
The proportion of medical procedures unsupported by evidence may be nearly half - lnguyen
https://www.vox.com/the-big-idea/2017/12/28/16823266/medical-treatments-evidence-based-expensive-cost-stents
======
bob_theslob646
>As surgeon and health care researcher Atul Gawande observes, “Millions of
people are receiving drugs that aren’t helping them, operations that aren’t
going to make them better, and scans and tests that do nothing beneficial for
them, and often cause harm.”

I am not trying to defend doctors but the article left out a little detail
that messes up the entire system.

Malpractice Insurance

In the United States, if God forbid , they happen to not do a procedure or
precautionary test, and the patient ends up affected or imparied in some way
or form, R.I.P that doctor's insurance.

Only in America can you sue to get that _witchcraft money_ ( apparently
copious amounts of money brings someone back to life) when someone dies after
surgery complications in that life saving procedure.

Doctors/surgeons are not God, their is always a risk in surgery.

~~~
restuijs
People should be able to sue. It's the only natural incentive for good
practice. Otherwise there's no consequences for poor practice.

On the other hand, people should also be able to lose those lawsuits, and
should also be able to sue for unnecessary preventative procedure, and the
basis of winning or losing should be based on empirical evidence pertaining to
risk.

Insurance isn't the problem, nor are malpractice lawsuits. It's the inherent
risk in the field. Malpractice issues are greatly overstated in health care
debates.

~~~
rscho
Well, from what I see in the US, the risk to be sued actually encourages a lot
more damaging procedures than it makes people rigorous. That's not to say
people shouldn't be allowed to sue. Actually, there is really no good solution
to this problem.

The best situation I have seen is where people do sue, but hospitals provide
legal protection for their employees (public sector in western Europe).
Employees there still fear for their jobs, but not enough to put patients
through nearly as much useless and risky crap as in the US. Patients there are
also far less prone to sue, since the success rate of legal action is low. All
in all, everyone seems to benefit from a little less tension in the system.

Of course, you will always find people who feel (perhaps rightly so) that they
were wronged, and that we should cut the hands of the bad docs. Finding
balance in those matters is a difficult social exercise.

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otp124
After journal bias, conflicts of interests, and corruption, I now hold little
remaining faith in the justice of “science”. It seems the “scientific method”
I learned decades ago is inconvenient to publishers and consumers alike.
(Also, I’ve had personal doctors push drugs on me when it was clear they were
getting a kickback).

It’s frustrating when people read headlines and claim ”science” in a
conversation, when the root of the research is fraudulent and the observer has
never attempted to verify. When I challenge their assumptions, they are
incredulous that I would question “science”.

~~~
maroonblazer
Let's not throw the baby out with the bathwater. There's still plenty of
excellent science being done every day; it's just not being written about in
outlets like vox.com.

The solution to the problems you cite is more and better science.

~~~
joe_the_user
Even more, it's only now that we're seeing some people apply a rigorous
scientific and statical lens to medicine as a whole,

A good portion of that fifty or whatever percent of procedures that don't any
backing evidence exist through being grandfathered-in from the medical
tradition. Beyond the germ theory of disease, medicine circa 1900 was
appalling in multiple ways.

Medicine continually advances, at least in parts. Hopefully that advance can
continue against the grain of multitude of problems we see.

------
tcj_phx
If science advances one funeral at a time, what can be done about institutions
that insist on bing wrong? The American Heart Association has a lot to answer
for.

Sometimes doctors do good work, sometimes their training leaves much to be
desired.

~~~
kiliantics
> their training leaves much to be desired

As someone who teaches pre-med students, I can attest to this! When I see
their performance in my class and realise they are trying to become doctors
and surgeons, I shudder to imagine being treated by them. I think easily 80%
don't show enough competence at that point to have my trust in their
abilities. I teach them a required experimental physics class and believe
doctors should have a scientific mentality when it comes to treatment but very
few come out appreciating the scientific method and how to approach empirical
problems. I fear many will just end up treating patients with a cookie-cutter
approach and cashing in.

~~~
ams6110
Isn't it the case that every common diagnosis has an established "reasonable
and prudent" treatment?

It seems to me that the main skill of a doctor is making the correct
diagnosis. Once that's done, treatment (at least in the vast majority of
cases) is going to be perfunctory.

And even the diagnosis itself is going to be, in most cases, the "most likely"
condition that explains the patient's symptoms.

~~~
tcj_phx
Sometimes a diagnosis is useful, sometimes it's a useless (harmful)
simplification. People are always more complex than their diagnosis.

Specialists have a stranglehold on medicine:
[https://www.nytimes.com/2017/06/03/opinion/sunday/the-
specia...](https://www.nytimes.com/2017/06/03/opinion/sunday/the-specialists-
stranglehold-on-medicine.html)

------
rednerrus
The first day of med school they tell you "50% of what we tell you isn't true,
we don't know which 50%."

~~~
rhinoceraptor
Except for the diet stuff, that is totally based on rock solid evidence,
there's no possible way that they've been dead wrong for 50 years and are
covering it up. Just because a high fat low carb diet improves every possible
health marker doesn't mean it's healthy!

------
trhway
a joke either from Gray's Anatomy or something similar: The dean of med school
at graduation ceremony - "Half of what we've taught you here will be proven
wrong in 5 years. The problem is what we don't know which half. "

------
sandworm101
>> Before being randomized to receive the operation or the sham...

I know that people opt-in to such studies, but what exactly does a "sham"
stenting procedure involve? I find it hard to believe that any hospital would
insert something along a blood vessel and into a heart, or even just
anesthetize a patient, for the purposes of staging a false surgery. These are
commonplace but not risk-free procedures. What exactly does it take to
convince someone that a piece of metal has been inserted into their heart? Are
they presented with false x-rays and other records? Are they ever told the
truth? How do they react when they learn that it has all been a sham?

~~~
nonbel
Here is one example:

>"In all patients, a research invasive physiological assessment of fractional
flow reserve (FFR) and instantaneous wave-free ratio (iFR) was done. After the
administration of intracoronary nitrate, a pressure wire was placed in the
distal vessel at least three vessel diameters beyond the most distal stentable
stenosis.

[...]

In the placebo group, patients were kept sedated for at least 15 min on the
catheter laboratory table and the coronary catheters were withdrawn with no
intervention having been done.

[...]

After the follow-up assessments, study participation was complete, and
patients and physicians were then unblinded to the treatment group allocation.
Patients who had the placebo procedure had the opportunity to choose to
undergo PCI after consultation with their physician."

[http://www.thelancet.com/journals/lancet/article/PIIS0140-67...](http://www.thelancet.com/journals/lancet/article/PIIS0140-6736\(17\)32714-9/abstract)

So it looks like they did an exploratory surgery on the sham patients, then
just left them laying sedated on the table.

------
raverbashing
Ok, so how installing a shunt on a blocked artery can possibly _not work_?
(Not alleviating chest pain is "understandable", not reducing the risk of
heart attacks makes no sense to me)

This article makes some "hand waves" about how understanding of the disease
was simplified [https://www.vox.com/science-and-
health/2017/11/3/16599072/st...](https://www.vox.com/science-and-
health/2017/11/3/16599072/stent-chest-pain-treatment-angina-not-effective) but
the fact is blocked arteries don't let blood flow.

~~~
joshgel
So ya that's what all cardiologists thought. Many still think this. They may
even be right. But we don't have EVIDENCE that this does anything to prevent
death, heart attacks or even reduce chest pain.

To be clear though, they aren't talking about ACUTELY closed arteries as in a
heart attack or myocardial infarction, when there is a plaque rupture and a
blood thrombus that develops to cut off blood supply suddenly. But rather,
when blood flow, which has been slowly narrowing over years, starts causing
chest pain on physical exertion, when the heart muscle distal to the narrowing
is asking for more oxygen than the artery can supply.

We put stents in a lot of these people, because we like to try to help them,
but there isn't much evidence that it helps. It may help, but we haven't been
able to prove it yet. Or it may help select people, but we don't know which
people to select. But many will still keep getting these stents. Medicine is
tricky.

------
stcredzero
I would hazard a guess that the overall proportion of business procedures
unsupported by evidence is nearly half as well.

~~~
jayd16
Are any? What kind of double blind business experiments have taken place?

~~~
stcredzero
You do realize that there are forms of "supported by evidence" which fall far
short of double blind tests.

