
Medical Reversals - mzs
https://elifesciences.org/articles/45183
======
J-dawg
I am reminded of this story of a medical reversal:
[https://www.badscience.net/2011/03/when-ethics-committees-
ki...](https://www.badscience.net/2011/03/when-ethics-committees-kill/)

> _This is not an abstract problem. Here is one example. For years in A &E,
> patients with serious head injury were often treated with steroids, in the
> reasonable belief that this would reduce swelling, and so reduce crushing
> damage to the brain, inside the fixed-volume box of your skull._

> _Researchers wanted to randomise unconscious patients to receive steroids,
> or no steroids, instantly in A &E, to find out which was best. This was
> called the CRASH trial, and it was a famously hard fought battle with ethics
> committees, even though both treatments – steroids, or no steroids – were in
> widespread, routine use. Finally, when approval was granted, it turned out
> that steroids were killing patients._

> _This was an extraordinary piece of work. At the end of the trial, where the
> head injuries were pretty bad (a quarter of the people died), it turned out
> there were two and a half extra deaths for every one hundred people treated
> with steroids._

~~~
e40
_in the reasonable belief that this would reduce swelling_

It's amazing to me that they wouldn't track this from the beginning, and do
the experiment, to vet the idea. I mean, they went all in on it, why not give
it to 50% of the head injuries and see?

~~~
e40
It seems like part of the world is going in the direction of verify don't
assume, and the other half has decided that their gut always has the right
answer. It's a strange time to be alive.

~~~
AstralStorm
Except some of those won't be. We're taking life or death decisions here. (Or
at least productive years of life.) There is always a cost and this cost did
come to bite you sooner or later.

The highest standard for decision making is definitely not "going with your
gut". I wonder if anyone is actually claiming this or you just like to build
strawmen. Typical reasons to adopt a practice is politics and marketing, then
legacy, only then followed by effectiveness...

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jessriedel
I'm first in line to criticize unnecessary medicine based on flimsy evidence,
but in principle there's nothing wrong with medical reversals. As you begin to
collect data about anything, your best guess for the truth will be bouncing
around wildly and only slowly settle down as the data accumulates. "Do no
harm" is ok as a rule of thumb to counteract the natural tendency for doctors
to err on the side of over-medicating (and to account for our expectation that
a random intervention is net negative), but it's silly to use as an inflexible
principle. If you're so cautious that you never recommend harmful
interventions, you're missing out on plenty of interventions that are positive
in expectation.

Do any of these studies of "medical reversals" attempt to estimate how often
reversals should be made ideally?

~~~
J-dawg
I suppose if you end up reversing an established thing, you'd better have a
damn good reason why you were doing that thing in the first place.

Why give any treatment that hasn't been through a randomised trial? (Unless,
of course, you are giving it as part of a trial)

~~~
the_af
I'm not sure I understand the terminology. If "medical reversal" means --
apologies if I misunderstood -- "stopping a medical treatment which hasn't
been shown to be helpful, or one that is not backed by evidence", why is the
reversal itself the problem?

Shouldn't the focus be on applying treatments backed by robust evidence in the
first place, rather than on medical reversals? Of course the two are
connected, but the wording seems odd. Medical reversals seem to be a symptom
of the problem, not the root cause.

Of course, I might be misunderstanding the terminology.

edit: I've read the abstract and it seems I am indeed misunderstanding the
definition, but for the life of me I cannot understand what "medical reversal"
means in layman words.

~~~
scott_s
My laymen's definition of medical reversal: a current medical practice that is
worse than what we did before.

~~~
the_af
Ah, thanks! So indeed I was mistaken. I misunderstood it to mean "reverting an
unproven/inconclusive treatment" when it actually means "conducting an
unproven/inconclusive treatment".

I was confused because "reversal" sounds to me as the act of ceasing to do
something, i.e. "reverting" the treatment (if you're a programmer: I thought
of "reversal" as in "reverting a mistaken commit using git"). I now see it's a
technical term which means the opposite!

Now it all makes sense.

~~~
scott_s
Hmm. Sorry, no, that's not my understanding. I think the phenomenon of
_discovery_ is distinct from the changing of behavior. I believe it is the
discovery itself that is called a "medical reversal." I think the submitted
paper defines it in relatively laymen's terms: "Medical reversal occurs when a
new clinical trial — superior to predecessors by virtue of better controls,
design, size, or endpoints — contradicts current clinical practice."

I think an important difference is that current clinical practice is not
necessarily _thought_ to be "unproven/inconclusive." Rather, I think people
think it has a solid foundation, but better investigation reveals that not to
be true.

------
DoreenMichele
Someone on HN once left a comment that made it really clear why it is better
to "let x guilty men go free than incarcerate one innocent man." A big part of
their point: if you put an innocent man in prison, you are _still letting a
guilty man go free._ The real killer is still out there. And you aren't even
looking for him because you have announced "case closed."

So this is similar to part of the problem with low value or harmful medical
practices proliferating. If you are doing x, you probably won't be doing y.
Its use actively excludes the use of better therapies in most cases.

But, worse, biological processes are complicated and there can be critical
windows of time for x to happen. If people are ignorant of such a window and
how to use it effectively, some people will have dramatically better outcomes
than others in a way that promotes the all-too-common perception that it's
just random. For medical issues, this can be literally life or death.

Furthermore, use of low value procedures pollutes the data with lousy
outcomes. If you don't identify that x treatment is the culprit, then the
perception that patients with x condition have yadda prognosis proliferates.
This actively promotes poor outcomes by encouraging doctors and patients alike
to accept a poor outcome as _the norm_ and _to be expected_ for your
condition.

Additionally, once a practice proliferates, it tends to persist. It becomes a
habit. Habits are hard to break.

And doctors are people. Most people want to _do something, anything_ rather
than doing nothing. For a doctor, doing _something, anything_ is probably less
likely to get them sued for malpractice than taking a wait-and-see approach,
even if waiting is the wiser move. It's going to be harder to defend the
choice to do nothing if it goes to court. It flies in the face of how the
human mind works.

It takes substantial education, wisdom and self restraint to do nothing when
the problem is your responsibility to fix. Even if you know that's currently
the best course of action, it is all too easy to cave in the face of social
pressure, especially if you have reason to believe that not _going along to
get along_ may come with substantial penalties (like a malpractice lawsuit).

To my mind, the following linked article is related to that last point, but I
also wrote it and I've had four hours of sleep. Apologies if it seems
unrelated:

[https://raisingfutureadults.blogspot.com/2019/01/the-hand-
li...](https://raisingfutureadults.blogspot.com/2019/01/the-hand-licking-
incident.html)

~~~
colechristensen
>want to do something, anything

Culture could be changed from the expectation that most encounters with a
doctor result in an action. The problem is visiting a doctor costs hundreds of
dollars for a short amount of time. It doesn't matter if you have insurance or
free universal health care, it still costs hundreds of dollars regardless of
the layers of abstraction you put on top of the billing.

I personally wish encounters with doctors resulted in more tests or other data
gathering (and hopefully that data made available de-identified for analysis)

------
ncmncm
This work seems to assume that "randomized, controlled trials" necessarily
produce correct and meaningful results, that such a trial is necessarily
meaningfully possible at all, and that, where either of these is false, the
treatment is valueless.

But a randomized, controlled trial can produce meaningful results only where
just one malady is being treated. The DSM is full of diagnoses that lump
together a whole family of pathologies with (sometimes only superficially)
similar symptoms, but entirely different causes. This is especially notable in
psychiatry, but far from unique; for an extreme example, cancers.

The reason such trials produce bad results is that there is no way to know
which patients have the particular pathology whose cause is addressed by the
treatment under test, without actually administering it to see.

Actually performing such a trial, with an effective treatment agent, tends to
produce strong results for a few patients, and null or actually harmful
results in the rest. Nothing is wrong with the treatment, when applied to the
patients who should get it, but the trial fails to produce a positive result.

Confusing a bad trial with a bad treatment should be an error made only by
ignorant observers, but it is all too commonly seen in apparently respectable
media.

~~~
AstralStorm
> Actually performing such a trial, with an effective treatment agent, tends
> to produce strong results for a few patients, and null or actually harmful
> results in the rest. Nothing is wrong with the treatment, when applied to
> the patients who should get it, but the trial fails to produce a positive
> result.

Do you have any actual data to support this assertion, or is it just a weak
sophism, same as used to support ineffective "integrative medicine" practices?

~~~
ncmncm
What sort of data do you imagine would convince you? Or is this just a
reflexive rejection of change?

Insisting on data that demonstrates invalid RCTs while assuming that DSM
diagnoses precisely distinguish causes, on the basis of no data at all, puts
the cart before the horse.

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Gatsky
Searching for the scientific interest here... this is a list of trials that
changed medical practice. The senior author has previously published such a
list and written a book about it. What does this article add?

