Flummoxed by shifting Covid advisories? Medicine makes progress sometimes by reversing well-accepted advice

The worst public health crisis in a century has brought with it some swiftly changing coronavirus health measures, and many by now are reacting with weary exasperation, asking: “Why can’t doctors get it straight? Why do they keep changing their minds and telling us to do so many different things?”

Yes, the public health messaging during the pandemic has left much to be desired, especially as too many parties have politicized or debased medical-scientific information and spread disinformation with ugly urgency.

But much of the disconnect between the public and the health experts comes from fundamental misconceptions about medicine, mainly in the extremes that doctors and scientists either walk on water or are all wet. Critics somehow want us to believe that patient care, especially in an emergency, should proceed in a neat and orderly way. Desiring a consistency in medical care has become a hobgoblin of pandemic thinking.

The advance of medicine follows its own, irregular path. It does not race straight ahead, going from one progress in science to the next, with absolutes in the field lining up in tidy fashion. Instead, medicine is rifer than ever with uncertainty, complexity, and for patients, high risks, costs, rewards, and losses.

These challenges have become glaring during the pandemic. But many patients and their loved ones also confront fast-shifting circumstances in daily fashion as they cope with late-stage illness and devastating injury.

Modern medicine has put huge strains on us all — to be as informed and thoughtful as possible and to ensure that doctors share with candor the best evidence they have for any given course of care. That may not make difficult medical journeys any easier. But it can be crucial to improving treatments available to us all, especially in these pandemic times.

So in this issue of our newsletter, let’s put some context into pandemic medical care, so we can all understand better how medicine really works in the 21st century.

As any patient who has recent experience with serious illness or injury can attest, it is simply false to suggest that medicine magically has “set it and forget it” approaches to treatment, whether with a novel infection like the coronavirus or with well-known threats to health.

§ A friend may cajole his buddy to go to an emergency room because the pal — who is not drinking — suddenly feels dizzy, has trouble walking, slurs his speech, and may have weakness in an arm. It’s a good bet that speedy ER response may rocket this patient, seemingly OK an hour or so before, into significant care for stroke, with many treatments launched.

§ Similarly, her family might take to the ER a woman who cut her hand in the kitchen a few days earlier when she develops signs of a serious infection, including chills, fever, disorientation, slow breathing, and plunging blood pressure. This patient may be headed to intensive care, undergoing dramatic treatment for sepsis.

§ An older man may resist seeing a doctor for what he thinks is a bad cold, muscle aches, high fever, coughing, labored breathing, and tiredness that has lasted for a few days. This patient also may quickly be admitted to an ICU for drastic measures to save his life from pneumonia.

While patients might accept how much medical responses change in emergencies like these, they still may be thrown for a loop as their treatments shift in less urgent conditions. They insist that doctors provide them with personalized, individual attention and care. But they may not see all that this means.

Individuals differ, and so too does their care

Because we are all alike and still all unique, we can respond to therapies and prescription medicines in very different ways. A drug that is considered standard and effective for most patients might not be for a sizable number of others, depending on factors such as gender, race, age, overall health, and the seriousness of the condition. Your doctor, based on considerations including your medical history and his or her  experiences with you as a patient, may not prescribe drugs for you that your friends are taking for a similar disorder. You may react to them differently, including with risky side effects. 

You also may start treatment for one condition that causes you to feel poorly and quickly find your doctor treating one, two, or several others. Federal researchers have found that more than a quarter of U.S. adults suffer from two or more “co-morbidities,” serious conditions that include high blood pressure, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, asthma, or chronic obstructive pulmonary disease. Doctors can’t get patients into more optimal shape by treating just one condition and ignoring others. It can be frustrating to patients, though, to learn that their care will be more difficult, complex, and sustained than they first thought.

Doctors’ significant effects on patient treatment

They and their loved ones also should know that doctors and hospitals themselves may affect patients’ treatment and outcomes — to the positive and negative.

Doctors may, for example, subject patients — sometimes almost routinely — to a cascade of exams, tests, and procedures that may be invasive, painful, costly, and sometimes unnecessary. Over-testing, over-diagnosis, misdiagnosis, and over-treatment plagued U.S. medicine in pre-pandemic times. It’s a topic worthy of a whole newsletter, but know this: When it comes to medical screenings and tests, more isn’t always better. Early detection may not be all that helpful with some conditions and diseases, contrary to popular belief. And it’s, well, malarkey that doctors do something useful when they argue they practice defensive medicine against medical malpractice lawsuits by ordering excessive tests or procedures, just in case.

As health officials try to contain medical services’ soaring costs, they have zeroed in on an important gateway: over-screening, over-diagnosing, misdiagnosing, and over-treating that add $200 billion in unnecessary expenses to our care, with over-treatment costing 30,000 lives a year of older (Medicare) patients alone.

It isn’t taking patients’ temperatures or checking their blood pressure or getting them one or two tests that reformers assail. It is the cascade of costly, invasive, painful, and unneeded tests and procedures that follow. Every medical intervention carries with it an element of risk — indeed, some experts estimated that medical errors ranked as the No. 3 killer of Americans, claiming 250,000 lives annually in pre-pandemic times.

An exasperating chunk of those preventable deaths occur each year due to health-care-acquired infections (HAIs). Due to overuse and abuse of antibiotics and poor infection-control practices, already sick or injured patients get worse when in medical care and exposed to an array of increasingly virulent bugs that teem in doctors’ offices, clinics, hospitals, nursing homes, and other long-term care facilities.

Institutions insist they are doing their best to stamp out HAIs, including struggling with outbreaks of “superbug” (antibiotic resistant) infections. Patients and their loved ones must be on alert, for example, whether health workers do simple things like washing their hands and maintaining facilities that at least appear orderly and clean (though they still may not be hygienic) and are not malodorous. It also makes no sense to play the odds with your well-being by loading up with too casual or frequent exposure to the health care system.

Medicine’s huge strides can’t be ignored

To be fair, heroic medical professionals also have made revolutionary improvements in our health — with rigorous scientific study (randomized clinical trials), breakthrough thinking, and better treatments, whether with prescription drugs or surgical procedures (see sidebars). Medical knowledge is exploding and this poses big challenges to experts in sorting out what it all means and how it best benefits patients.

Polio and smallpox, deadly infections that once mowed down huge swaths of humanity, have been largely eradicated, thanks to vaccines.  HIV-AIDS is now a chronic and treatable condition, not a nearly automatic death sentence. The pandemic has upset positive trend lines. But death rates were on the decline for roughly half of common cancers. Deaths from heart disease have fallen dramatically over the past 50 years in the United States. Deaths from stroke also declined over the same period. Many of us, when we “go under the knife,” even for major surgeries, have laparoscopic procedures involving only tiny incisions and maybe local rather than general anesthetic. It no longer is earth-shattering for patients to undergo life-changing and -saving transplants of an array of major organs and tissues, including hearts, lungs, kidneys, and livers.

Even the most cursory glance through medical history textbooks or a trip through fading recollections of people of a certain age will reveal how fraught were the prospects of success for what are now considered medical marvels, whether transplantation’s early period marked by death and failure or retrovirals’ rocky and angry path to providing a working treatment for HIV. Many medical advances occur after perceived failure and often after researchers take circuitous paths to favorable outcomes.

The New York Times reported on the decades of toil by Katalin Karikoa, a Ph.D. and a leading researcher in the science that led to the current, innovative coronavirus vaccines. Her “overnight” success not only debunks the widely spread falsehood that the vaccines cannot be trusted because they seemed to appear so quickly. Her commitment to science and what she considered a vital aspect of research is inspiring, humbling, and confounding in the ups — and plenty of downs — that she had to endure

The criticism of “flip-flopping” pandemic health responses comes at a curious time in medical research. That’s because investigators are pursuing a rising area of study on widely accepted treatments and how and why they win acceptance — and, more importantly, whether they work.

Doctors have come up with a telling name for the meandering course of many purported therapeutic advances, dubbing them “medical reverses.”  But reverses can mean progress, as medicine sheds time-honored treatments once scientific study proves them to be inef

The expanding catalog of these unnecessary and unhelpful approaches might stun many patients. Researchers scrutinized 3,000 or so studies published in top medical journals, finding that 396 involved 180-degree shifts in existing thought or with “practices that have been found, through randomized controlled trials, to be no better than a prior or lesser standard of care.” 

Doctors once blamed high stress and excess stomach acid, for example, for causing patients’ ulcers. This erroneous belief led surgeons to perform serious operations in which they severed a key nerve to the stomach or to surgically remove part of that organ. In 1982, two researchers won a Nobel Prize for showing definitively that a bug named Helicobacter pylori causes peptic ulcers. Their study upended doctors’ long belief that bacteria just could not possibly survive in an acidic environment like the stomach.

Drs. Vinay Prasad (University of California, San Francisco) and Adam Cifu (University of Chicago) have written extensively about medical reversals, reporting in one of their published studies:

“In the late 20th century, sudden cardiac death, particularly during the vulnerable period after [a heart attack], was deemed a ‘worldwide public health problem.’ A type of heart rhythm, premature ventricular contractions (PVCs), was thought to contribute to such deaths. A new generation of anti-arrhythmic therapy was developed with the ability to suppress PVCs up to 85% of the time. Cardiologists began using these medications in widespread fashion.

“In the late 1980s, the Cardiac Antiarrhythmic Suppression Trial (CAST) was conducted to assess the safety of what was then commonplace. Interestingly, recruitment for the trial was hindered by physicians who refused to let patients undergo randomization with a 50% chance of not receiving these medications. Fortunately, the trial was completed and showed that these drugs (encainide, flecainide, and later, moricizine) conferred greater mortality than placebo, and their use was curtailed for this indication.

“Vertebroplasty, the injection of medical cement into fractured bone, achieved widespread use without good evidence that it worked. First described in the late 1990s, vertebroplasty quickly gained popularity. In 2005, it was performed more than 27,000 times in the United States. A pair of articles published in the New England Journal of Medicine in 2009 conclusively showed that the procedure was no better than [a] placebo …”

A catalog of treatments turning 180 degrees

Prasad, Cifu, and other experts point to other major medical reversals, including:

The 1990s scandal involving the purported weight-loss drug combination nicknamed Fen Phen. It became a diet fad, boosted by expensive Big Pharma advertising and marketing campaigns about a supposedly easy, convenient way to just pop pills to deal with obesity. But cardiologists reported increasing numbers of cases in which patients, many of them women, suffered serious heart damage after even limited exposure to the drug combination. Thousands of lawsuits against a drug maker ended the Fen Phen phenomenon, but not before significant numbers of patients suffered greatly.

For more than 50 years, hormone replacement therapy (HRT) was thought to prevent chronic disease, such as cardiovascular disease, in menopausal women. Several more recent (and more powerful) studies showed HRT provides no such benefits, and that some combinations of it may increase the risk of certain cancers, stroke, and blood clots. HRT may still be recommended for women with significant menopausal symptoms, such as hot flashes, but it is no longer prescribed to prevent chronic disease.

Surgery once was a common approach for a meniscal (cartilage) tear with osteoarthritis of the knee for adults ages 45 and older. This combination of problems is common among older adults and is detected often by MRI scans for knee pain. A 2013 study found that treatment first with physical therapy was just as effective as immediate surgery. Guidelines soon changed to advise nonsurgical treatment as the initial approach for knee problems in most middle-aged or older patients.

Distressing as the list of medical reversals may be — and Cifu and Prasad have included a whole chapter of them in their book Ending Medical Reversal: Improving Outcomes, Saving Lives — the  increasing awareness of them also represents important progress, the doctors contend.

That’s because they argue that too much of health care, even now in the 21^st century, is taken for granted or relies on the idea of medicine as art rather than science. Medicine is conservative. It can take two decades or so for innovations on average to go from publication in respected journals to routine practice. But many routine practices also go unexamined and unquestioned for even longer, experts say.

The flood of money into medicine already has doctors under extreme time pressure — to see more patients, and to order more tests, procedures, and prescription medications. It is, at the same time, daunting toil — for patients and doctors — to stay current with the flood of information about medical practice.

Besides going along with long-standing medical practices, “just because,” doctors may be too problem-focused and willing to offer what they think will be quick, “common sense” solutions, they have written:

“In current practice we continue to adopt new technologies not because they are supported by the strongest evidence base, but based on a common sense appeal that they should work. We can extend ‘common sense’ to signify any set of surrogate data trials, basic science rationale, or observational results … [This] prevailing attitude must be reconsidered. A common sense standard that a treatment will work can no longer justify its adoption. Twenty years into the era of evidence-based medicine, we must recommit to practicing based on good evidence.”

Good evidence must matter — not just in courtrooms but also in the practice of medicine, right?

So, tired as we all may be of the coronavirus and the damage it has inflicted (including hundreds of thousands of deaths and tens of millions of infections), the evidence is abundant that the public battle waged against the disease by serious people in medicine has not been a willy-nilly effort.

Just a reminder: It was only in January 2020 that Chinese researchers, at great risk to themselves, published the detailed gene sequence of a highly contagious virus that apparently had mutated recently and made the leap from animals to humans. Despite shambolic political reactions to the pandemic, medical scientists in short order dug into a substantial body of research on coronaviruses and vaccines, producing three shots that have proven safe and effective when given to hundreds of millions of people — and with rare side effects. Frontline health workers successfully have treated millions of patients for a deadly disease that was unknown mere months ago. Their work also has more than held up as the virus has mutated, throwing up multiple variants, including the highly contagious Delta strain.

Despite furious resistance from people proceeding without facts or science, public health officials, as retrospective studies already are starting to show, put in place measures that protected most Americans from calamitous illness and death.

It has been a rocky go. But along the way, officials have delivered the data, studies, and clinical observations so reasonable people could consider them — and by large, they have — and followed public health measures.

Frustration turning, wrongly, to abuse

Still, for exhausted health professionals, the unrelenting resistance they have encountered has been damaging, as a physician wrote on KevinMD.com, a site that gives doctors a public voice on issues that concern them. This practitioner was distressed at the negative reaction she received after signing a published letter urging people to carefully consider and to follow medical-scientific recommendations to quell the pandemic:

“As a relative political outsider, and someone who reads Nature and JAMA [the Journal of the American Medical Association] instead of the New York Times and the Washington Post, was it foolish of me to believe that evidence-based medicine was a stance unto itself? … Why is following medical recommendations now described as a political leaning? This is the era of guidelines and recommendations for all medicine. The only difference: Now the news covers us like we’re the Olympics. The protocols for treating Covid aren’t much older or better tested than the vaccine. Even beyond widely accepted (but new) Covid treatment protocols: how many patients and families have called out for anything at all, any drug or treatment — no matter how experimental — once they’re sick? Were the people who aimed to ‘cancel’ me online suggesting they won’t take any evidence-based treatment from a doctor?”

Prasad and Cifu have called on — and called out — doctors for failing to step up their practice, subjecting many of their treatments to randomized clinical trials with rigorous standards for the evidence they obtain. They concede that such trials are not always easy, nor cheap to run. They may not be feasible, depending on the risks they might subject patients to, or the complications that cannot be ruled out and might cloud their results.

Still, the profession harms its crucial credibility when it does not just replace one treatment with another but reverses itself on a procedure or drug. This is an avoidable blunder, the doctors say.

They and others underscore the importance of communicating constantly and with candor with patients about risks and rewards in their care. Doctors bear a huge responsibility, of course, to ensure their patients receive their fundamental right to informed consent. This means they are told clearly and fully all the important facts they need to make an intelligent decision about what treatments to have, where to get them, and from whom.

Prasad, who has extended his study of medical reversal to examining how hype and big money can harm patients by gulling them into taking costly cancer drugs with limited effects, also has this important view about taking the extreme view of medicine as a failure. As he told a colleague-interviewer:

“It is very tough as a clinician to go in there and say, ‘Look, I was wrong about something I was doing. I wasn’t wrong because I was ill motivated. I was wrong because everyone was wrong about this.’ But I think we have to be honest about it. We do get things wrong. [But] we should be careful not to use these examples as reasons to dismiss all of Western medicine or all of biomedicine. There are a lot of people out there right now who are willing to seize upon the imperfections of medicine as reason for why we’re wrong about everything, why vaccines may cause autism, or all sorts of conspiracy theories. We have to be careful to say, ‘Look, we have gotten this wrong, but yet, medicine is still the best way of moving forward about issues of health.’” 

Prasad, by the way, has stressed the pragmatic aspects of the call for practice reforms that he and Cifu have made, notably in discussing therapies in which there is “tremendous effect size,” which he has explained, thusly:

“The classic example is you don’t need a randomized trial for wearing a parachute when you jump out of an airplane. That’s an intervention that has a 99.9999% improvement in overall mortality in a very short period of time. No one has ever called for a randomized trial of the parachute, and similarly, no one has called for a randomized trial of if I got hit by a bus and my femur were exploded out of my leg, and I had a compound fracture, no one has said, ‘You need a randomized trial of putting it back in my leg or just leaving it out and letting nature take its course.’”

Are we at similar tipping points with public health advisories on the pandemic? We now know that disinfecting groceries didn’t affect coronavirus infections, so we stopped this. We know that the Delta variant is savaging the unvaccinated and increasing risks for those who have gotten shots, while the vaccines’ side effects have been rare. So, we’re pushing for more people to get the jab.

And, yes, while the data may not be as iron-clad about face covering and distancing, when these practices occur, infections, community spread, hospitalizations, and deaths from the coronavirus have declined in this pandemic and other major outbreaks of infectious diseases. More data and study are under way.

Skepticism, not nihilism

But as the pandemic rages, isn’t it weak tea for extremists and the resistant to complain about inconvenience, discomfort, or their asserted claims of inconsistency while huge numbers of people get sick, overwhelm hospitals, clinics, and health workers, and die? Is it clear now that the unvaccinated pose big risks to us all, not only when their illnesses stagger the health system but how they may be fostering the rise of even more problematic coronavirus variants? While health officials share more and more information about the steps they want us to take and why (i.e., real evidence), do we give platforms and credence to nonexpert opining — from political columnists, broadcast commentators, and people lacking in experience or credentials?

When the mechanic wants to weigh in on statistical data on community spread, is it time to remind him how he couldn’t find the rattle in the car that eventually caused it to go dead? When the expert on public polling methods offers his ideas about pulmonary diagnoses and the proper application of certain prescription medications, is it time to remind him that critics say he was misguided on results of recent elections (something closer to his actual expertise)? When the nervy aunt is rattling the kids as they are setting off to school by discussing her “fact-checking” of public health data with her excellent Excel skills, is it too curt to remind her she hasn’t even won the office baseball betting pool in years?

We can and should be skeptical — but not cynical or nihilistic — about medicine and medical information, which we can consume and apply with common sense and good judgment. We can help push our own harried doctors to stay current, too.

It is unacceptable, though, that the frustration with the inevitability of change in both the pandemic and medicine itself  becomes a reason for a vocal extremists to berate and abuse medical personnel trying to provide reasonable care to the sick and injured and to save lives. Health workers, especially nurses, already are overwhelmed and upset that their lives are still upside-down with a fourth, Delta-variant surge.

Here’s hoping we turn a lasting corner, and we quell the pandemic, so we don’t need yet more public health recommendations. All medical interventions carry risks. But vaccines’ benefits clearly outweigh their risks, so, if you haven’t done so, please get your shots and help your loved ones get theirs. Face masks? Yes, please. They fall, really, into the category of seat belts, football helmets, prophylactics, telephone headsets, clean underwear, and more — they may not be optimal or always comfortable to don.  But they protect both our own health and that of those around us. So we regret them more if we don’t use them.

Of course, here’s hoping that you and yours stay far from coronavirus illness and that you stay healthy throughout 2021 and far beyond!