand the terminology. If "medical reversal" means -- apologies if I misunderstood -- "stopping a medical treatment which hasn't been shown to be helpful, or one that is not backed by evidence", why is the reversal itself the problem? Shouldn't the focus be on applying treatments backed by robust evidence in the first place, rather than on medical reversals? Of course the two are connected, but the wording seems odd. Medical reversals seem to be a symptom of the problem, not the root cause. Of course, I might be misunderstanding the terminology. edit: I've read the abstract and it seems I am indeed misunderstanding the definition, but for the life of me I cannot understand what "medical reversal" means in layman words.
- hannob 7y ago
  I think you're not misunderstanding, it's exactly what the term "Medical Reversal" is trying to capture. I.e. of course it's only a symptom, but it's something that can be measured to show there's a problem early on.
- scott_s 7y ago
  My laymen's definition of medical reversal: a current medical practice that is worse than what we did before.
  - the_af 7y ago
    Ah, thanks! So indeed I was mistaken. I misunderstood it to mean "reverting an unproven/inconclusive treatment" when it actually means "conducting an unproven/inconclusive treatment". I was confused because "reversal" sounds to me as the act of ceasing to do something, i.e. "reverting" the treatment (if you're a programmer: I thought of "reversal" as in "reverting a mistaken commit using git"). I now see it's a technical term which means the opposite! Now it all makes sense.
    - scott_s 7y ago
      Hmm. Sorry, no, that's not my understanding. I think the phenomenon of discovery is distinct from the changing of behavior. I believe it is the discovery itself that is called a "medical reversal." I think the submitted paper defines it in relatively laymen's terms: "Medical reversal occurs when a new clinical trial — superior to predecessors by virtue of better controls, design, size, or endpoints — contradicts current clinical practice." I think an important difference is that current clinical practice is not necessarily thought to be "unproven/inconclusive." Rather, I think people think it has a solid foundation, but better investigation reveals that not to be true.
- YeGoblynQueenne 7y ago
  I was wondering the same thing. I found this definition: Medical reversal occurs when a new clinical trial — superior to predecessors by virtue of better controls, design, size, or endpoints — contradicts current clinical practice. In recent years, we have witnessed several instances of medical reversal. Famous examples include the class 1C anti-arrhythmics post-myocardial infarction (contradicted by the CAST trial) or routine stenting for stable coronary disease (contradicted by the COURAGE trial). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3238324/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3238324/ The article I link to has one author common with the paper originally posted, way above. Shame that this author seems to have lost the skill of ensuring that terms are propery defined.
ChrisSD 7y ago
IMHO, mostly due to history and some caution. A thoroughly oversimplified history would go something like this: In days past a lot of medicine was based on what seems to work or what ought to work. Unless the effect is really obviously disastrous it's easy to believe an intervention is helping even if it's not. Medical research was of course done but doctors mostly went with their gut or whatever article they'd recently read in a journal and liked the sound of. It's only since the late 80's and through the 90's that Evidence Based Medicine really started to get going. Since then doctors have (sometimes slowly) come round to the idea. However all this research takes time. What do you do about those interventions that haven't been tested yet? You could stop doing anything that hasn't been thoroughly researched, but that risks letting people die or suffering unnecessarily.
- DoreenMichele 7y ago
  It also risks malpractice suits. Over-testing and over-prescribing are rooted in part in doctors trying to cover their own ass and avoid being sued, plus having a good defense in the event they do get sued.
  - AstralStorm 7y ago
    You do know that ineffective practice also risks malpractice suits if it's identified? Even worse if by trying random approaches (face it, an untested experimental medicine is mostly random) you end up harming the patient.
FPGAhacker 7y ago
Sometimes the trial itself is an ethical dilemma. Sometimes it's impossible to control because a placebo that effectively mimics side effects of the subject are not feasible.
jessriedel 7y ago
Because sometimes we have good reasons to believe something works even without an RCT, and it would be unethical to withhold such treatment. (Not to mention that there is a continuum of RCT quality, so it's unclear what would even count and "proven".) The classic tongue-in-cheek example is parachutes: > Objectives: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. > Design: Systematic review of randomised controlled trials. > Main outcome measure: Death or major trauma, defined as an injury severity score > 15. > Results: We were unable to identify any randomised controlled trials of parachute intervention. > Conclusions: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute. https://www.bmj.com/content/327/7429/1459 https://www.bmj.com/content/327/7429/1459
- pmyteh 7y ago
  This year's Christmas BMJ actually contained an RCT of parachute use when falling out of aeroplanes. It found no effect. It turns out that study design can also be a problem, even with 'gold standard' designs like the RCT... https://www.bmj.com/content/363/bmj.k5094 https://www.bmj.com/content/363/bmj.k5094
- scott_s 7y ago
  This is why David Gorski and Steven Novella advocate for Science Based Medicine: https://www.painscience.com/articles/ebm-vs-sbm.php https://www.painscience.com/articles/ebm-vs-sbm.php Basically, it advocates incorporating scientific principles into reasoning about medical practices.

by J-dawg 7y ago

the_af 7y ago

I'm not sure I understand the terminology. If "medical reversal" means -- apologies if I misunderstood -- "stopping a medical treatment which hasn't been shown to be helpful, or one that is not backed by evidence", why is the reversal itself the problem? Shouldn't the focus be on applying treatments backed by robust evidence in the first place, rather than on medical reversals? Of course the two are connected, but the wording seems odd. Medical reversals seem to be a symptom of the problem, not the root cause. Of course, I might be misunderstanding the terminology. edit: I've read the abstract and it seems I am indeed misunderstanding the definition, but for the life of me I cannot understand what "medical reversal" means in layman words.

hannob 7y ago
I think you're not misunderstanding, it's exactly what the term "Medical Reversal" is trying to capture. I.e. of course it's only a symptom, but it's something that can be measured to show there's a problem early on.
scott_s 7y ago
My laymen's definition of medical reversal: a current medical practice that is worse than what we did before.
- the_af 7y ago
  Ah, thanks! So indeed I was mistaken. I misunderstood it to mean "reverting an unproven/inconclusive treatment" when it actually means "conducting an unproven/inconclusive treatment". I was confused because "reversal" sounds to me as the act of ceasing to do something, i.e. "reverting" the treatment (if you're a programmer: I thought of "reversal" as in "reverting a mistaken commit using git"). I now see it's a technical term which means the opposite! Now it all makes sense.
  - scott_s 7y ago
    Hmm. Sorry, no, that's not my understanding. I think the phenomenon of discovery is distinct from the changing of behavior. I believe it is the discovery itself that is called a "medical reversal." I think the submitted paper defines it in relatively laymen's terms: "Medical reversal occurs when a new clinical trial — superior to predecessors by virtue of better controls, design, size, or endpoints — contradicts current clinical practice." I think an important difference is that current clinical practice is not necessarily thought to be "unproven/inconclusive." Rather, I think people think it has a solid foundation, but better investigation reveals that not to be true.
YeGoblynQueenne 7y ago
I was wondering the same thing. I found this definition: Medical reversal occurs when a new clinical trial — superior to predecessors by virtue of better controls, design, size, or endpoints — contradicts current clinical practice. In recent years, we have witnessed several instances of medical reversal. Famous examples include the class 1C anti-arrhythmics post-myocardial infarction (contradicted by the CAST trial) or routine stenting for stable coronary disease (contradicted by the COURAGE trial). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3238324/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3238324/ The article I link to has one author common with the paper originally posted, way above. Shame that this author seems to have lost the skill of ensuring that terms are propery defined.

ChrisSD 7y ago

IMHO, mostly due to history and some caution. A thoroughly oversimplified history would go something like this: In days past a lot of medicine was based on what seems to work or what ought to work. Unless the effect is really obviously disastrous it's easy to believe an intervention is helping even if it's not. Medical research was of course done but doctors mostly went with their gut or whatever article they'd recently read in a journal and liked the sound of. It's only since the late 80's and through the 90's that Evidence Based Medicine really started to get going. Since then doctors have (sometimes slowly) come round to the idea. However all this research takes time. What do you do about those interventions that haven't been tested yet? You could stop doing anything that hasn't been thoroughly researched, but that risks letting people die or suffering unnecessarily.

DoreenMichele 7y ago
It also risks malpractice suits. Over-testing and over-prescribing are rooted in part in doctors trying to cover their own ass and avoid being sued, plus having a good defense in the event they do get sued.
- AstralStorm 7y ago
  You do know that ineffective practice also risks malpractice suits if it's identified? Even worse if by trying random approaches (face it, an untested experimental medicine is mostly random) you end up harming the patient.

FPGAhacker 7y ago

Sometimes the trial itself is an ethical dilemma. Sometimes it's impossible to control because a placebo that effectively mimics side effects of the subject are not feasible.

jessriedel 7y ago

Because sometimes we have good reasons to believe something works even without an RCT, and it would be unethical to withhold such treatment. (Not to mention that there is a continuum of RCT quality, so it's unclear what would even count and "proven".) The classic tongue-in-cheek example is parachutes: > Objectives: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. > Design: Systematic review of randomised controlled trials. > Main outcome measure: Death or major trauma, defined as an injury severity score > 15. > Results: We were unable to identify any randomised controlled trials of parachute intervention. > Conclusions: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute. https://www.bmj.com/content/327/7429/1459 https://www.bmj.com/content/327/7429/1459

pmyteh 7y ago
This year's Christmas BMJ actually contained an RCT of parachute use when falling out of aeroplanes. It found no effect. It turns out that study design can also be a problem, even with 'gold standard' designs like the RCT... https://www.bmj.com/content/363/bmj.k5094 https://www.bmj.com/content/363/bmj.k5094
scott_s 7y ago
This is why David Gorski and Steven Novella advocate for Science Based Medicine: https://www.painscience.com/articles/ebm-vs-sbm.php https://www.painscience.com/articles/ebm-vs-sbm.php Basically, it advocates incorporating scientific principles into reasoning about medical practices.