Healthy Skepticism Library item: 10125

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Picard A.
When 'tried and true' can make you sick
The Globe and Mail 2007 May 17
http://www.theglobeandmail.com/servlet/story/RTGAM.20070517.wxlpicard17/BNStory/specialScienceandHealth/home

Full text:

In our impatient society, the pressure on the health system to deliver is enormous.

We clamour constantly for the latest treatments; we want promising drugs while they are still in the experimental stage, we demand state-of-the-art technology, we yearn for the most modern infrastructure and we carefully search the media for the latest tidbits of health information, hoping to remain ahead of the curve.

New drugs and technologies are often oversold: Their benefits are exaggerated and their risks played down. The costs are invariably far greater than what they are replacing.

And what about the old stuff?

In many cases, old drugs and technologies are not replaced. Rather, new medications and devices supplement or complement existing treatments. This is true even when the older techniques are clearly inferior and when outmoded drugs and equipment actually pose a danger to patients.

“We don’t deal with obsolescence very well at all,” said Tom Noseworthy, the director of the Centre for Health and Policy Studies at the University of Calgary.

In a recent speech to a conference hosted by the Canadian Agency for Drugs and Technologies in Health – one of the hidden gems of Canada’s health system – he made a powerful case for the need to assess old drugs and technologies as rigorously as the new ones.

Dr. Noseworthy said that re-assessing, decommissioning and declaring obsolete drugs and technologies is an important element of patient safety and that unlearning so-called tried-and-true interventions is as important as learning about new methods.

Examples of medical interventions found to be ineffective or harmful are legion. Bloodletting is the classic example, having been practised from 3000 BC right through to the 19th Century. It was not until French scientist Pierre-Charles Alexandre Louis conducted a crude clinical trial demonstrating that bloodletting caused far more harm than good that the practice waned, but even then surgeons swore by the method for decades.

There are, of course, far more recent and no less egregious examples:

Routine episiotomy during birth;

Radiation for the treatment of acne;

The drugs thalidomide and DES to treat pregnant women;

Colectomy – removal of part of the colon – for the treatment of epilepsy;

Gastric freezing of peptic ulcers;

Routine prescription of hormone replacement therapy at menopause.

What these treatments all have in common is that they continued to be used for far too long. They were approved on scant evidence (and sometimes wishful thinking) and there was little monitoring.

Thalidomide, for example, remained a common treatment for sedating pregnant women years after it became clear that their babies were being born without arms, legs and ears.

The reason bad technologies linger is, in part, because there are vested interests who profit from their continued use.

Dr. Noseworthy said that monitoring the safety, quality and effectiveness of existing drugs and treatments is just as important as for new arrivals, and that the retirement of old methods should be taken as seriously as the introduction of new methods.

“Obsolescence is far less recognized in health care than in industry,” he said.

We don’t build cars the same way today as in the 1950s, or even the 1990s. Factories are constantly upgraded, assembly lines made more efficient, workers retrained and the end product is safer. How many people drive around in cars that are a decade or two old?

Yet, look at our hospitals. More often than not, they are ancient, decrepit and inefficient. So are many of the technologies inside them, like X-ray and MRI machines that give off far too much radiation.

The practices of health-care professionals can be equally out of date and harmful. Doctors and nurses are not routinely retested and recertified. While many take their continuing medical education seriously, bogus credits are easy to come by.

There is also no formal, systematic method for health professionals to keep up with new developments. Many actually depend on daily newspapers to keep pace.

While there are drug and medical equipment salespeople to keep them informed on the new developments, who is educating health professionals (and patients) about discredited or obsolete practices?

Many emergency rooms still do routine electrocardiograms despite the fact they have little value; women are subjected to shockingly high rates of episiotomy and hysterectomy despite the scientific evidence; and a lot of little boys are mutilated by circumcision for no good medical reason.

“Why should we deal with this?” Dr. Noseworthy asked rhetorically. “Because we have to.”

Ignoring obsolescence is, well, obsolete thinking.