When Medicine Reverses Itself

хороший текст о том, почему в медицине так многое изменилось и современные врачи лечат не так, как лечили еще даже 10-20 лет назад, и что крайне важна практика использования научно проверенных на безопасность и доказанных в плане эффективности методов, чтобы вернуть доверие пациентов

имхо евмные (доказательные) фанаты в этом плане вредят медицине не меньше, чем врачи, назначающие фуфломицины

искушение врача продавить своим авторитетом соблюдение пациентом их назначений и рекомендаций - практика, которой много веков, и которая тешит ЧСВ врача, но подрывает доверие к научно обоснованной медицине в целом


(с) well.blogs.nytimes.com 

The boy in the emergency room sat, swinging his legs. He smiled as I examined him, despite having a fever and a throb in his ear. Crouching at his side, I could see through the otoscope an angry drum, bulging and red — mystery solved.

After medicines quelled the pain, his mother and I talked about ear infections, how long they linger, what to watch for and what to do: anti-inflammatory medicine, ear drops for pain and a recheck in two days.

Mom raised an eyebrow. “When his sister had ear infections they always gave her antibiotics.”

This is a dreaded moment for doctors: the “medical reversal” discussion. She was right, of course. While the latest guidelines make it clear that most ear infections should not be treated with antibiotics, that’s a big change — and a good example of how seesaw science frustrates doctors and leads to tricky moments in the exam room.

Dr. Vinay Prasad has been studying and writing about medical reversals since 2012 when, as a fellow at the National Cancer Institute, he published a series of papers introducing the term and cataloging more than a hundred examples. His work caused a stir, hand-wringing editorials in top medical journals and an explosion of press coverage. His book “Ending Medical Reversal,” written with Dr. Adam Cifu, was released this month, expanding on prior work and tackling a problem that continues to vex.

The consequences of medical reversal are complicated. For starters, reversal challenges the notion that medicine is scientific — the premise that a century ago helped doctors to exorcise images of snake oil and hucksterism. But despite impressive progress, faith in medical leadership is currently at its lowest point in 50 years, a decline likely accelerated by a widespread sense that medical dogma often flip-flops.

On a practical level, reversals also mean accomplishing the near impossible: convincing people to abandon strongly-held convictions. Antibiotics have been used for ear infections for so long, and so pervasively, that years after studies showed they do more harm than good, parents and doctors continue to believe.

My own mother rushed me to the doctor to get antibiotics for my ear infections more times than I can count — and as she points out, I always got better. Why change now? Yet the problem is fueling a worldwide antibiotic crisis, costing billions, and leading to serious side effects and sporadic deaths, despite public health campaigns and physician initiatives.

The reasons treatments like antibiotics for ear infections persist are complicated. Patient expectation, patient-doctor communication, cultural norms, time pressures and financial factors all contribute, making solutions fraught. Meanwhile, scientifically-debunked practices remain common, and troubling.

Famous past examples include hormone replacement therapy, for years recommended and routinely prescribed to prevent heart attacks in women. When finally tested in trials, the pills were found to increase heart attacks and breast cancer. Huge trials demonstrate that prostate-specific antigen as a cancer screen failed to reduce deaths while increasing surgeries and complications, findings that led even the inventor to renounce the test. And yet its use is still routine. Cardiac stenting, an invasive and potentially risky heart procedure, can save lives during a heart attack, but large studies show that stents placed in most other circumstances — the great majority of stents — had no beneficial effects.

Dr. Prasad and Dr. Cifu have pointed out that both PSA tests and coronary stents were introduced well before high quality trials tested their efficacy. Now, as with antibiotics for ear infections, it is difficult to pull back. Some physicians are even calling for increased use of PSA based on proposed changes in its use and interpretation. Frustratingly, these changes may be genuine improvements but — here we go again — they are untested in trials.

In one timely section of the book, Dr. Prasad discusses screening mammography, a practice intertwined with the treatment of ductal carcinoma in situ, two widespread practices teetering on the edge of reversal. In mega-trials analyzed more than a decade ago, mammograms failed to save lives (findings reconfirmed yet again this year), while last month the largest ever study of D.C.I.S. found the condition confers no increased risk of dying from breast cancer and may not benefit from treatment at all.

The pattern repeats: A promising new therapy or technology is introduced based on weak data and later, more rigorous studies discredit the practice. When I spoke with Dr. Prasad, he suggested a more staid, scientific approach. “The adoption of practices based on little or no good evidence is our biggest problem,” he said. “If we decide to use new technologies while waiting for definitive studies, they should be labeled ‘experimental,’ and patients should be counseled appropriately.”

Changing the way we communicate and think about what is proven, and what is a best guess, may seem like a lofty goal. But perhaps it shouldn’t be. The persistence of debunked practices and doubt about unambiguously safe and effective ones like childhood vaccination, suggests that medicine needs a strategy to restore trust.

Dr. Newman is author of “Hippocrates Shadow: Secrets From the House of Medicine.” 

(с) well.blogs.nytimes.com