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Thursday, December 17, 2015

Cleaning the House of Medicine

A recent report in JAMA Internal Medicine highlights prevailing medical practices that should be “reconsidered” in 2015 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 over-diagnosis, and over-treatment. 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 over-diagnosis 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 1 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 new 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 2015, 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 indictment has 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 percent 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, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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