Believing In Medical Treatments That Don't Work

Hugh Pickens writes "David H. Newman, M.D. has an interesting article in the NY Times where he discusses common medical treatments that aren't supported by the best available evidence. For example, doctors have administered 'beta-blockers' for decades to heart attack victims, although studies show that the early administration of beta-blockers does not save lives; patients with ear infections are more likely to be harmed by antibiotics than helped — the infections typically recede within days regardless of treatment and the same is true for bronchitis, sinusitis, and sore throats; no cough remedies have ever been proven better than a placebo. Back surgeries to relieve pain are, in the majority of cases, no better than nonsurgical treatment, and knee surgery is no better than sham knee surgery where surgeons 'pretend' to do surgery while the patient is under light anesthesia. Newman says that treatment based on ideology is alluring, 'but the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.' The Obama administration's plan for reform includes identifying health care measures that work and those that don't, and there are signs of hope for evidence-based medicine: earlier this year hospital administrators were informed by the Centers for Medicare and Medicaid Services that beta-blocker treatment will be retired as a government indicator of quality care, beginning April 1, 2009. 'After years of advocacy that cemented immediate beta-blockers in the treatment protocols of virtually every hospital in the country,' writes Newman, 'the agency has demonstrated that minds can be changed.'"

Comments

And next up

[m0s3m8n]

Just wait. Next up will be treatment based on life expectancy and quality. I see this becoming an issue based on my experience working for a group of Eye docs (retinal specialists). I often see very elderly (and often demented) patients receiving very expensive treatment of eye conditions. do they need the treatment - sure, to preserve their sight. Does the treatment improve their quality of life - maybe. So who decides, the patient or family, or BIG government?

Re:And next up

[gerf]

Isn't it Japan that was looking to fine people for being overweight, since it would cost the government more for health care? And don't they stop treating cancer patients in some European countries if they're too old?

While the idea of universal free happy healthy health care sounds sugary sweet, there are some dire consequences of handing our individual health to governmental control.

Re:And next up

[bargainsale]

This is in fact the way things work now in the UK.

There is a pretend-independent government committee called NICE (yup) which decides which treatments are to be made available through the free-at-the-point-of-delivery government health service, the NHS.

They do indeed make heavy use of QALYs, "Quality-Adjusted LifeYears" in much this way.

Although the way NICE works in specific instances has led to a lot of very justified criticism, there seems to be no realistic alternative to something like this if you have a tax-financed system that the sick don't pay for directly. There just isn't enough money to do everything possible for every patient.

I don't know the right answer. I work for the NHS (as a retinal specialist too!) and have had endless grief getting funding for some treatments for my patients; on the other hand, I've worked in systems where the first question you have to ask is not "what does this patient need?" but "what can this patient afford?" and I prefer the former despite all its problems and stupidities.

Re:And next up

[JohnFluxx]

The scientist in me likes the ideas of NICE. If an operation neither extends life nor increases quality of life, then what's the point in the operation?

Of course, it never works perfectly, but I'd be interested in what the critisms against NICE are?

Re:And next up

[Anonymous Coward]

I often see very elderly (and often demented) patients receiving very expensive treatment of eye conditions. do they need the treatment - sure, to preserve their sight. Does the treatment improve their quality of life - maybe. So who decides, the patient or family, or BIG government?

This isn't about BIG government telling you you can't take homeopathic remedies, or OTC cough medicine, or sit under a pyramid. This is about government funding research that reveals snake oil as snake oil. If the $8 bottle of robitussin is no more effective than lemon tea, what reasonable consumer would buy the robo? Hooray, I say, for a government that encourages open and honest markets.

Re:And next up

[syntaxglitch]

Although the way NICE works in specific instances has led to a lot of very justified criticism, there seems to be no realistic alternative to something like this if you have a tax-financed system that the sick don't pay for directly. There just isn't enough money to do everything possible for every patient.

Who says it has to be tax-financed?

In the USA, much health care is funded by insurance companies that essentially serve the function of averaging medical expenditure among a group of people. The net result of this is that an individual with insurance has every incentive to spend as much as the insurance while let them, because the costs will distribute to all policy holders. When everyone does this, insurance policy costs keep going up. The insurance companies, trying to get costs back down, have incentive only to pay as little as possible, not prioritize approved treatments by QALYs or any other similar metric.

Then, due to all that, you end up with people who are uninsured or otherwise unable to afford health care ending up with emergency conditions, receiving expensive treatment, and being forced into bankruptcy. This also drives up cost (as the hospitals are forced to absorb the cost of treatment) and harms society (a financially ruined citizen accomplishes less and pays less tax).

And thus, we come to this, the worst of all possible worlds.

Re:And next up

[ZombieWomble]

And don't they stop treating cancer patients in some European countries if they're too old?

This is a fairly ubiquitous practice - most cancer treatments are nasty. Invasive surgery, chemotherapy and radiotherapy all potentially have significant negative impact on quality of life. If someone has the option of a certain number of relatively comfortable years, or a few additional years filled with serious complications, many doctors will recommend the latter option, and this is sometimes reflected in treatment options.

Re:And next up

[similar_name]

So who decides, the patient or family, or BIG government?

Under our current system, insurance companies decide. It seems disingenuous to imply that patients have the choice and that the current system(private insurance companies) pays for every treatment than anyone could ever want/need. There are plenty of people who have been denied claims. I also don't understand why you can't still have private insurance if there is national health care. Did the advent of Blue Cross/Blue Shield make it impossible to get Aetna?

Re:And next up

[BarryJacobsen]

I can testify that knee surgery is sometimes a wonderful cure. I suffered terrible pain for years and two new artificial knees are better than the originals in many ways and they never,ever hurt at all.

The knee surgery being referred to is the kind where they don't replace anything, just dinkering around in there - I believe. They aren't arguing that artificial knees don't work.

Re:And next up

[cptdondo]

As opposed to not having health care at all?

Having universal gov't health care doesn't stop the wealthy from buying more health care than anyone else; it provides health care for the 30% or so of Americans who have none.

It would also control some of the ridiculous cost spirals. Doctors have no idea how much treatment costs; I've asked how much a certain procedure might cost and I'm always met with a blank stare. All the doctors know is that they get a kickback from the lab/hospital/etc for ordering some test. They don't really care if it's necessary or useful.

I'm familiar with both Japanese and European health care systems. The Japanese system provides universal care to everyone. It's basic and no-frills, but it covers nearly all.

The European System (actually Czech Republic) is much the same way. Its focus is on quality of life; they are less likely to provide life-extending care if it means being tethered to a hospital bed. They'll tell you to go home, have some beer, and enjoy what life you have left. They might even send you to a spa or a hot-springs at state expense.

Re:And next up

[sjames]

O nm, its the same ones who already pay for almost all the amenities to the poor and/or lazy.

WOW that was a loaded sentence. First you call life saving medical care an amenity then you paint one third of the population as lazy all in one stroke.

Re:And next up

[cptdondo]

From your nic, I assume ze jsi cech. I'm not sure where you live, but try the health care here in the US. When my kid broke his arm, my insurance refused to pay for the doctor, as it was "elective surgery", the doctor was not one of our preferred providers, and we did not get prequalified.

I guess we could have set his arm ourselves, or perhaps let it heal crooked....

For this we were billed $7,000....

One of my relatives is a doctor in the CR. As everywhere, there are good doctors, and bad doctors. All in all, the care I've received in the CR and Japan rivals that in the US, at a much lower cost.

Re:And next up

[anagama]

The problem is, any public health care system devised in the US is going to be one that benefits the insurance industry. The only way to cut costs is to CUT OUT the insurance industry from the process. I could be supportive of such a plan, but I have absolutely no expectation that will happen. Universal health care in the US will simply be forced subsidization of the insurance industry.

Re:And next up

[onionlee]

It isn't that evidence isn't used when considering treatments. In fact, there were studies in the 90s that supported the use of beta-blockers. The problem is that when later evidence shows up to prove otherwise - ie that it does not make a difference - the medical community has adopted the usage of such as standard procedure. Hard to change, no matter the evidence.

Re:And next up

[RobinH]

And don't pretend the US isn't a socialist nation. I spent 5 years in the US. You guys have a national program that pays farmers to *not farm* to increase the price that the rest of the farmers get for their produce. You also just gave $700 billion in hand outs to failing corporations. You give national subsidies to the states for building the highway system, but tie social policy to it (the states have to implement a minimum drinking age of 21 to qualify for the funding).

The US still pays for the poorest people to get free medical care even though middle income people can't afford it. That's much worse than the Canadian system (having used both). In Canada, the people who run the health care system have to eat their own dog food. Their kids use the system that they run. Do you think the people who run the Medicare system in the US use that system?

Goes to show.

[palegray.net]

The human body is pretty darn good at healing itself. There is absolutely no replacement for a decent diet, moderate exercise, and a positive attitude. The last factor alone has been repeatedly shown to boost immune system health over a variety of drug-based treatments.

Re:Goes to show.

[nloop]

The human body is pretty darn good at healing itself. There is absolutely no replacement for a decent diet, moderate exercise, and a positive attitude. The last factor alone has been repeatedly shown to boost immune system health over a variety of drug-based treatments.

While I agree that a lot of our respective societies health issues are preventable, I am 26 years old, can run a marathon, and rarely ever touch red meat and I call shenanigans on the idea that diet and exercise are a cure-all! I have 140/85 blood pressure (high) despite doing cardio work 5 days a week and eating right. I have knee problems when it's cold, back problems all the time, and suffer from bronchitis every winter from exercise in the cold. Sometimes I feel like a healthy lifestyle is making me fall apart.

However, my qualm is more with more with scientologists, and that various left field christian sects that refuse to immunize their kids or see doctors. Modern medicine is useful. Really. It is. There is more than diet, exercise, and positive thinking.

Re:Goes to show.

[lawpoop]

I think that the human organism basis some of its healing on its perception of its role in society. We are a social creature. Every culture has some kind of 'theory of medicine' -- that disease has a cause, which can be treated by certain practices, procedures, and bitter plant concoction ( the taste of 'bitter' is the chemical recognition of alkaloids, or drug compounds, in a plant ).

If we are receiving 'treatment', or attention from the community when we are known to be sick, then our body's healing response will amp up.

Likewise, people can die basically 'on command' in certain circumstances, when a doctor or sorcerer pronounces them dead. In some tribe somewhere, if a shaman does a certain ritual called a 'bone-pointing', the person who gets cursed will sicken and die in about three days -- shorter than you would die from thirst or hunger. Likewise, back in the 80s when AIDS was first on the scene, people would sometimes die within days of a diagnosis. Doctors didn't find any physical cause; they just kind of willed themself to death, probably because of the severe social stigma and lack of hope that an AIDS diagnosis meant at that point.

So I think placebo medicine will be a big insight into understanding human health in the future.

Inefficiency

[syntaxglitch]

It's well-established that Americans as a whole pay far too much for health for far too little benefit, compared to other first-world nations.

Can some of this discrepancy be explained by high availability of essentially useless or even harmful "treatments"?

Sinusitis

[jonpublic]

My experience with sinusitis definitely confirms this. Every 3 months or so I would come down with another sinus infection. Each time I would goto the doctor and get a prescription for antibiotics. I wasn't asking for antibiotics. I was looking for a solution to the problem. One time the doctor wanted me to switch to a much more expensive antibiotic. Sure enough I ended up getting some nerve damage from the antibiotic. Nothing permanent, but the numbness lingered for over a year.

What the kicker here is that if the doctor had looked at my chart and said, maybe we should take another approach after the 5 or 6th time, the whole situation would have been avoided.

I got a neti pot and I haven't had a sinus infection since, I just use the neti pot whenever I feel my head getting clogged up. $20 dollar solution.

Ignorance is the best medicine

[Hogwash McFly]

As any man knows, if you ignore it for long enough, it will eventually go away. Just like the pain in my tooth and the blood on my toilet paper. I haven't been to the doctor in years, and I am as fit as

Symptoms versus infection

[DrYak]

Cough syrups *do* work. ...BUT...

They don't combat the infection. They alleviate the symptoms.
They don't kill the bug which is causing the cough, they only make the patient cough less (and thus sleep better, feel more comfortable).

So if you count the days spent being sick, a cough syrup won't make any difference. On the other hand if you look which makes happier the patient, one should prescribe the cough syrup anyway. (Same goes for lots of other ailment : most of the treatment prescribed by doctors for common illnesses are only to make the symptoms more bearable, not to kill the bug faster).

There's a saying here among doctors telling that a "cold" last one week without treatment and 7 days with treatment.

I am more astonished about the prescription of antibiotics. Here around in Europe, there have been large campaign to make the public aware that most common infections (bronchitis, sinusitis, sore throats, ear infections, etc...) are due to viruses and thus there's no point in insisting until the doctor prescribes antibiotics.
I would have expected that the same reduction in use of antibiotics would have happened in the US too.

Disclaimer : Although IAAMD, I happen to work in research for the last few years so other medical /.ers should have better knowledge than me.

patients are just customers

[misanthrope101]

I'm sure doctors are performing some treatments that aren't warranted. However, I assure you that patients want treatment. I work in the medical field, and the psychology of medicine is weird. Parents want antibiotics for their children, and they don't really care about research that says the antibiotics aren't necessary or may even cause harm. Everyone wants a pill for what they have, and they want it now. I've seen people demand x-rays for their pinkie toe, even though the doc told them outright that it wouldn't make a bit of difference. If the doc doesn't order the x-ray (or fork over the pills), the patient is unhappy, and unhappy patients are vastly more likely to sue.

I've had a woman bring her kid to the ER with an cold and tell me in the triage room "I can't get in to see the pediatrician till Wednesday, and by then she'll get well on her own." I'm not making this up---she was rushing to make sure her kid got seen by a doctor, because she knew the kid would get well if she waited too long. She wasn't a drooling idiot, but part of her mental checklist of being a good parent included "If kid is sick, see doctor." If docs don't hand out antibiotics for every earache and sore throat, the patient will just come back tomorrow or the next day and complain "I'm still sick." If the second doc gives them pills, they'll tell everyone they know about the first doc, who is obviously an idiot who didn't have the intelligence to see how direly ill they were. "I needed antibiotics, and he didn't give me anything!"

So all told, I don't blame the docs too much. They are working against hypochondriac patients who demand a pill for everything. In a weird way, people want to be sick, or at least they want their routine aches and pains dignified with snazzy medical terms. I've actually had patients get mad at me when I told them that a contusion is just a bruise, and cephalgia is just a headache.

Idiotic.

[DrYak]

Every 3 months or so I would come down with another sinus infection. Each time I would goto the doctor and get a prescription for antibiotics.

This is indeed idiotic. You should shot your doctor. There's plenty of evidence that chronic sinusitis aren't caused by bacteria (the only thing killed by antibiotics).

If the doctor really wanted to try something, he should have made a try with an anti-fungic (some studies tend to show that part of recurring sinusitis might be due to bugs more of the fungi persuasion).

I got a neti pot and I haven't had a sinus infection since, I just use the neti pot whenever I feel my head getting clogged up. $20 dollar solution.

Brilliant. Washing the nasal cavity is a method which also works for viruses which you most likely had like most of the adult population (and against which antibiotics are no use).
It's part of what we prescribe here around (although as I said in another post, I now work in research).

For extra, you can also buy sprays containing carbocisteine (an agent helping making the mucus more fluid), but you should use sprays containing beta-mimetics more than 1-2 weeks.

But the basic "clean the cavity with water" $20 solution works too.

Re:You have too much optimism

[the eric conspiracy]

You do realize I hope that carcinogenic and toxic chemicals are present in great quantities in the natural environment too? For example the human bloodstream naturally contains small amounts of formaldehyde. It is hard to imagine how it would be possible to eliminate exposure to these materials when they are present in every plant or animal through their natural metabolisms.

Sperm count studies that claim reductions in sperm count over time are very questionable. There have been a number of publications in the literature that claim sloppy investigative practices are the reason for this perception. And it definitely has not been world-wide. The data vary greatly by region.

As far as immune system affects of nuclear testing - there is no evidence of such effects even in areas directly downwind of radiation hotspots like Hanford. The only studies showing such affects are in populations exposed to far greater doses, i.e. Nagasaki survivors or children exposed in the Chernobyl accident.

NICE does the job but people don't like it

[Kupfernigk]

There is evidence that drug companies have orchestrated campaigns to get the general public to agitate for their treatments when NICE has identified that they do not work, or do not work well. Many cancer treatments are actually pretty ineffective, but of course dying people clutch at straws - as I may do one day - and if they are told that X treatment is very expensive but may prolong their lives, they will probably demand it. They may not be told that, say, the side effects are awful and they will get six months of life instead of three.

We need NICE because ethical drug companies are no longer ethical, and that in part reflects our demand for magical cures. The really serious problems we face - like TB and avian flu - are of little interest to drug companies because (in the first case) most people affected are poor and cannot afford expensive medicine and (in the second case) vaccines are usually a one or two off and do not represent a continuing revenue stream paid for by insurance. We cannot rely on insurance companies to control public health because their aim is to balance revenue and cost - they are not interested in controlling the diseases of the poor, and they do not want diseases cured to the extent that their revenue goes down. We as taxpayers need agencies like the NIH in the US and the NICE in the UK to advise and regulate in our interests, not those of shareholders only.

Corrupt Doctors

[bloobamator]

The single biggest factor driving health care costs in America is the corruption of doctors. Too many doctors are on the take from Big Pharma.

I personally know one who makes millions dispensing medicines pushed by the pharmaceutical companies. He owns a big house in the Westchester, a swank apartment on the Upper East Side, 2 BMW's, a Mercedes, pays hefty child support, alimony (which includes a third mortgage on his ex-wife's big house in Westchester), and he parties like a freak.

He's not even a surgeon. How does he make so much money? By accepting kickbacks from the pharmaceutical companies for the medicines he prescribes and dispenses (his specialty allows him to dispense certain injections to relieve back pain.)

All this guy does is inject people's backs with something that is clearly ineffective, and then refers them on to his surgeon buddy when the injections don't work. What a scam!

He bragged to me on several occassions, while drunk, how the Big Pharma companies wined and dined him in super-expensive Manhattan restaurants, and how they paid for ultra-luxurious island vacations. I know there was more he wasn't telling me.

I met another "doctor" who actually just owned a bunch of clinics in NJ. He was the dumbest son-of-a-bitch I have ever met, and he walked, talked and dressed like a wiseguy. Yet he drove 2 Rolls-Royces and invested heavily in porn sites and strip clubs in FL. He was scary, really scary, yet he was a "leader in quality private health care in the greater NJ region". *shiver*

It's time we cracked down on medical waste and fraud.

Ear infections TYPICALLY recede in a few days?

[Kral_Blbec]

So what about those that dont? When I was a kid, our doctor refused to give me anything based on this reasoning. As a result of chronic untreated ear infections, I developed a speech impediment that i had to have therapy for until i was almost 16 and still lingers today. I attribute a lot of my anti-sociality in my youth (and now) to being embarrassed to talk. Thanks for nothing doc.

its usually the rich who are lazy..

[spiffmastercow]

If my experience of moving from minimum wage to upper-middle class in the span of 3 years has taught me anything, its that the amount you're paid is inversely proportional to how hard you work. I still work, but not nearly as hard as when I was an intern. And when I was an intern, I didn't work nearly as hard as when I was a janitor. Looking up on the pay scale, I see that most of the execs at my company make $300-500k to sit around and talk out thier asses, and come up with ideas that lose the company millions of dollars.

Re:aprilfools

[davester666]

Great. I took one and now I can't access gmail.