Feb 18, 2016 | By George Gantz
The Quandary of Medical Reversal – New Evidence!
We have spent some time in this forum on the issues of bias and uncertainty, and recently included posts dealing with these challenges in medical testing and reproducibility in psychological research. All these findings support the call for humility in claims about what we know and, more importantly, what the experts think they know. Drs. Adam Cifu and Vinayak Prasad have recently addressed the extent of these problems in the practice of medicine in their book: Ending Medical Reversal: Improving Outcomes, Saving Lives (2015).
In an interview on EconTalk dated February 15, 2016, Dr. Cifu explained that medical reversal is a term they apply to the experience of having to reverse a longstanding clinical practice on the basis of new research that undermines or invalidates the original research that led to the practice. In a detailed analysis of a decade of published research in the New England Journal of Medicine, they found more than a hundred instances of medical reversal. The authors also experienced the phenomenon of having to reverse recommendations in their own clinical practices. Dr. Cifu speculated that such reversals might occur 30 percent of the time or more. In many cases, practicing physicians will continue an outdated practice either because they are unfamiliar with the new research, or they remain convinced of its efficacy through experience with their own patients. Medical reversal can sometimes leave a physician in the uncomfortable position of having nothing to recommend for a patient; or patients themselves may request an invalidated treatment based on their own beliefs.
One source of medical reversal is the deficiency of older research studies, particularly those that failed to control for the placebo effect. When a patient strongly believes in the efficacy of a treatment, the treatment is more likely to show significant benefits, reinforcing the feedback to the patient’s doctor that the treatment is effective. Yet full double-blind trials (where neither patient nor doctor knows who is getting the treatment or the placebo) often later confirm that the treatment itself has no effect – or even negative effects – on patients.
The quandary for medical practitioners and for patients is significant. A patient needs to trust their doctor and have faith that the treatment being prescribed will work in order to secure the best possible outcome. Doctors want and need to offer confident and accurate recommendations to their patients. Yet the evidence for efficacy for any given recommendation may be weak! Perhaps the best we can hope for is effective and engaged communication between doctor and patient – the options are laid out, as are the qualifications and potential risks. Together a choice is made that feels the best to the patient – and in which both patient and doctor can then invest a maximum level of optimism.
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