When our doctors recommend a treatment, we assume our doctors have good reasons for doing so. We assume that studies have shown the treatment to help, or even cure, what ails us. Is it possible your doctor might prescribe a medication, treatment, or even surgery if there was no evidence of benefit? Yes! Why does this happen? Should you trust your doctor’s recommendations? What can you do?
What exactly are we talking about?
We’re talking about practices, some of which are expensive and invasive, that offer little or no benefit to the patient, but can cause discomfort and potential serious harm. There are low-value medical practices that “are either ineffective or that cost more than other options but only offer similar effectiveness“. And there are “medical reversals” – when new, well-designed studies contradict the current practices. Additionally, there are medical practices with unknown effectiveness. Not only can these practices lead to physical and emotional patient harm, they can also lead to a distrust of the medical world and increased medical spending.
To be clear, medical practices include medications, treatments, and professional medical advice.
How common are treatments that are ineffective, harmful or medical reversals?
Researchers recently evaluated 3,000+ studies published between 2003-2017 in highly regarded medical journals. They found 396 routine medical practices that studies in leading journals clearly contradicted. In other words, they concluded there are almost 400 practices that doctors consider conventional wisdom even though there is no scientific proof of effectiveness.
And, another study examined the findings of 363 articles in a leading medical journal, each of which evaluated an existing medical practice. In these 363 articles, 40.2% found the existing practice to be no better than a lesser therapy, while 38% reaffirmed that the existing practice was better than a lesser standard.
Another analysis on the value of treatments.
Additionally, researchers in another study analyzed randomized controlled trials on the harms and benefits of 3,000 medical treatments. The researchers rated the likeliness of benefits and harms for each treatment, with the following results:
- 11% – beneficial
- 23% – likely to be beneficial
- 7% – trade-offs between benefits and harms
- 6% – unlikely to be beneficial
- 3% – likely to be ineffective or harmful
- 50% – unknown effectiveness
Most noteworthy in these results, researchers found that approximately 1,500 treatments (50% of all reviewed) have an unknown effectiveness. This means no randomized controlled trials have shown the effectiveness, or ineffectiveness, of these 1,500 treatments.
We are all at risk.
Since at least 396 routine medical practices were identified as low-value, and 1,500 categorized with unknown effectiveness, it’s safe to assume that many of our doctors have at some point recommend low-value or unproven treatments. And since doctors make these recommendations, and private and public insurers pay for these treatments, it’s easy for patients to feel comfortable with doctor recommendations.
Sometimes unproven treatments are the only choice.
Clearly, when we, or our loved ones, have a life-threatening or severely debilitating condition, we want a cure. But when there is no known cure, or when available treatments fail, unproven treatments can be a welcomed risk. So it’s not always a bad idea to choose an unproven treatment.
Examples of low-value or unproven practices.
Unproven treatments and medical advice commonly provided by doctors include:
- The frequent prescriptions for dangerous opioids. The 1990s brought widespread prescribing of opioid painkillers, creating an epidemic of addiction and death in the US. How did this happen? Without scientific evidence, doctors believed pharmaceutical companies who told them patients would not get addicted to opioid pain relievers. Today, in the US, more than 130 people die every day from opioid-related drug overdoses.
- The use of magnesium oxide to ease nighttime leg cramps, even though research shows magnesium oxide and a placebo both led to a similar reduction in the number of nighttime leg cramps.
- Bed rest for pregnant women at risk for preterm births, even though research shows that bed rest doesn’t prevent preterm births, nor does it increase infant birth weight. On the contrary, studies show maternal bed rest leads to lower birth weight and lower gestational age at birth. Furthermore, research shows that pregnancy bed rest causes maternal health issues including muscle atrophy, weight loss and bone loss.
- The ketogenic (keto) diet for patients with obesity and type 2 diabetes, despite a lack of evidence about the potential benefits for those with these conditions.
A few examples in cardiac care.
Doctors continue to give beta-blockers to patients in the early stages of a heart attack in order to calm and slow a heart under strain, even though 26 out of 28 studies found no increase in survival rates for patients given beta-blockers. Moreover, a large, well-designed study in 2005 showed that giving beta-blockers in the early hours of heart attacks didn’t save lives, but did cause a definite increase in dangerous heart failure.
Additionally, doctors routinely use of supplemental oxygen for patients with suspected heart attacks (who don’t have abnormally low blood oxygen levels), even though research indicates this practice does not reduce mortality rates.
Furthermore, doctors frequently use stents (little mesh tubes) for patients with chest pain caused by narrowed or blocked arteries. Although the goal is to ease pain and reduce the risk of a heart attack in the future, studies show that stents don’t help patients live longer or reduce their risk of heart disease. Ironically, the actual procedure to insert a stent can lead to heart attacks and strokes. And it’s questionable if stents relieve chest pain.
A few examples in orthopedics.
Surgeons commonly perform arthroscopic surgery for degenerative knee disease, even though a review of studies found this surgery doesn’t result in long-term improvements in pain or function, when compared to physical therapy, exercise, placebo surgery and other treatments. Furthermore, these researchers strongly recommend against the procedure, even for patients who have imaging evidence of osteoarthritis, mechanical symptoms or a sudden onset of symptoms. Yet, globally this surgery is performed 2 million+ times a year. And in the US, these surgeries cost $3 billion every year.
Additionally, doctors routinely inject cement into broken vertebrae fractures, yet research shows the procedure does not relieve pain any better than a placebo. The researchers found that pain goes away or lessens within six weeks without the procedure.
Why do doctors recommend these types of treatments?
There are many reasons doctors recommend treatments that are ineffective or unproven, including:
First, some doctors cannot break the habit of recommending treatments once considered standard care, even after randomized controlled trials find the practice ineffective or harmful. Unfortunately, it can take years, even decades, for the medical community to reverse its’ stance on conventional practices.
And sometimes doctors don’t know the latest research findings. Or, doctors recommend treatments based on studies that did not prove effectiveness in the first place. Additionally, sometimes doctors continue to recommend treatments because to them, it seems logical that the treatments should work, even though they don’t.
In other situations, doctors realize their recommendations are unproven or ineffective, but they are driven by profits. And sometimes doctors relent to the demands of patients who insist on particular treatments.
Finally, when there is no known cure or treatment, doctors may offer unproven treatments. In these cases, doctors should tell their patients that their recommendations are unproven for the patients’ conditions.
Importantly, even smart, experienced doctors can recommend low-value and/or unproven practices or those considered “medical reversals”.
What can you do?
No one wants treatments that are ineffective, and certainly no one wants treatments that may cause harm. What can you do?
Research your options!
Research treatment options with the resources included in the Zaggo Resource Center. One noteworthy option, the website and app Choosing Wisely from the American Board of Internal Medicine, helps patients choose care that is 1)supported by evidence; 2) not duplicative of other tests or procedures already received; 3) free from harm; 4) truly necessary. Search by keyword to learn about medical practices that lack evidence, cause harm, or for which better approaches exist.
Additionally, you can reach out to patients with the same condition to learn about their experiences – other patients can be a great source of information (learn more in my blog post Can You Trust Advice from Other Patients?)
And, ask your doctor(s) about less invasive options and the risks of a “wait and see” approach.
Get a second opinion.
And always get a 2nd, or even a 3rd, opinion. Don’t worry, you won’t insult your doctor. (Actually, if your doctor urges you not to get a 2nd opinion, and your condition doesn’t require immediate attention, it might be time for a new doctor.)
You might find these posts helpful:
- The Dangers of Too Many Tests and Treatments for Patients
- 10 Tips to Communicate Better with Doctors
- Help for Hard to Diagnose Health Issues
- Trustworthy Sources for Medical Information on the Internet
- Should you Speak Up if You Think Your Doctor is Wrong? YES!