Doctors slow to correct their blunders

Possibly the most important orthodox medical statement in over 50 years.

We know—or we think of—orthodox medicine as pretty clueless, right? We know that; but orthodox doctors don’t.

In fact, the truth is, some do. I was once very much part of orthodoxy (we,, for about 3 years!), before I jumped the fence. But there are good and true doctors still inside the fence, trying to make it right. I honor them and you should too.

They stick it out, through thick and thin, knowing that the vast majority of their colleagues are clueless, don’t care and don’t WANT to know any better (that’s why I walked out on it all).

So how often does medical consensus turn out to be wrong?

In a quote that has become part of medical school orientations everywhere, David Sackett, often referred to as the “father of evidence-based medicine,” once famously said to medical students and doctors:

Half of what you’ll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half–so the most important thing to learn is how to learn on your own.

Sackett, to be sure, was making an intentionally wild estimate when he said “half.” A fascinating study out today in the Archives of Internal Medicine gives a clue as to the real figure. It’s not as high as 50% but it is SHOCKING because it’s proven, not just an opinion.

The authors of the study, from Northwestern and the University of Chicago, looked at a year’s worth of studies in the New England Journal of Medicine (NEJM) that “made some claim with respect to a medical practice.” There were 124 such studies, and 16 — that’s 13 percent, or about one in 8 — constituted reversals.

A reversal meant that it was no longer considered proper or safe to do what was once “correct” medicine. Doctors had reversed their position, from what was stated to be scientific, evidenced-based  medicine (you know, the kind of crap they like to beat alternative practitioners over the head for not having!)

It’s almost like Russian roulette, with a 1:6 chance of getting it “wrong” (dead)!

As these authors note:

Reversals included medical therapies, invasive procedures and screening tests. In several cases, current guidelines were contradicted by the study in question, in other words a complete 180 degrees turnaround.

The results mean that a good chunk of current medical practice is likely to be reversed over time. And although that doesn’t mean all of those original papers should be retracted (they were probably fine at the time), it does mean doctors must be far more humble about what they consider the “correct” thing to do.

In the current state of arrogance, you would think it’s all covered; there is an answer (or a drug) for everything; it all makes sense. But then that would mean patients never died, wouldn’t it?

The reality is that for a long time, there has been a pervasive problem in modern medicine.  Namely, that new technologies and therapies are being adopted, without clear evidence that they work. This is often under extreme pressure—or outright lies—from the pharmaceutical industry and its tricky spokesmen. Then later, the truth us allowed to emerge and it was being done wrong all along. But at whose expense? The patients’ of course.

Often these corrections are very slow in coming; meanwhile Big Pharma or the extensively wealthy surgeons and other profiteers, go on milking the system, fully aware it’s all wrong. But disguising their misfeasance under the banner of “accepted practice” or “evidence based” or, more usually, just consensus view.

The latter is not very comforting, of course. If you spent time in jails you would also find people there with a consensus view that murder and robbery were acceptable practice (evidence-based even?)

All this violates the fundamental rule of good medicine, which is ‘first do no harm’.  First, there is harm to the patients who underwent the therapy during the years it fell in favor, and second, the harm to future patients until there is a change in practice. And lastly, there are the diffuse harms, such as loss of trust in the medical system.

So how long do these kinds of reversals typically take?

No one so far has looked at how long practices survive before they are ‘reversed.’  The authors of this study argued that it has changed over the years, and reversal probably happens faster now (though still pretty slow).

Then there is the fact that, even when a contradictory paper has shown clearly that modern methods are damaging, there is STILL a delay in its acceptance and adopting new methods. Up to a decade, according to John Ioannidis (professor and chairman at the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine as well as tenured adjunct professor at Tufts University School of Medicine and Professor of Medicine and Director of the Stanford Prevention Research Center at Stanford University School of Medicine). He published a paper called Persistence of Contradicted Claims in the Literature.

10 Years is totally unacceptable.

Of course, it doesn’t mean doctors who use evidence that is later shown to be wrong have bad intentions. (In fact, as long as they’re using evidence, they’re ahead of some physicians.)

SOURCES:

[The Frequency of Medical Reversal, Arch Intern Med. 2011;0(2011):archinternmed.2011.295v1-2.]

Arch Intern Med. Published online July 11, 2011. doi:10.1001/archinternmed.2011.295

See also the Retraction Watch page here:

http://retractionwatch.wordpress.com/2011/07/11/so-how-often-does-medical-consensus-turn-out-to-be-wrong/#more-3192