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By Mary Carpenter
“WHEN EVIDENCE Says No, But Doctors Say Yes” headlined a 2017 collaboration between the Atlantic and investigative journalists at ProPublica that investigated unnecessary and potentially harmful medical interventions, including sinus surgery and arthroscopic knee surgery. While other “evidence” recommends many of these procedures, poor communication and deteriorating trust in science can make it hard to keep track.
Blame for overuse of the disputed interventions goes to greedy doctors, pushy patients, fear of malpractice and flawed science. But while the Atlantic article makes a good case against some oft-performed procedures, like stents implanted to treat stable angina, many of the other treatments it mentions remain controversial, such as daily aspirin to lower risks of heart attack, stroke and colon cancer; and hormone replacement therapy (HRT) to counter heart disease in post-menopausal women. Also up for grabs are less familiar regimens, such as the need for prophylactic antibiotics before dental surgery on those with artificial joints.
For public health interventions, such as cardiopulmonary resuscitation (CPR), the Atlantic laments the lagging adoption of compression-only CPR–without the addition of rescue breathing. According to emergency medicine experts, however, while compression-only CPR works well in cases of sudden, “primary” heart attack, rescue breathing remains “essential” in cases of secondary arrest—that can accompany near-drowning, opioid overdose or suffocation—to get oxygen moving into the body.
The Atlantic article refers to the RightCare Alliance that “seeks to counter a trend: increasing medical costs without increasing patient benefits…Even if a drug you take was studied in thousands of people and shown truly to save lives, chances are it won’t do that for you.” Similar organizations include the Lown Institute, the Cochrane Reviews and Do No Harm.
“The most widely prescribed medications do little of anything meaningful, good or bad, for most people who take them,” concludes the Atlantic. RightCare Alliance is currently waging a campaign against the newly FDA-approved drug Aduhelm for Alzheimer’s treatment, which “has not been clinically proven to work [to prevent decline of cognitive function] and will cost $56,000 a year.”
The “missionary waste-hunting zeal of the ‘less is more’ movement,” however, is how Harvard Medical School professor and cardiologist Lisa Rosenbaum, writing in the New England Journal of Medicine, describes such organizations. Rosenbaum noted the “suspect” methodology of a major study that found 30% waste in U.S. health care, and criticized the less-is-more movement for putting “dangerous pressure on physicians to abstain from recommending some helpful treatments.” To explain growing support for less-is-more, she blamed erosion of trust in medical science as well as in physicians and their recommendations.
Many treatments most deplored by the watchdog groups, meanwhile, remain as recommendations by reputable medical organizations. According to Mayo clinic sites, for example, daily aspirin “may lower the risk of heart attack and stroke…depends on your age, overall health and history of heart disease;” while HRT treats common menopausal symptoms and has “been proved to prevent bone loss and reduce fracture in postmenopausal women [depending on] type of therapy, dose, how long the medication is taken and… individual health risks.”
The Atlantic article highlights criticism of arthroscopic knee surgery to clear out damaged tissue and shave cartilage on the meniscus as “one of the most popular surgical procedures in the hemisphere… at a cost of around $4 billion a year [but] does not work for the most common varieties of knee pain.” Arthroscopic surgery may also increase the risk of knee osteoarthritis, the story contends. It mentions studies showing that physical therapy alone performed as well as that combined with surgery; and a Finnish study that found “sham surgery” —cutting into all participants’ knees, including those in the control group who had no work done (to avoid the placebo effect) —performed as well as the real surgery.
And RightCare Alliance’s report on ESS (endoscopic sinus surgery) to alleviate sinus infections pointed to “an open secret within otolaryngology that patients are being abused with unnecessary surgery,” according to Northwestern University otolaryngologist Arthur Curtis. “None of the usual sources… recommend ESS for most of the conditions for which it is utilized,” including nasal allergies, non-allergic rhinitis and nasal polyps.
Opposing research, however, points to positive results for both surgeries. For ESS, the surgery’s “primary goal [is] to improve the quality of life of patients who have failed medical therapy…prevent complications and potentially alter the natural course of the disease,” according to Greek researchers. Their study of almost 1,000 patients who had ESS surgery after 12 weeks of resistance to medical (antibiotic) treatment found benefits in postoperative quality of life and especially in “emotional/general symptoms.”
When a group comprised of patient advocates as well as clinicians focused on underuse—along with overuse—of medical procedures, almost half of the 10 recommendations dealt with improving communication to patients. The panel noted its work “to steer patient and provider views away from rationing and…to improve the overall quality and value of care provided.” (The first recommendation, to deal with a major complaint of hospitalized patients as well as a potential impediment to healing, was to “implement programs designed to promote sleep in the inpatient setting.”)
Over the years when I had meniscus and then sinus surgery, our trusted family pediatrician said he’d heard these “didn’t work.” But for me, both surgeries put an end to miserable difficulties: sinus surgery, to more than five years of infections causing pain and making sleep almost impossible; and meniscus surgery, to shooting pain down my calf at any unexpected movement —every time I tried to play catch with my sons.
What persuaded me to have both surgeries was advice from people I trusted. For my knee, a physical therapist who had helped everyone in my family explained that a key variable in deciding to have surgery is whether the pain interferes with an activity important to me. For sinus surgery, a reliable good friend who’d suffered similar infections told me how surgery relieved her suffering. More important to me than large population studies that discouraged these surgeries was having advice from two people who were both familiar with my particular knee and sinus problems—and who knew me.
—Mary Carpenter regularly reports on need-to-know topics in health and medicine.