Thursday, January 27, 2011

Why Almost Everything You Hear About Medicine Is Wrong

Why Almost Everything You Hear About Medicine Is Wrong

by Sharon Begley, Newsweek, January 24, 2011

"If you follow the news about health research, you risk whiplash. First garlic lowers bad cholesterol, then—after more study—it doesn’t. Hormone replacement reduces the risk of heart disease in postmenopausal women, until a huge study finds that it doesn’t (and that it raises the risk of breast cancer to boot). Eating a big breakfast cuts your total daily calories, or not—as a study released last week finds. Yet even if biomedical research can be a fickle guide, we rely on it.

But what if wrong answers aren’t the exception but the rule? More and more scholars who scrutinize health research are now making that claim. It isn’t just an individual study here and there that’s flawed, they charge. Instead, the very framework of medical investigation may be off-kilter, leading time and again to findings that are at best unproved and at worst dangerously wrong. The result is a system that leads patients and physicians astray—spurring often costly regimens that won’t help and may even harm you.

It’s a disturbing view, with huge implications for doctors, policymakers, and health-conscious consumers. And one of its foremost advocates, Dr. John P.A. Ioannidis, has just ascended to a new, prominent platform after years of crusading against the baseless health and medical claims. As the new chief of Stanford University’s Prevention Research Center, Ioannidis is cementing his role as one of medicine’s top mythbusters. “People are being hurt and even dying” because of false medical claims, he says: not quackery, but errors in medical research.

This is Ioannidis’s moment. As medical costs hamper the economy and impede deficit-reduction efforts, policymakers and businesses are desperate to cut them without sacrificing sick people. One no-brainer solution is to use and pay for only treatments that work. But if Ioannidis is right, most biomedical studies are wrong.

In just the last two months, two pillars of preventive medicine fell. A major study concluded there’s no good evidence that statins (drugs like Lipitor and Crestor) help people with no history of heart disease. The study, by the Cochrane Collaboration, a global consortium of biomedical experts, was based on an evaluation of 14 individual trials with 34,272 patients. Cost of statins: more than $20 billion per year, of which half may be unnecessary. (Pfizer, which makes Lipitor, responds in part that “managing cardiovascular disease risk factors is complicated”). In November a panel of the Institute of Medicine concluded that having a blood test for vitamin D is pointless: almost everyone has enough D for bone health (20 nanograms per milliliter) without taking supplements or calcium pills. Cost of vitamin D: $425 million per year.

Ioannidis, 45, didn’t set out to slay medical myths. A child prodigy (he was calculating decimals at age 3 and wrote a book of poetry at 8), he graduated first in his class from the University of Athens Medical School, did a residency at Harvard, oversaw AIDS clinical trials at the National Institutes of Health in the mid-1990s, and chaired the department of epidemiology at Greece’s University of Ioannina School of Medicine. But at NIH Ioannidis had an epiphany. “Positive” drug trials, which find that a treatment is effective, and “negative” trials, in which a drug fails, take the same amount of time to conduct. “But negative trials took an extra two to four years to be published,” he noticed. “Negative results sit in a file drawer, or the trial keeps going in hopes the results turn positive.” With billions of dollars on the line, companies are loath to declare a new drug ineffective. As a result of the lag in publishing negative studies, patients receive a treatment that is actually ineffective. That made Ioannidis wonder, how many biomedical studies are wrong?

His answer, in a 2005 paper: “the majority.” From clinical trials of new drugs to cutting-edge genetics, biomedical research is riddled with incorrect findings, he argued. Ioannidis deployed an abstruse mathematical argument to prove this, which some critics have questioned. “I do agree that many claims are far more tenuous than is generally appreciated, but to ‘prove’ that most are false, in all areas of medicine, one needs a different statistical model and more empirical evidence than Ioannidis uses,” says biostatistician Steven Goodman of Johns Hopkins, who worries that the most-research-is-wrong claim “could promote an unhealthy skepticism about medical research, which is being used to fuel anti-science fervor.”

Even a cursory glance at medical journals shows that once heralded studies keep falling by the wayside. Two 1993 studies concluded that vitamin E prevents cardiovascular disease; that claim was overturned by more rigorous experiments, in 1996 and 2000. A 1996 study concluding that estrogen therapy reduces older women’s risk of Alzheimer’s was overturned in 2004. Numerous studies concluding that popular antidepressants work by altering brain chemistry have now been contradicted (the drugs help with mild and moderate depression, when they work at all, through a placebo effect), as has research claiming that early cancer detection (through, say, PSA tests) invariably saves lives. The list goes on...."

Tuesday, January 18, 2011

Second opinion can give patient confidence about care

Consumer Reports Insights: Second opinion can give patient confidence about care

NYT, Tuesday, January 18, 2011; 12:00 AM

"About half of all Americans never seek a second opinion about a diagnosis, treatment, drug or operation, according to a 2005 Gallup poll. But if you want a second opinion, you needn't worry, says Orly Avitzur, medical adviser to Consumers Union.

Physicians are bound by a code of ethics to cooperate fully with patients seeking a second opinion, including sending records, prescriptions, test results, letters and photographs to other physicians. Any responsible doctor won't be insulted if you seek advice from another practitioner. In fact, if your doctor discourages you from seeking another opinion, you have even more reason to get one.

Here are six other reasons:

l You don't have confidence in your doctor. Avitzur found that patients are less likely to follow a course of treatment when it's prescribed by a doctor they don't trust anymore. She sends her own patients for second opinions when she knows she's not getting through to them. For example, a patient she strongly suspected had multiple sclerosis was clearly - and understandably - resisting the diagnosis. Because the disease might progress without treatment, Avitzur suggested the patient seek a second opinion from a specialist at a university medical center. It helped reassure her that medication was warranted, and she's now doing very well with treatment.

l You think there might be other treatments. If your doctor tells you there is only one course of action, it should raise a red flag. That's what happened to a physician who developed a painful kidney stone. His first doctor told him that if the stone didn't pass in a month, he could have a procedure in which it would be removed through an endoscopic tube. When he sought a second opinion at another medical center, he learned he was a good candidate for extracorporeal shock-wave lithotripsy, a less-invasive treatment that uses sound waves to pulverize the stone and allow it to pass. The first doctor hadn't even mentioned this idea, which may or may not have been related to the fact that his center didn't own a lithotripsy machine.

l Your doctor dismisses your concerns. One individual developed recurrent bouts of vertigo, but her family doctor said that nothing was wrong with her and that her symptoms were due to the stress of her mother's recent death. A second opinion uncovered an inner-ear disorder that promptly improved with vestibular rehabilitation therapy. You know your body best, and if your doctor doesn't take your symptoms seriously, see someone else.

l You're not getting better. This is the most common reason patients seek a second opinion. Medicine is as much an art as a science, so a fresh viewpoint might make all the difference if you're not recovering from an illness or surgery at the pace you expected. The amount of time a doctor spends with a new patient is two to four times as long as a follow-up visit, so not only will you get a new perspective but also more attention.

l Your doctor recommends surgery. An astute orthopedist recently asked Avitzur to see a woman with a foot drop (the inability to raise the front part of the foot) after another neurologist had referred her to him for surgery. She repeated the muscle and nerve tests and, as the orthopedist suspected, concluded that surgery was the wrong course of action. Anytime your doctor recommends elective surgery to correct such ills as back pain, cataracts, gallstones or a hernia, consider a second opinion.

l Your condition is uncommon. Some conditions are so rare that a primary-care physician encounters only one or two cases in a career. It's worthwhile to consult a doctor at a major medical center with expertise in cases like yours. You can find more information on rare diseases from the National Institutes of Health (https://rare diseases.info.nih.gov/gard) and from the National Organization for Rare Disorders (www.rarediseases.org)."

(c) Copyright 2010. Consumers Union of United States Inc.