An epidemic of unnecessary and unhelpful medical treatments

One interesting point made in the article is that an awful lot of the gains we have made in life expectancy have come from public health rather than medical advances. The article claims that the increase from the public health revolution in the late 1800s did more to increase life expectancy than antibiotics. Which makes sense, not getting sick is more effective than any treatment once you are sick.<p>A sibling comment mentions that lobbyists worked to get the <i>21st Century Cures Act</i> passed, but a potentially bigger issue with the act is that it transfers $3.5 billion of public health spending to medical research.

Adding to this article (I&#x27;m not a medical professional and not giving advice), the same inferior medical outcomes are attributed to most, if not all forms of back surgery. Physical therapy outperforms most or all back surgery with much fewer side effects, etc. This is covered extensively in the book How Doctors Think (<a href="https:&#x2F;&#x2F;www.amazon.com&#x2F;How-Doctors-Think-Jerome-Groopman&#x2F;dp&#x2F;0547053649&#x2F;ref=mt_paperback?_encoding=UTF8&amp;me=" rel="nofollow">https:&#x2F;&#x2F;www.amazon.com&#x2F;How-Doctors-Think-Jerome-Groopman&#x2F;dp&#x2F;...</a>) as well as articles like this Ars Technica one: <a href="https:&#x2F;&#x2F;arstechnica.com&#x2F;science&#x2F;2017&#x2F;02&#x2F;doctors-lower-back-pain-is-like-a-cold-minor-annoying-and-temporary&#x2F;" rel="nofollow">https:&#x2F;&#x2F;arstechnica.com&#x2F;science&#x2F;2017&#x2F;02&#x2F;doctors-lower-back-p...</a>. You see the same with exercise outperforming anti-depressants in most cases, again with much fewer side effects. (For example: <a href="https:&#x2F;&#x2F;www.theatlantic.com&#x2F;health&#x2F;archive&#x2F;2014&#x2F;03&#x2F;for-depression-prescribing-exercise-before-medication&#x2F;284587&#x2F;" rel="nofollow">https:&#x2F;&#x2F;www.theatlantic.com&#x2F;health&#x2F;archive&#x2F;2014&#x2F;03&#x2F;for-depre...</a>)<p>The kicker is that doctors will often refuse these same treatments when offered, which is not a good reflection on their efficacy (again covered in How Doctors Think). This is not an indictment of modern medicine (which is often very effective on acute care), just a recognition of the limitations.

This is only a problem in the US (aka &quot;list of countries with private healthcare&quot;). In Canada, we are actively trying to prevent any medical procedure possible because of the huge expense.<p>I just completed a huge app to educate and prevent diabetic foot amputations. It costs $70,000 to remove a foot and the government is really trying to cut down on these if they are preventable. Patient gets to keep their foot, government doesn&#x27;t have to spend money - win win!<p>In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don&#x27;t get the $70k from the surgeries and you also don&#x27;t get to subscribe them to a lifetime of therapy and prosthetics. Chop off more feet, I say!

Sadly, the problem is not just excessive treatment, but also lack of them, for the exact same reason: medics seemly hate science.<p>Example: Thyroid disease diagnostic and treatment problems are so common, that there are organizations made solely to support thyroid patients, including having lawyers specialized in suing doctors to force them to start treatment...<p>The reason for that, is that although there is plenty of research showing that the 80s blood tests are too conservative (they only show positive to people that are usually too damaged beyond any repair), many doctors insist in using solely those tests, and ignore symptoms and newer blood tests.<p>This does have to do with pharmaceutic industry though, some of the organizations pushing for the 80s tests are all supported by pharma companies, and the same companies also have lobbists that try to get in the way of allowing research of treatments that would skip such companies, for example many patients only improve when using &quot;alternative&quot; but centuries old methods that were known to work for centuries, yet lobbists and pharma companies try to convince doctors and politicians that these ancient methods are &quot;wrong because they are old&quot;, and don&#x27;t allow even research to proceed properly, the leading manufacturer of thyroid medicine that works is in Thailand, because in most other countries their business is considered shady or sketchy.<p>Same thing happen in psychiatry, problems that are popular in the public mind are overdiagnosed, specially when they have expensive medication, yet when the problems aren&#x27;t popular, psychiatrists refuse to treat sufferers. I found a strange case with ADHD: kids are being pumped full of meds due to the fact that they keep disrupting classrooms and ADHD is a &quot;popular&quot; disease with kids, but all adults I know that are actual sufferers from ADHD to the point of disrupting their adult lives, struggle to find treatment, with the usual excuse from doctors being that the meds are &quot;too dangerous&quot; (then why give it to the kids by the boatload?) or that people in their 20s seeking meds must be some kind of junkie looking to boost academic performance, nevermind if non-academic symptoms are there too.

&gt;The 21st Century Cures Act—a rare bipartisan bill, pushed by more than 1,400 lobbyists and signed into law in December—lowers evidentiary standards for new uses of drugs and for marketing and approval of some medical devices.<p>It shows again that we will not have sane healthcare system when there are thousands of lobbyist working to keep it insane.

Surprised every time I&#x27;m in the US and see commercials for drugs and procedures that are administered by doctors being directed towards patients with the ending &quot;ask your doctor about xyz&quot;.<p>I&#x27;m fairly sure this kind of thing ends up with patients asking&#x2F;pressuring doctors for treatments they don&#x27;t need.

Is there a process or technology to avoid unnecessary medical treatment?<p>The article mentions how one patient googled his condition and sought a second opinion. I imagine that this direction is common among patients.<p>I am afraid that once I get old I will also be pushed to have unnecessary treatments.

Sometimes medicine helps patients, sometimes the medical-industrial complex makes work for itself. I took a lot of medicaid patients to &amp; from doctor appointments where nothing much was accomplished.<p>&gt; In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that <i>stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all.</i> In general, Brown says, <i>“nobody that’s not having a heart attack needs a stent.”</i> [...] Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure. [emphasis added]<p>(This comment recycled from the earlier submission of the propublica version this story: <a href="https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=13705761" rel="nofollow">https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=13705761</a> )

This is a very important issue. Doctors are over prescribing and jumping to unneeded surgeries. The question is, are they doing it out of fear of a malpractice lawsuit for denying a patient what they need or is it from kickbacks, incentives and the knowledge that the persons insurance will pay them?<p>Just because something works doesn&#x27;t mean it&#x27;s not a broken system.<p>Suprised that no one else has commented on this article.

<i>Three months later, his cholesterol had improved markedly, he had lost 15 pounds, and the chest pain never returned.</i><p>And it just goes to show you, that Dr. Brown might have saved the executive a stent procedure, but they are still promulgating the myth that cholesterol causes CHD. It&#x27;s a side effect not the cause. There are plenty of people that have high cholesterol and don&#x27;t have blocked arteries.<p>&lt;sigh&gt;

I have, according to my MRI, severe cervical stenosis. I also have carpal tunnel, which was diagnosed first. Based on my symptoms and the awful looking MRI, 4 highly regarded spine surgeons recommended a 2 level fusion right away. The 5th doctor, instead recommended carpal tunnel and ulnar nerve releases. My symptoms abated by 80+% and is something I can live with comfortably.<p>None of the 4 other doctors even considered dealing with my carpal tunnel first, which, combined with stenosis causes what&#x27;s called a &#x27;double crush&#x27; scenario. Only one surgeon recommended the least invasive and risky procedure for me! Even though a fusion in the future is likely, for now the risk - reward for such a procedure does not warrant immediate action.<p>I also think it&#x27;s worth noting that that 5th doctor is the only female of the group. She was the only one that didn&#x27;t seem gung-ho about the fusion. I&#x27;m not saying gender plays a role but...

The article gives an introductory example of a patient that was referred to two different cardiologists, both of whom wanted to do an angiogram. The article doesn&#x27;t mention of course that the cardiologists get paid per angiogram performed. The remuneration per unit time for seeing the patient in clinic and carefully discussing the options and evidence is drastically less than just doing the angiogram. Some cardiologists will also have a target number of angiograms they need to perform every year specified by arrangements with the angiogram facility.<p>So although it is widely known that doing angiograms and inserting stens in patients with stable coronary artery disease is a waste of time, perverse incentives in a fee for service model result in these outcomes. As such it isn&#x27;t a good example of evidence-free medicine. In Australian public hospitals, the cardiologists are paid the same salary regardless of whether they do zero or 1000 angiograms a year. They are very happy not to do unnecessary angiograms in line with the current evidence. If anything, this introductory example shows that a health system needs to be set up to facilitate and encourage evidence-based practice.<p>Otherwise this article rehashes many points about clinical trials and interpreting medical evidence, without a really coherent theme, except maybe to (yet again) criticise doctors.<p>Things have improved in the last 10 - 15 years. Clinical trials come under more scrutiny, trial pre-registration has become more common (although not strictly enforced), health systems gather more and more data about patient outcomes outside of clinical trials and manipulative marketing practices by pharmaceutical companies have been curtailed drastically.<p>In my opinion, the challenges for evidenced based medicine in the next decade are:<p>1. Getting some decent data about nutrition. There are really remarkably few useful things we can say about how nutrition relates to health.<p>2. Reducing unnecessary interventions towards the end of life in an ageing population. Healthcare and healthcare research is not well suited to de-escalating care.<p>3. Transitioning from a one-size-fits-all approach doing clinical trials in 1000s of undifferentiated patients, to collecting 1000s of data points about each individual patient (blood and metabolic variables, genome sequencing, immune profiling, microbiome etc) and using that data to get them healthy and keep them that way. Needless to say, the difficulties in doing this will make doing a randomised controlled trial look like a walk in the park.<p>4. Fighting pseudo-scientific diagnostic tests and treatments. Examples of this are everywhere - Theranos, gene therapy clinics in undisclosed locations in South America, quantified self services that have no proven health benefits, virtually every supplement ever sold, multivitamins...<p>5. Fighting the politicisation of health care. This is a very worrying trend that can easily render all our scientific efforts irrelevant - eg anti-vaxxers, far-right intolerance of harm minimisation measures like abortion and decriminalising drug use.

Does anyone know what the problem is that the 21st Century Cures Act is solving? The claim was made that treatments are being withheld pending FDA approval. Is it illegal to use FDA-unapproved drugs, or is it that insurance is not covering unproven treatments?

&gt; Steven Galson [...] has called the strengthened approval process created in 1962 the FDA’s “biggest contribution to health.” Before that, he said, “many marketed drugs were ineffective for their labeled uses.”<p>Sam Peltzman in &quot;Regulation of Pharmaceutical Innovation&quot; provides statistical evidence that the &quot;safe and effective&quot; 1962 Amendments reduced the development of new effective treatments as well as new ineffective ones, for a net decrease in positive results.

This is an excellent and disturbing article. However, something very important was missed.<p>Let me start by saying that I think that whenever we have a problem in this country, one of the things we should do is look at how other countries handle it to see if there is anything useful we could learn.<p>That being the case, we need to know how other countries handle the over-treatment problem. Are there studies on this? Perhaps the authors could write a follow-up article.

Speaking from my personal experience…<p>My way of life dictates adequate exercise, healthy diet and normal sleep patterns.<p>I come from a family of strict vegans. No, I’m not here to promote either veganism or non-veganism. I’m in my early 40’s and have been exercising since I was a teenager. My routine includes running, cycling, strengthening exercises, lifting light weights, and I do one or two of these a couple times a week. IMO, any and all physical activity is a form of exercise. Usually, my day starts in the early hours. And, as I’m getting older, my endurance levels have been getting significantly better now than during my schooldays, 20’s, or 30’s and with regard to my work I’m getting more productive, too.<p>I also think that those who are not predisposed to any genetic conditions are in a league of their own. Even those who inherit a predisposition can benefit from delayed onset of a condition by practicing a healthy lifestyle. I’m not a medical professional, so my assumptions may or may not carry any weight.<p>All I’m trying to do is keep such treatments as are being discussed here at bay and I will keep at it as long as I possibly can :)

Is this a correlating effect with the fact that a large number of published scientific results are botched? If researchers are not allowed to do good science they are no more progressive than the augur reading from the entrails of a fish.