By Kelley Talbot, Class of 2016
What medications do you take? Your parents? Your children? They may not be as effective as you think.
My grandfather was a successful family doctor for generations. We all went to him for our various aches and pains, and were often disappointed when – nine times out of 10 – he dismissed the latest prescription or treatment as unproven. We went home empty-handed. Especially as he got older (and we were less intimidated by him!) we sometimes slapped a label of old-fashioned or curmudgeonly on him.
But it looks like he was on to something.
He insisted that many treatments were unproven – despite FDA approval. And that they didn’t work well enough to justify their side effects, much less their cost. He was truly angry about what he saw as unnecessary patient suffering brought on by over-treatment. Now The Atlantic and ProPublica have co-published an in-depth story that seemingly supports this more conservative approach and may have you questioning you doctor’s next advice.
This isn’t a story bashing pharma or glorifying “natural” living – it’s a story of multiple flawed systems, doctors slow to change, and patients eager for cures. Here are key takeaways from David Epstein’s article.
- It is shockingly common for patients to get treatments proven ineffective or dangerous. Epstein reports that a 2013 study published in Mayo Clinic Proceedings, found 146 studies that proved or strongly suggested that a current standard practice either had no benefit at all or was inferior to the practice it replaced. A 2012 study funded by the Australian Department of Health and Ageing identified 156 active medical practices that are probably unsafe or ineffective. Stents, statins and sleeping pills are examples of very common treatments that can be both ineffective and overused. And this isn’t really breaking news – this evidence has been building for a long time.
- Care that doesn’t improve outcomes isn’t just an expensive hassle: It can hurt people. Stents can cause complications that directly or indirectly lead to death; statins may lower blood pressure but not necessarily prevent heart attacks or extend life – so patients merely have better blood pressure when they die; sleeping pills in seniors rarely improve sleep but can cause fogginess, memory loss or serious accidents. Even screenings have their downsides: Epstein cites a new study looking at doctors’ perception of disease-screening tests and found that “they tend to underestimate the potential harms of screening and overestimate the potential benefits.”
How can this be?
Why would doctors prescribe treatments that don’t work? Profit motive above everything? Bad science? Isn’t the FDA supposed to protect us? Epstein breaks it down for us:
- Testing and approval practices are flawed. The results of even randomized controlled trials can be difficult to interpret. “Therapies are frequently approved for use based on clinical trials that can’t actually prove whether they work,” Epstein asserts. “According to a new paper in the Journal of the American Medical Association Oncology, even when cancer drugs clearly do work in trials, they often don’t work or work substantially less well in the real world, perhaps because subjects in trials are not representative of typical patients."
- There is a medical and publishing culture that emphasizes breakthroughs but gives short shrift to replication or later findings that show inefficacy. Academic journals and the mainstream press are more likely to publish studies about promising new treatments. Doctors, in turn, rely in part on journals to keep current. “Failing to publish negative results is recognized to be a massive source of scientific misinformation,” Epstein notes.
- Providers are slow to adapt their treatment to new research. “A 2007 Journal of the American Medical Association paper coauthored by John Ioannidis — a Stanford University medical researcher and statistician who rose to prominence exposing poor-quality medical science — found that it took 10 years for large swaths of the medical community to stop referencing popular practices after their efficacy was unequivocally vanquished by science.”
- Doctors have financial incentives to treat patients, and worry about being sued if they don’t. While financial incentives are shifting, getting paid more for more treatment is deeply ingrained in our healthcare system.
- Patients pressure doctors to treat them, even against doctors’ advice. Many patients will shop around until a doctor agrees. John Christoforetti, an orthopedic surgeon in Pittsburgh, tells the story of a patient who wanted a particular type of knee surgery and when he explained that it was inappropriate, was hit with a negative review.
Is this changing?
Epstein cautions that the 21st Century Cures Act could exacerbate regulatory shortcomings, and that “FDA approved” won’t guarantee the same safeguards it does today. On the other hand, providers do adapt their treatment to new findings, it just needs to happen more quickly; financial incentives have been shifting to reward outcomes rather than volume; emphasis on replication in the medical and academic publishing communities has resurged; and researchers are improving and expanding registries that use massive data-sets to track real-world drug efficacy. These points suggest the need for vigilance and further work, as well as opportunities for growth – including in efforts to strengthen providers’ access to relevant findings and develop systems that support doctors when they appropriately decline to treat patients.
Read the entire article for additional details and attention-grabbing stories.