A report in JAMA Internal Medicine highlights prevailing medical practices that should be “reconsidered” in 2018 based on the weight of evidence. The paper, appropriately, is written in the matter-of-fact style customary for the peer-reviewed literature. To some extent, that semblance of analytical calm belies the storm swirling between the lines of the report, and the mess it has long been making in the House of Medicine.
The authors, for instance, note that excessive zeal for cancer screening results in “unnecessary surgery and complications.” As a statement, that is rather bland, and even when statistics are attached to show scale, as the authors do, it likely fails to evoke any deep impression. But consider any time you have been through surgery yourself, either as the patient, or as a family member. Unless you are the rare individual who has avoided the OR entirely, even by proxy, those occasions are likely indelible in your memory, and easy to recall.
Why? Because when we, or loved ones, are the patient, surgery is a very big deal. There is, inevitably, a major disruption to our lives and routines, and often, at least a brief period of truly noteworthy pain. (As an aside, the pain I felt waking from anesthesia after one of my ACL reconstruction surgeries was orders of magnitude more excruciating than any I have otherwise known, and that despite the fact that I have broken roughly 20 bones doing various rambunctious things.) And even these memorable unpleasantries are trivial in comparison to the casually appended “complications,” which may be things that linger a long time, if not forever, and extend all the way to the most permanent of them all: death.
The authors refer to overuse of CT imaging of the head when it is of little value, and the tendency for such unwarranted imaging to yield overdiagnosis, and overtreatment. Here, too, the language is clinically dispassionate, and thus prone to conceal more than it reveals. If unfounded CT imaging of the head is producing overdiagnosis in the form of what we in medicine disparagingly call “incidentalomas,” those unwarranted concerns are, obviously, also directed at the head. That in turn means that if treatment follows, it, too, is directed at the head. I think we can all agree that’s not a place we want surgeons directing sharp objects without a darn good reason. Even when surgery does not ensue, follow up testing can result in harms ranging from radiation exposure, to vascular injury, to serious and even life-threatening side effects of contrast material.
The authors note as well a common tendency to over-prescribe narcotics for extended periods of time, especially for young patients of relatively low socioeconomic status. Here, too, the commentary is blandly declarative, and thus lacks the relevant emotional impact. Opioid addiction is recognized as a national crisis, and one of the great urgencies of modern public health. If prevailing medical practice figures in its propagation, as seems to be the case, that is far from trivial.
This litany could continue, as it does in the article, but the point has been made. It requires two characterizations, one somewhat extenuating, the other, compounding the indictment.
The first is that modern medicine can be, and often is, truly marvelous. Lives are saved by it every day. We must be careful to forswear the overly common tendency to disregard the baby in the bathwater. From antibiotics to chemotherapy, organ transplantation to arthroplasty, the prowess and promise of modern medicine is abundantly evident. We should be able to chronicle the failings without failing to note the life-altering, and life-saving triumphs.
Second, however, is the rather damning fact that the practices catalogued in the paper are generally part of the “standard” of practice. The authors are not addressing malpractice, or individual practitioners run amok; they are addressing prevailing practice patterns. This means, quite simply, that in 2018, and despite the volume of noise about “evidence based” medicine, much of conventional medicine is at odds with evidence these authors were able to find and summarize quite handily. Nor is this, by any means, the first time this indictmenthas been served. Conventional medicine is, simply, what we tend to do. Some of it is reliably evidence-based. Some of it lacks evidence. And some of it is robustly opposed by evidence.
That is cause for concern, and a bracing dose of humility, and that much more so when an even wider array of topics is scrutinized. We screened routinely for prostate cancer long before knowing if it was beneficial, only to learn we were imposing net harm. We issued breast cancer screening guidelines with convictions unjustified by uncertainties that prevail to this day. We inserted right-heart catheters routinely in our ICU patients before ever learning how often they were unnecessary, unhelpful, and potentially harmful. We use proton pump inhibitors, with evidence showing they increase mortality. We have managed to be wrong about hormone replacement at menopause in every direction, misinterpreting and misapplying evidence along the way.
Again, I am a practitioner of conventional medicine- I have not come to bury it. But we must concede that the scope of standard, conventional practice encompasses not only what is reliably beneficial and solidly evidence-based, but also what is as yet unsubstantiated, and even what is decisively harmful and at odds with the weight of evidence.
At the same time, and equally important, a certain sanctimony about evidence-based medicine results in contemptuous disregard for the “unconventional.” This broad designation may, at times, refer to so-called “alternative” medicine, where detractors will suggest one is headed toward voodoo. But it also refers to lifestyle interventions that are very far from the worrisome realm of “woo.” If, for instance, schools can do what bariatric surgery can do for severely obese adolescents, is the emphasis of the former and neglect of the latter really about “evidence,” or about the powers that be protecting the profits that are?
In our own work, colleagues and I showed that it was possible to reduce medication use for ADD/ADHD by some 33% with a simple, school-based physical activity program. This and related research suggest that we are blithely misdiagnosing rambunctiousness in children as pathology to justify the use of drugs to treat what recess would cure. This is very sad testimony to the state of our cultural priorities.
Finally, I can’t help but note our profound cultural hypocrisy regarding health. We routinely market to kids food we know is implicated in such travesties as adult-onset diabetes in childhood, even as we study treatments of these unnecessary harms, up to and including bariatric surgery. I am not conspiracy-theory minded, but it’s hard to resist the macabre fantasy of Big Food and Big Pharma behind closed doors, concluding: it’s a deal. We will profit from causing the disease, you can profit from treating it- and everybody wins! Everybody except the public, that is.
To the best of my knowledge, a rather boisterous group in cyberspace calling itself “science based medicine” is silent on all of this. They preferentially malign all alternatives to conventional medicine, implying that problems of evidence and its application lie entirely without, and not within. This, in turn, makes it clear that such protest is itself unconcerned with the underlying evidence, and born instead of ideological zealotry. If evidence matters, it matters equitably, and universally.
Were I tasked with rebutting the very case I am making in this column, I would say: well, the articles cited here are evidence that conventional medicine is policing itself, seeking ever more evidence and a higher standard. That is just what we would hope to see.
That is the best, and perhaps only argument for the defense, and might matter if it managed to thrive, but alas, it is stillborn. The simple fact is that the products of conventional medicine- Big Pharma, Big Tech, and the associated patents- are routinely promulgated, widely practiced, and massively reimbursed, often for years, before there is evidence to support them. Evidence to repudiate them comes after, and this despite our prime directive: first, do no harm. In stark contrast, the often kinder, gentler, but unpatented offerings of other domains are repudiated for years until or unless evidence comes in to exonerate them, and sometimes, even then.
In other words, the prevailing pattern is that “we” (i.e., conventional medicine) are innocent until proven guilty, but everyone else is guilty until proven innocent. No special olfactory acuity is required to discern how bad that smells.
The House of Medicine is home to much that is powerful, effective, life-altering, and life-saving. But it is home to quite a bit of rubbish as well. The House of Medicine, in other words, could use a good cleaning.
The cleanup will certainly not come courtesy of those calling themselves “science based,” who live within its glass walls, tossing stones outward. They produce nothing more useful than shards of glass.
It will come courtesy of those who concede, with suitable humility, that no single domain of influence has a monopoly on dirty boots. It will come courtesy of those who like a level playing field, and respect the potential for baby and bathwater in any given tub.
It will come courtesy of those who acknowledge that the blank in “_____ based medicine” has a long and rather unsavory list of applicants: profit; pharmaceutical; habit; preference; patent; turf; privilege; and status quo, to name a few. It is up to us to fill in that blank with a designation that is both desired, and deserved; both what we want, and what we actually do. That requires a much harder task than calling out the dirt on everyone else’s boots. It requires a serious devotion to cleaning our own house.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and current President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.