Which Medical Practice Will Be Discredited Next?

An editorial in the current British Medical Journal makes a very sharp point that many of us have probably been thinking about in the last few weeks while reading the latest medical news in the papers:

It’s easy to feel contempt for deluded practitioners of the past who advocated bloodletting and tonsillectomies for all. Easy, that is, until one considers emerging evidence that coronary stenting and postmenopausal hormone replacement therapy may well be the contemporary equivalents of those now discredited practices.

This recent New York Times article tells of the compelling study which found that coronary stenting is typically no more effective than heart drugs, even though it is far more invasive — and, to be sure, profitable for the medical personnel involved.

Indeed, another article in the same issue of BMJ suggests that stenting is less common in Europe than in the U.S. mainly because “there have not been the same financial incentives to carry out some stenting.”

FWIW, we mentioned this subject briefly in Freakonomics:

If you were to assume that many experts use their information to your detriment, you’d be right. Experts depend on the fact that you don’t have the information they do. Or that you are so befuddled by the complexity of their operation that you wouldn’t know what to do with the information if you had it. Or that you are so in awe of their expertise that you wouldn’t dare challenge them. If your doctor suggests that you have angioplasty-even though some current research suggests that angioplasty does little to prevent heart attacks-you aren’t likely to think that the doctor is using his informational advantage to make a few thousand dollars for himself or his buddy. But as David Hillis, an interventional cardiologist at the University of Texas Southwestern Medical Center in Dallas, explained to the New York Times, a doctor may have the same economic incentives as a car salesman or a funeral director or a mutual-fund manager: “If you’re an invasive cardiologist and Joe Smith, the local internist, is sending you patients, and if you tell them they don’t need the procedure, pretty soon Joe Smith doesn’t send patients anymore.”

The BMJ editorial also asks a wise question. Perhaps some of you can offer an answer: “What other medical orthodoxies might join hormone replacement therapy and stenting on the ever-growing list of discredited interventions?”

I have one prediction: late-stage chemotherapy for many types of cancer.

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  1. RJS says:

    I have one prediction: late-stage chemotherapy for many types of cancer.

    This is typically done at the behest of the families and patients, not because doctors think there’s any hope. Most docs would rather prescribe hospice care for late-stage cancer patients, but people like to cling to false hope, so unpleasant treatments continue up until the very end.

    It’ll stop when insurance companies decide to stop paying for it.

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  2. RJS says:

    I have one prediction: late-stage chemotherapy for many types of cancer.

    This is typically done at the behest of the families and patients, not because doctors think there’s any hope. Most docs would rather prescribe hospice care for late-stage cancer patients, but people like to cling to false hope, so unpleasant treatments continue up until the very end.

    It’ll stop when insurance companies decide to stop paying for it.

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  3. HeatmiserAZ says:

    As more and more “targeted” therapies are developed, that is, therapies that attack specific proteins or pathways in tumor cells, you will see fewer cases of non-specific chemo used for late-stage.

    As these drugs get better and our techniques for identifying which proteins and pathways are mutated in a person’s indvidual tumor improve, physicians will be able to make better selections for chemo regimens.

    This is happening in isolated places today and the clinical trials to determine its effectiveness are just getting started. Regardless of the short term, I don’t think you’d find too many people in the field who would argue that this isn’t the way it will be in 20 years.

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  4. HeatmiserAZ says:

    As more and more “targeted” therapies are developed, that is, therapies that attack specific proteins or pathways in tumor cells, you will see fewer cases of non-specific chemo used for late-stage.

    As these drugs get better and our techniques for identifying which proteins and pathways are mutated in a person’s indvidual tumor improve, physicians will be able to make better selections for chemo regimens.

    This is happening in isolated places today and the clinical trials to determine its effectiveness are just getting started. Regardless of the short term, I don’t think you’d find too many people in the field who would argue that this isn’t the way it will be in 20 years.

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  5. Willy says:

    I actually would pose a complementary question, what simple things are doctors not doing that could help patients significantly?

    It seems to me that most doctors know very little about nutrition, diet, and exercise. If they do know something, they’re certainly not sharing it. Why not? No incentives. Offering comprehensive diet and exercise plans to patients brings in no revenue and significantly decreases the chances that patients will need more care.

    Interventions that I think may end up being discredited:

    HPV vaccine for all young women (very expensive, unknown long-term risks, insignficant improvement of health outcomes)

    Use of statins to lower cholesterol (the link between these drugs and reduced risk of heart attack sounds pretty shaky)

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  6. Willy says:

    I actually would pose a complementary question, what simple things are doctors not doing that could help patients significantly?

    It seems to me that most doctors know very little about nutrition, diet, and exercise. If they do know something, they’re certainly not sharing it. Why not? No incentives. Offering comprehensive diet and exercise plans to patients brings in no revenue and significantly decreases the chances that patients will need more care.

    Interventions that I think may end up being discredited:

    HPV vaccine for all young women (very expensive, unknown long-term risks, insignficant improvement of health outcomes)

    Use of statins to lower cholesterol (the link between these drugs and reduced risk of heart attack sounds pretty shaky)

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  7. mee23 says:

    I think the trend in cardiology will increasingly be towards discrediting practices for specific groups (i.e., women and minorities).

    I’m not sure cancer will follow the same path. Cancer research has been increasingly specialized since the 1970s, but most of the apparent improvement is still ultimately due to a handful of statistical artifacts. Because so many researchers have incentives to prevent this artifact from becoming public knowledge, I suspect that it will continue to fly under the media’s radar.

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  8. mee23 says:

    I think the trend in cardiology will increasingly be towards discrediting practices for specific groups (i.e., women and minorities).

    I’m not sure cancer will follow the same path. Cancer research has been increasingly specialized since the 1970s, but most of the apparent improvement is still ultimately due to a handful of statistical artifacts. Because so many researchers have incentives to prevent this artifact from becoming public knowledge, I suspect that it will continue to fly under the media’s radar.

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