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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COMMENTS: 80


  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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  9. gr44 says:

    Chemotherapy for advanced cancer has been tested multiple times. There are even have meta-analyses (where multiple studies are combined to assess the benefits of a given treatment). While some may disagree about the magnitude of benefit, most therapies given to advanced cancer patients (especially common ones like breast, lung, and colon cancer) have been tested in randomized, double-blind, placebo controlled trials, already. These treatments generally meet the most rigorous endpoints: they make people live longer and feel better.

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  10. gr44 says:

    Chemotherapy for advanced cancer has been tested multiple times. There are even have meta-analyses (where multiple studies are combined to assess the benefits of a given treatment). While some may disagree about the magnitude of benefit, most therapies given to advanced cancer patients (especially common ones like breast, lung, and colon cancer) have been tested in randomized, double-blind, placebo controlled trials, already. These treatments generally meet the most rigorous endpoints: they make people live longer and feel better.

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  11. ekrdpt says:

    My suggestion is Spinal Fusion Surgery for Low Back Pain. The logical rationale for this surgery is shaky, it causes dysfunction at the segments above and below the fusion, and has been shown in some studies to be only minimally better than a wait and see approach. Improvements in non-surgical treatment of back pain, ie. Manual Physical Therapy, and alternative surgical fixes such as total disc replacements will make spinal fusion seem archaic and a thing of the past.

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  12. ekrdpt says:

    My suggestion is Spinal Fusion Surgery for Low Back Pain. The logical rationale for this surgery is shaky, it causes dysfunction at the segments above and below the fusion, and has been shown in some studies to be only minimally better than a wait and see approach. Improvements in non-surgical treatment of back pain, ie. Manual Physical Therapy, and alternative surgical fixes such as total disc replacements will make spinal fusion seem archaic and a thing of the past.

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  13. ajkrik says:

    How about C-sections and epitomizes? Though not unnecessary at times they are probably an example of medical exploitation of fear and ignorance.

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  14. ajkrik says:

    How about C-sections and epitomizes? Though not unnecessary at times they are probably an example of medical exploitation of fear and ignorance.

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  15. egretman says:

    Why stop at individual procedures?

    The entire medical profession is a distorted market morass of ethically compromised actions and reactions. The reason is the lack of true market competition being replaced by insurance nonsense.

    The good news is that it’s all falling apart and we will soon have government health care. The bad news is that it’s all falling apart and we will soon have guvment health care.

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  16. egretman says:

    Why stop at individual procedures?

    The entire medical profession is a distorted market morass of ethically compromised actions and reactions. The reason is the lack of true market competition being replaced by insurance nonsense.

    The good news is that it’s all falling apart and we will soon have government health care. The bad news is that it’s all falling apart and we will soon have guvment health care.

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  17. chebuctonian says:

    The whole debate about stenting amazes me. There are ways of managing heart disease without drugs OR surgery. We should have gotten a lot more data about this since Ornish published his protocol, but it seems to be flying under the radar. Drugs are more invasive than diet and lifestyle changes, but the incentives for doctors aren’t there.

    Nutrition and the role of intestinal flora might be next. When will doctors face sanctions for prescribing antibiotics for common colds?

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  18. chebuctonian says:

    The whole debate about stenting amazes me. There are ways of managing heart disease without drugs OR surgery. We should have gotten a lot more data about this since Ornish published his protocol, but it seems to be flying under the radar. Drugs are more invasive than diet and lifestyle changes, but the incentives for doctors aren’t there.

    Nutrition and the role of intestinal flora might be next. When will doctors face sanctions for prescribing antibiotics for common colds?

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  19. nwhitehe says:

    I think the real scandal is how unscientific nutrition and principles of general health are. Probably half of all health problems in the US are related to poor diet, muscular atrophy, and lack of exercise. And yet we rely on fad diets, self-help books and infomercials to deal with the problem. For my money it’s more ridiculous than blood-letting.

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  20. nwhitehe says:

    I think the real scandal is how unscientific nutrition and principles of general health are. Probably half of all health problems in the US are related to poor diet, muscular atrophy, and lack of exercise. And yet we rely on fad diets, self-help books and infomercials to deal with the problem. For my money it’s more ridiculous than blood-letting.

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  21. chrisbryan says:

    Hi, I live in Canada, so health care’s free. But drop-in clinics, run by general practitioners (GP), suffer from gross failures concerning the proper diagnosis of people and often fail to give them the necessary medical attention. Since these practitioners receive wages in part based on the number of visits, they have an incentive to rush you through the visit and will usually prescribe some kind of antibiotic or some other quick-fix. For example, I didnt get a proper medical diagnosis until I went to a hospital, instead of a GP.

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  22. chrisbryan says:

    Hi, I live in Canada, so health care’s free. But drop-in clinics, run by general practitioners (GP), suffer from gross failures concerning the proper diagnosis of people and often fail to give them the necessary medical attention. Since these practitioners receive wages in part based on the number of visits, they have an incentive to rush you through the visit and will usually prescribe some kind of antibiotic or some other quick-fix. For example, I didnt get a proper medical diagnosis until I went to a hospital, instead of a GP.

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  23. furiousball says:

    I’m more appalled by heath insurance practices than the medicine being practiced.

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  24. furiousball says:

    I’m more appalled by heath insurance practices than the medicine being practiced.

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  25. billypilgrim37 says:

    So Dubner tosses a softball to the anti-physician crowd, even to go as far as to try to discredit one of the most researched, evidence-based fields in all of medicine (oncology)? Nice.

    For one thing, to lump “cancer” as one disease is pretty telling of the vein of this thread. Chemo protocols are highly specific, and rigorous clinical trials evaluate benefit to both quantity AND quality of life improvements. Sometimes the risk and benefits, well-quantified, are so close that individual patients have to make tough decisions.

    To suggest that oncologists are throwing chemo at dying folks for no reason demonstrates a glaring inability to use MedLine or UpToDate. Cancer sucks, chemo sucks, and we dump a lot of resources into research into balancing the two.

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  26. billypilgrim37 says:

    So Dubner tosses a softball to the anti-physician crowd, even to go as far as to try to discredit one of the most researched, evidence-based fields in all of medicine (oncology)? Nice.

    For one thing, to lump “cancer” as one disease is pretty telling of the vein of this thread. Chemo protocols are highly specific, and rigorous clinical trials evaluate benefit to both quantity AND quality of life improvements. Sometimes the risk and benefits, well-quantified, are so close that individual patients have to make tough decisions.

    To suggest that oncologists are throwing chemo at dying folks for no reason demonstrates a glaring inability to use MedLine or UpToDate. Cancer sucks, chemo sucks, and we dump a lot of resources into research into balancing the two.

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  27. GreatOne08 says:

    Yes, using Chemo is basically poisoning the cancer and the patient’s heathly cells. But it is one of our best weapon right now. I agree with Dubner in that one day grandchildren will look back and be horror at the fact that we poison our cancer patients.

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  28. GreatOne08 says:

    Yes, using Chemo is basically poisoning the cancer and the patient’s heathly cells. But it is one of our best weapon right now. I agree with Dubner in that one day grandchildren will look back and be horror at the fact that we poison our cancer patients.

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  29. egretman says:

    Ok billypilgrim37, I’ll give you your little fairy tale. And raise you reality.

    Here’s how it really goes down. Doctor tells cancer patient that his/her cancer has returned. But good news, there’s a new treatment out for just this case. A real miracle drug that has shown great promise. Would you like to have it?

    Patient says, “well, hell yes!”. Patient gets new drug. Dies in 2 months.

    Turns out the new drug extented the life of such patients by 1 to 3 months in clinical trials. More often than not the trials were made statistically significant by cherry picking the data.

    I’m with Dubner here. Pretty much a scam. When your data shows complete remission for 5 years in even 5 out of 10, then you may have an argument for the drug. You may argue for 3 out of 10. Otherwise, get back to work.

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  30. egretman says:

    Ok billypilgrim37, I’ll give you your little fairy tale. And raise you reality.

    Here’s how it really goes down. Doctor tells cancer patient that his/her cancer has returned. But good news, there’s a new treatment out for just this case. A real miracle drug that has shown great promise. Would you like to have it?

    Patient says, “well, hell yes!”. Patient gets new drug. Dies in 2 months.

    Turns out the new drug extented the life of such patients by 1 to 3 months in clinical trials. More often than not the trials were made statistically significant by cherry picking the data.

    I’m with Dubner here. Pretty much a scam. When your data shows complete remission for 5 years in even 5 out of 10, then you may have an argument for the drug. You may argue for 3 out of 10. Otherwise, get back to work.

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  31. Connie H. says:

    What the medical/insurance hierarchy isn’t doing properly: adequate support of diabetics, especially daily maintenance. Do you know many insurance plans only pay for one blood sugar test strip per day? Since the long-term damage from diabetes can be caused by widely fluctuating blood sugar levels, it would seem that the wisest and most cost-effective support would be at least three tests a day to adjust insulin as needed.

    Don’t even get me started about making syringes and needles prescription-only, while we’re on the subject of stupid “medical” practices.

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  32. Connie H. says:

    What the medical/insurance hierarchy isn’t doing properly: adequate support of diabetics, especially daily maintenance. Do you know many insurance plans only pay for one blood sugar test strip per day? Since the long-term damage from diabetes can be caused by widely fluctuating blood sugar levels, it would seem that the wisest and most cost-effective support would be at least three tests a day to adjust insulin as needed.

    Don’t even get me started about making syringes and needles prescription-only, while we’re on the subject of stupid “medical” practices.

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  33. billypilgrim37 says:

    egretman, the absolute vast majority of chemotherapeutic trials right now are not for new drugs. They’re for combinations of chemo agents and dosing regimens trying to optimize outcomes.

    I’m not sure where you derive your supposed knowledge of oncologist behavior, but I’m fairly certain that your characterization of docs pushing supposed miracle drugs is absolutely irrelevant to reality. It certainly wasn’t reality for my family member that died of colon cancer back in February.

    Cardiologists have tremendous financial incentives to perform stenting procedures, but those same financial incentives simply don’t exist in oncology on any similar scale.

    Evidence-based palliative chemotherapy is a good thing when a patient stands to gain a balance of quantity and quality of life. And its existence doesn’t affect an oncologist’s bottomline significantly enough to bolster your anti-physician conspiracy theory.

    “When your data shows complete remission for 5 years in even 5 out of 10, then you may have an argument for the drug.”

    Umm, late stage chemotherapy is typically for palliative purposes only. An extra 3-6 months of quality life would be a pretty noble goal. If that’s the rigor you demand of cancer therapeutics, then we might as well throw most cancer patients out the window of a 20 story building and save you the trouble.

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  34. billypilgrim37 says:

    egretman, the absolute vast majority of chemotherapeutic trials right now are not for new drugs. They’re for combinations of chemo agents and dosing regimens trying to optimize outcomes.

    I’m not sure where you derive your supposed knowledge of oncologist behavior, but I’m fairly certain that your characterization of docs pushing supposed miracle drugs is absolutely irrelevant to reality. It certainly wasn’t reality for my family member that died of colon cancer back in February.

    Cardiologists have tremendous financial incentives to perform stenting procedures, but those same financial incentives simply don’t exist in oncology on any similar scale.

    Evidence-based palliative chemotherapy is a good thing when a patient stands to gain a balance of quantity and quality of life. And its existence doesn’t affect an oncologist’s bottomline significantly enough to bolster your anti-physician conspiracy theory.

    “When your data shows complete remission for 5 years in even 5 out of 10, then you may have an argument for the drug.”

    Umm, late stage chemotherapy is typically for palliative purposes only. An extra 3-6 months of quality life would be a pretty noble goal. If that’s the rigor you demand of cancer therapeutics, then we might as well throw most cancer patients out the window of a 20 story building and save you the trouble.

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  35. Willy says:

    Although medicine (oncology or otherwise) may be one of the “most research, evidence-based fields,” who is funding this research and what are the incentives for finding “evidence” that points in a certain direction.

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  36. Willy says:

    Although medicine (oncology or otherwise) may be one of the “most research, evidence-based fields,” who is funding this research and what are the incentives for finding “evidence” that points in a certain direction.

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  37. jkasbury says:

    Improved imaging techniques will soon make routine screening colonoscopies (talk about invasive) a thing of the past. Likewise, though we have a ways to go at present, vaccines against HPV will hopefully make PAP smears (and the necessary pelvic exams for symptom-free women) unnecessary. Diabetics will be happy to hear that trials are underway for inhaled insulin. Islet cell transplants will one day make type 1 diabetes a thing of the past.

    However, the biggest leaps in medical therapeutics will come when we begin to harness stem cells for targeted tissue regeneration. For example, people suffering from heart failure may receive doses of autologous stem cell that have been pre-treated with surface proteins which targets heart muscle. The result: regenerated heart muscle.

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  38. jkasbury says:

    Improved imaging techniques will soon make routine screening colonoscopies (talk about invasive) a thing of the past. Likewise, though we have a ways to go at present, vaccines against HPV will hopefully make PAP smears (and the necessary pelvic exams for symptom-free women) unnecessary. Diabetics will be happy to hear that trials are underway for inhaled insulin. Islet cell transplants will one day make type 1 diabetes a thing of the past.

    However, the biggest leaps in medical therapeutics will come when we begin to harness stem cells for targeted tissue regeneration. For example, people suffering from heart failure may receive doses of autologous stem cell that have been pre-treated with surface proteins which targets heart muscle. The result: regenerated heart muscle.

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  39. billypilgrim37 says:

    –Imaging colonoscopies won’t remove the need for biopsies of suspicious lesions, which are pretty dang common. They’ll be a great advance and will probably save money and trouble, but they won’t make the mechanical procedures rare by any stretch.

    –Gardasil only targets the HPV subtypes responsible for about 70% of cervical cancers. That’s a LOT of cervical cancer, but I’d be very surprised to see the pap go anywhere during our lifetime.

    –Pfizer’s Exubera (inhaled insulin) is already on the market. We don’t have sufficient data for long-term pulmonary safety, and for some strange reason, Pfizer decided to issue the med in metric units rather than the more familiar IUs. Docs and patients are underwhelmed on the whole.

    I only jumped on Dubner for making a really bad choice in his selection of a therapeutic intervention that will go away soon. I certainly don’t give a blank check to drug and device companies.

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  40. billypilgrim37 says:

    –Imaging colonoscopies won’t remove the need for biopsies of suspicious lesions, which are pretty dang common. They’ll be a great advance and will probably save money and trouble, but they won’t make the mechanical procedures rare by any stretch.

    –Gardasil only targets the HPV subtypes responsible for about 70% of cervical cancers. That’s a LOT of cervical cancer, but I’d be very surprised to see the pap go anywhere during our lifetime.

    –Pfizer’s Exubera (inhaled insulin) is already on the market. We don’t have sufficient data for long-term pulmonary safety, and for some strange reason, Pfizer decided to issue the med in metric units rather than the more familiar IUs. Docs and patients are underwhelmed on the whole.

    I only jumped on Dubner for making a really bad choice in his selection of a therapeutic intervention that will go away soon. I certainly don’t give a blank check to drug and device companies.

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  41. egretman says:

    An extra 3-6 months of quality life would be a pretty noble goal. If that’s the rigor you demand of cancer therapeutics, then we might as well throw most cancer patients out the window of a 20 story building and save you the trouble

    billypilgrim37, that is exactly what I am advocating. It would be more humane to throw them out of a 20 story building than what late-stage practicing oncologist put their patients through.

    A promise of 1 to 3 months is statistical foolishness. Just be honest. Tell them there is nothing you can do. Kiss their butt goodbye and arrange their affairs. Adios amigos.

    Otherwise you are just sucking the hind tit of the health care system.

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  42. egretman says:

    An extra 3-6 months of quality life would be a pretty noble goal. If that’s the rigor you demand of cancer therapeutics, then we might as well throw most cancer patients out the window of a 20 story building and save you the trouble

    billypilgrim37, that is exactly what I am advocating. It would be more humane to throw them out of a 20 story building than what late-stage practicing oncologist put their patients through.

    A promise of 1 to 3 months is statistical foolishness. Just be honest. Tell them there is nothing you can do. Kiss their butt goodbye and arrange their affairs. Adios amigos.

    Otherwise you are just sucking the hind tit of the health care system.

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  43. crquack says:

    This is a fine example of a broad statement which selects one trial and then applies the result to the procedure across the board and is therefore grossly misleading. The trial on angioplasty applied to the treatment of *stable* coronary disease and looked at outcomes such as death and myocardial infarction.

    Most cardiologists agree that PTCA (angioplasty) *is* effective in preventing the above in cases of acute coronary syndrome, particularly with high risk features. Furthermore, PTCA is more effective in relieving symptoms than medication.

    Ask any cardiologist what they would have themselves if they had any of the above conditions.

    Where did you get the idea that hormone replacement therapy was “discredited”? Just because one trial showed that starting it late after menopause is probably harmful does not mean that it applies to patients who are peri-menopausal and suffer the most symptoms. In fact *no* trial showed that these patients are at significant risk.

    Try living with a woman with peri-menopausal symptoms. Many will tell you that a heart attack is a minor risk compared to the daily misery.

    One should avoid generalizations without understanding the deeper issues.

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  44. crquack says:

    This is a fine example of a broad statement which selects one trial and then applies the result to the procedure across the board and is therefore grossly misleading. The trial on angioplasty applied to the treatment of *stable* coronary disease and looked at outcomes such as death and myocardial infarction.

    Most cardiologists agree that PTCA (angioplasty) *is* effective in preventing the above in cases of acute coronary syndrome, particularly with high risk features. Furthermore, PTCA is more effective in relieving symptoms than medication.

    Ask any cardiologist what they would have themselves if they had any of the above conditions.

    Where did you get the idea that hormone replacement therapy was “discredited”? Just because one trial showed that starting it late after menopause is probably harmful does not mean that it applies to patients who are peri-menopausal and suffer the most symptoms. In fact *no* trial showed that these patients are at significant risk.

    Try living with a woman with peri-menopausal symptoms. Many will tell you that a heart attack is a minor risk compared to the daily misery.

    One should avoid generalizations without understanding the deeper issues.

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  45. egretman says:

    One should avoid generalizations without understanding the deeper issues.

    Where’s the fun in that?

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  46. egretman says:

    One should avoid generalizations without understanding the deeper issues.

    Where’s the fun in that?

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  47. synapticmisfires says:

    @ nwhitehe

    ITA, my friend, ITA. Just look at the amount of fairly mainstream diet advice that is in complete, and direct opposition to some other mainstream advice. It’s scary.

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  48. synapticmisfires says:

    @ nwhitehe

    ITA, my friend, ITA. Just look at the amount of fairly mainstream diet advice that is in complete, and direct opposition to some other mainstream advice. It’s scary.

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  49. Marco Polo says:

    A surely more relevant question would be, what factors were involved in persuading people (both practitioners and the suffering public) to give up these, now seen as ineffective, practices?

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  50. Marco Polo says:

    A surely more relevant question would be, what factors were involved in persuading people (both practitioners and the suffering public) to give up these, now seen as ineffective, practices?

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  51. Isn’t it disheartening to know that doctors are motivated by financial incentives just like so many other businesspeople. The fact that so few doctors emphasize nutrition education is good evidence of that. Another fact that bears this out is how effective pharmaceutical companies are in serving as a significant source of medical information for doctors, which became evident in the Vioxx case, when the “dodge” strategy worked so well.

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  52. Isn’t it disheartening to know that doctors are motivated by financial incentives just like so many other businesspeople. The fact that so few doctors emphasize nutrition education is good evidence of that. Another fact that bears this out is how effective pharmaceutical companies are in serving as a significant source of medical information for doctors, which became evident in the Vioxx case, when the “dodge” strategy worked so well.

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  53. egrrl says:

    I would suggest that an awful lot of obstetrics probably should be abandoned because the research just doesn’t back up a lot of what is standard practice.

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  54. egrrl says:

    I would suggest that an awful lot of obstetrics probably should be abandoned because the research just doesn’t back up a lot of what is standard practice.

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  55. rcentor says:

    Oops! Dubner has made an understandable but major error. He has extrapolated the COURAGE study incorrectly. I have blogged at length on this mistake today – Freakology

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  56. rcentor says:

    Oops! Dubner has made an understandable but major error. He has extrapolated the COURAGE study incorrectly. I have blogged at length on this mistake today – Freakology

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  57. MHL says:

    Every the insurance companies pay for any surgery or treatment their rates increase. What about when patients can no longer pay for their insurance?

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  58. MHL says:

    Every the insurance companies pay for any surgery or treatment their rates increase. What about when patients can no longer pay for their insurance?

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  59. billypilgrim37 says:

    In the ideal health care setting, doctors would never counsel their patients on nutrition and exercise. Instead, we’d have much cheaper health educators patients saw in conjunction with their health maintenance visits.

    Policy wise, it’s simply not cost-effective to train a doc for 7-12 years and have them spend an hour a day (2min/patient, 30 patient average day) doing something someone could do with 1-2 years of training, and do much better.

    Given that clinical health educators are still rare, I surely wouldn’t say that docs shouldn’t be offering such counseling now. But that’s just a blatant market failure of a fragmented health care system.

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  60. billypilgrim37 says:

    In the ideal health care setting, doctors would never counsel their patients on nutrition and exercise. Instead, we’d have much cheaper health educators patients saw in conjunction with their health maintenance visits.

    Policy wise, it’s simply not cost-effective to train a doc for 7-12 years and have them spend an hour a day (2min/patient, 30 patient average day) doing something someone could do with 1-2 years of training, and do much better.

    Given that clinical health educators are still rare, I surely wouldn’t say that docs shouldn’t be offering such counseling now. But that’s just a blatant market failure of a fragmented health care system.

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  61. redman says:

    Egretman, your reasoning is applauded. The world needs many more open minds like yours. Thank you.

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  62. redman says:

    Egretman, your reasoning is applauded. The world needs many more open minds like yours. Thank you.

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  63. crquack says:

    You said it, billypilgrim37!

    Doctors do advise on the importance of proper nutrition, but without the details wherein the God lies, the advice is no more useful than that of an economist who tells you to “”Buy low, sell high”.

    One of the major obstacles to proper cardiac care in most Canadian cities (other than the major ones) is the lack and affordability of trained dietitians (their fees are not covered by our supposedly socialized medicare system).

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  64. crquack says:

    You said it, billypilgrim37!

    Doctors do advise on the importance of proper nutrition, but without the details wherein the God lies, the advice is no more useful than that of an economist who tells you to “”Buy low, sell high”.

    One of the major obstacles to proper cardiac care in most Canadian cities (other than the major ones) is the lack and affordability of trained dietitians (their fees are not covered by our supposedly socialized medicare system).

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  65. dbdy says:

    Coronary artery disease is a systemic process. Stenting is like plugging a hole in old dike with many potential holes. It’s only worth doing if there is an impending flood that will wash you away(ie kill you). Then there is the issue of the stent eventually clogging in a subset of cases.

    Statins however are underutilized and are truly a remarkable class of drugs. The #1 indication for them by the FDA is not to lower cholesterol#’s, but rather the prevention of heart attacks. If you survey MD’s, a very high percentage of them are taking them. But there is insufficient incentive to use them for docs. A stent pays the cardiologist a hundred times more than a prescription for a statin.

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  66. dbdy says:

    Coronary artery disease is a systemic process. Stenting is like plugging a hole in old dike with many potential holes. It’s only worth doing if there is an impending flood that will wash you away(ie kill you). Then there is the issue of the stent eventually clogging in a subset of cases.

    Statins however are underutilized and are truly a remarkable class of drugs. The #1 indication for them by the FDA is not to lower cholesterol#’s, but rather the prevention of heart attacks. If you survey MD’s, a very high percentage of them are taking them. But there is insufficient incentive to use them for docs. A stent pays the cardiologist a hundred times more than a prescription for a statin.

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  67. tgove says:

    There is very compelling evidence that cancer drug utilization is strongly influenced by the reimbursement rate — in other words, physicians use therapies that generate revenue (see the Jacobson, et al paper in Health Affairs from last March/April). Where reimbursement is not an issue (in academic centers, for example) or where reimbursement rates are modest (Medicare, some commercial markets), the dynamics of utilization look much different, and physicians ask a lot more questions about the efficacy/side effect tradeoff. Whereas in a high reimbursement market a product offering little or no benefit may be added to a regimen for financial reasons, in a low reimbursement market that product will not be added.

    This is not exclusively about late stage cancer, but earlier stage disease as well.

    Another factor that will influence the use or non-use of late-stage chemo will be the cost consequences to the patient. As patients pay more of the costs of the drugs, we should expect that treatments offering only marginal benefit (e.g. cetuximab, panitumumab) with significant side effect burdens and high costs (>$6,000/month) will see a moderation of use. Somewhat surprisingly, physicians believe many of these products to be “too much hype and not enough benefit”. The cost consequences to the patient, combined with deteriorating economics for physicians, will have a significant impact on the use of late-stage cancer therapeutics.

    Finally, while targeted molecular therapies look promising in some cases, with the exceptions of Gleevec and Herceptin, most of the current products have major weaknesses due largely to the fact that they target proteins that have a normal physiologic function (EGFR, VEGF, etc.) and, as a consequence, have significant serious side effects and risks of adverse events.

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  68. tgove says:

    There is very compelling evidence that cancer drug utilization is strongly influenced by the reimbursement rate — in other words, physicians use therapies that generate revenue (see the Jacobson, et al paper in Health Affairs from last March/April). Where reimbursement is not an issue (in academic centers, for example) or where reimbursement rates are modest (Medicare, some commercial markets), the dynamics of utilization look much different, and physicians ask a lot more questions about the efficacy/side effect tradeoff. Whereas in a high reimbursement market a product offering little or no benefit may be added to a regimen for financial reasons, in a low reimbursement market that product will not be added.

    This is not exclusively about late stage cancer, but earlier stage disease as well.

    Another factor that will influence the use or non-use of late-stage chemo will be the cost consequences to the patient. As patients pay more of the costs of the drugs, we should expect that treatments offering only marginal benefit (e.g. cetuximab, panitumumab) with significant side effect burdens and high costs (>$6,000/month) will see a moderation of use. Somewhat surprisingly, physicians believe many of these products to be “too much hype and not enough benefit”. The cost consequences to the patient, combined with deteriorating economics for physicians, will have a significant impact on the use of late-stage cancer therapeutics.

    Finally, while targeted molecular therapies look promising in some cases, with the exceptions of Gleevec and Herceptin, most of the current products have major weaknesses due largely to the fact that they target proteins that have a normal physiologic function (EGFR, VEGF, etc.) and, as a consequence, have significant serious side effects and risks of adverse events.

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  69. liam2007 says:

    I saw an article showing that survival rates in head injury cases improved when cranial pressure (due to swelling) was not relieved by doctors. Perhaps the icing of swellings in soft tissue injuries will be frowned on in future?

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  70. liam2007 says:

    I saw an article showing that survival rates in head injury cases improved when cranial pressure (due to swelling) was not relieved by doctors. Perhaps the icing of swellings in soft tissue injuries will be frowned on in future?

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  71. Marcello Jun says:

    Endoscopic Sinus Surgery.

    Not because it’s “quack” medicine, but simply because medical treatment and prophylaxis will become better and cheaper and more efficient.

    Posters would do better to realize, as Mr. Dubner subtley acknolowdges, that such is the nature of Science in general and Medicine in specific — the more we learn and evolve, the more likely our current state of knowledge and practices will seem counter-intuitive, naive, and absurd to future generations. No need for conspiratorial fantastical hysteria!

    Just like the ‘free market’ is wont to do, Science eventually corrects itself.

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  72. Marcello Jun says:

    Endoscopic Sinus Surgery.

    Not because it’s “quack” medicine, but simply because medical treatment and prophylaxis will become better and cheaper and more efficient.

    Posters would do better to realize, as Mr. Dubner subtley acknolowdges, that such is the nature of Science in general and Medicine in specific — the more we learn and evolve, the more likely our current state of knowledge and practices will seem counter-intuitive, naive, and absurd to future generations. No need for conspiratorial fantastical hysteria!

    Just like the ‘free market’ is wont to do, Science eventually corrects itself.

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  73. Valerie says:

    I can’t believe no one has mentioned the ridiculously risky gastric bypass. Not to mention that after a bypass one can no longer absorb enough nutrients from food to avoid deficiencies. Bypass patients have to drink protein shakes and take vitamins for the rest of their lives. And many patients don’t lose weight or manage to regain any weight lost!

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  74. Valerie says:

    I can’t believe no one has mentioned the ridiculously risky gastric bypass. Not to mention that after a bypass one can no longer absorb enough nutrients from food to avoid deficiencies. Bypass patients have to drink protein shakes and take vitamins for the rest of their lives. And many patients don’t lose weight or manage to regain any weight lost!

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  75. Brad says:

    I don’t feel that the general public just abides by their doctors diagnosis any more. With the wealth of information on the internet, you can type your diagnosis into a search engine and come up with hundreds of reliable sites giving suggestions.

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  76. Brad says:

    I don’t feel that the general public just abides by their doctors diagnosis any more. With the wealth of information on the internet, you can type your diagnosis into a search engine and come up with hundreds of reliable sites giving suggestions.

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  77. Lor says:

    You asked what should be discredited: Asthma medication is a huge farce – please research the Buteyko breathing method. Buteyko was a Russian professor, and his methodology has resulted in up to 96% success rates in small clinical trials. Success being defined as the ability of an Asthma sufferer to ditch the cortisone & inhalers (completely), and control their condition.

    But there is nothing to be sold, other than a few lessons in breathing. And it isn’t a solution in a bottle – it takes months to get ones breathing under control with the exercises. The Buteyko method is just not commercial, as there really isn’t any pill for the pharmaceutical companies to sell, but it is hugely effective.

    http://en.wikipedia.org/wiki/Buteyko_method

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  78. Lor says:

    You asked what should be discredited: Asthma medication is a huge farce – please research the Buteyko breathing method. Buteyko was a Russian professor, and his methodology has resulted in up to 96% success rates in small clinical trials. Success being defined as the ability of an Asthma sufferer to ditch the cortisone & inhalers (completely), and control their condition.

    But there is nothing to be sold, other than a few lessons in breathing. And it isn’t a solution in a bottle – it takes months to get ones breathing under control with the exercises. The Buteyko method is just not commercial, as there really isn’t any pill for the pharmaceutical companies to sell, but it is hugely effective.

    http://en.wikipedia.org/wiki/Buteyko_method

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  79. ajit says:

    Problem is defining “late stage” of cancer. Doctors are poor at determining who is in a last stage and thus fit only for hospice care. A study in British Medical Journal published in 2000 (volume 320, page 469) where 343 doctors estimated the survival of 468 terminally ill patients showed that only 20% of the predictions were accurate. Average life of a patient on the study was 24 days; most doctors (63%) overestimated it this by a factor of 5.
    Similar results were seen in a more recent study (Journal of Clinical Oncology 2007; 25; 3313), with estimates being “overtly optimistic”.
    When you think that a patient has a relatively long life in front of him/her, there is a temptation to try and prolong it by further treatment. More accurate predictors of prognosis are needed to avoid this.

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  80. ajit says:

    Problem is defining “late stage” of cancer. Doctors are poor at determining who is in a last stage and thus fit only for hospice care. A study in British Medical Journal published in 2000 (volume 320, page 469) where 343 doctors estimated the survival of 468 terminally ill patients showed that only 20% of the predictions were accurate. Average life of a patient on the study was 24 days; most doctors (63%) overestimated it this by a factor of 5.
    Similar results were seen in a more recent study (Journal of Clinical Oncology 2007; 25; 3313), with estimates being “overtly optimistic”.
    When you think that a patient has a relatively long life in front of him/her, there is a temptation to try and prolong it by further treatment. More accurate predictors of prognosis are needed to avoid this.

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