GlassHospital

Demystifying Medicine One Month at a Time

Tag: Adam Cifu

People of the Book

51LnzMAiHuL._SY344_BO1,204,203,200_Doctors are a group that prize scientific evidence in plying our trade — whether making recommendations to our patients or arguing with each other about how to interpret and act upon our profession’s ever-growing body of research.

I find it pretty easy to lapse into the rationalization that “the latest evidence” is usually right, and therefore should heavily weight both our actions and our “knowledge base.”

But a new book challenges this rationalizing — pointing out that over the decades, many assumptions about best medical practices later come into question and are thrown out — a process known as “Medical Reversal.”

I blogged about this before, as several articles in this genre stood out to me. Now that line of research has been turned into a book: “Ending Medical Reversal,” by Vinay Prasad and Adam Cifu. I was delighted to be asked to review this book for Johns Hopkins Press, and glad to see that they’ve published it (in fact, they used a statement in my review as a blurb (!) on the book jacket).

If you like to know how medical knowledge gets disseminated, communicated, retracted, and paved over, then this will be an enjoyable read. The NYTimes just reviewed the book, with a recommend, only questioning the rather esoteric title, suggesting instead that the book be called “OOPS!” or “Are You Kidding Me?”

I like those.

*                         *                         *                          *                         *                         *

This past week I had the opportunity to meet the great Roz Chast, author of the award-winning graphic memoir “Can’t We Talk About Something More Pleasant?”

She visited the Tulsa City-County Library as part of a series of programs put on in conjunction with Clarehouse, a local not-for-profit hospice. The goal of the series is to increase awareness and dialogue about improving care for people at the end of life.dr john schumann 3

A Brief Chat with Scott Simon

I wrote a new piece for Shots, the NPR health blog. In an especially nice turn, the piece was “picked up” for a discussion on NPR’s Weekend Edition Saturday. I had the chance to answer some questions from Scott Simon, longtime host of the program and one of my favorite radio broadcasters.

simon_mother_originalSimon is well-known for many reasons, but one of the most endearing things about him is the period when he sent numerous tweets from a Chicago ICU next to what turned out to be his mother’s deathbed. His tweets moved millions of us. [It turns out those tweets will now be used as narrative thread for a new memoir about his mother.]

I would’ve liked to tell Simon about how his tweeting impacted me, but this being national radio, we had to focus on the matter at hand, and I didn’t get the chance. Still, it was a thrill for me. Our conversation was whittled down to less than three minutes, and you can stream the audio anytime as it’s now permalinked to the written piece.

Give it a read and a listen. Hope you it makes you think.

Post by NPR.

Medical ‘Reversals’

Twenty-five years ago, the New England Journal of Medicine issued a report on a stunning new medical discovery: Aspirin helps prevent heart attacks.

Yes, good ol’ aspirin. Known since the time of Hippocrates for its magical abilities to quell fever and pain, it took only 2000 years for us to understand the science of it well enough to design a ‘sufficiently powered’ double-blind, placebo-controlled randomized trial on aspirin’s efficacy in preventing heart attacks. The Physicians’ Health Study, so named because the study subjects were randomly selected physicians from across the U.S. (whom it was correctly assumed would have higher adherence in swallowing daily pills), addressed the question of whether or not aspirin has true live-saving benefit.

It does. Citing aspirin’s “extreme beneficial effects on non-fatal and fatal myocardial infarction”—doctor speak for heart attacks–the study’s Data Monitoring Board recommended terminating the aspirin portion of the study early (the study also looked at the effects of beta-carotene). In other words, the benefit in preventing heart attacks was so clear at 5 years instead of the planned 12 years of study that it was deemed unethical to continue blinding participants or using placebo.

week_in_reverse3Confusingly, there is now strong evidence that what’s beneficial for hearts can be harmful in eyes: older people who routinely take aspirin are nearly three times as likely to develop macular degeneration than non-users. Macular degeneration is the leading cause of blindness in Americans 55 and older. It presents a vexing medical problem, in that once it’s discovered, it’s too late to do anything about it. Macular degeneration afflicts more than ten million people in the U.S., which is likely an underestimate of its true prevalence.

What we see in this situation is a classic story arc in modern American medicine: Wonder-drug saves lives. Study stopped. Practice adopted. Then, years later: wonder-drug causes harm. Edicts to stop prescribing it, or be much more selective about recommending it.

Adam Cifu, a doctor (and former colleague) at the University of Chicago, has written about the concept of “reversals” in 5741medicine. In a fascinating paper, Cifu and colleagues catalogued several examples of new knowledge leading to “abandonment” of mainstream medical practices. A major example is hormone replacement therapy for post-menopausal women. For decades estrogen was given to American women as an elixir for many ills. All of the data in support of the practice was observational–outcomes conformed neatly to expectations about the drug. When good science (a randomized, controlled trial called the Women’s Health Initiative) finally challenged the practice, it was almost entirely abandoned.

I asked Cifu for a prediction about the near-blanket recommendation to people of a certain age to take aspirin, which is prescribed so widely, including to many who do not actually have heart disease or elevated cardiovascular risk. In an email, he wrote:

The [Physicians’ Health Study] never showed mortality benefits but only benefit to lesser outcomes – such as [heart attack].  Even in the earliest studies there was evidence that the benefit was only in limited populations, older ones, and was balanced by significant risk of bleeding (GI [stomach, etc] and CNS [brain]).  I think what has happened is that as the scope of the trials have expanded in terms of both patients and endpoints, we have gotten a more nuanced view.  Certainly the idea that [not] everyone over 40 should be on aspirin is a reversal but we will probably always be giving prophylactic [aspirin] to a subset of patients.

Got that?

One thing seems to be sure in medicine: if we just wait long enough for excellent science to guide us ahead, things we trust as ironclad rules often change.

© 2019 GlassHospital

Theme by Anders NorenUp ↑