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We expect medicine to progress in an orderly fashion with good medical practices being replaced by better ones But some tests and therapies are discontinued because they are found to be worse or at least no better than what they replaced Medications like Vioxx and procedures such as vertebroplasty for back pain caused by compression fractures are among the medical advances that turned out to be danger. • Ending Medical Reversal is an essential book for medical students physicians and anyone even peripherally involved in medicine; for everybody else it's merely highly recommended The core of the book paraphrasing is that sometimes physicians decide to do things to patients without great evidence These practices are later on 'reversed' by well done trials often to the great surprise of thought leaders and experts in a specialty This is Medical Reversal which doesn't sound all too exciting but is actually super important • To understand why the underpinnings of the evidence based medicine community need to be examined The most important of them is the following medical theory in the sense of scientific models that allow for accurate prediction of real world outcomes is very poor Another way of saying this biology is very complex and predicting real world outcomes in biological systems with any precision is mostly impossible • The second most important assumption is that the vast majority of modern medical interventions even when they do work have modest effect sizes A new cancer drug if you're lucky might increase survival by an average of a month a new weight loss drug might let you lose another 5 10 lbs and a surgery might save 79% of patients instead of 77% These are made up numbers but the point stands on average when new drugs works which is itself rare they tend to be incremental improvements over the old standard of care• There are exceptions but they're rare in the modern era for instance you didn't need RCT's to see that antiseptic techniues improves surgery because the effect sizes were enormous for instance operating on the peritoneum previously a death sentence became possible Amputation mortality rates fell by than 50% The effects were so powerful they could be seen with practically any study design• The third tenet of EBM is that most interventions even the best funded and most plausible candidates fail when tested in the real world As the authors put in their book this means that the prior probability of any given intervention working is very low even in the late phases of drug development This has implications for the types of evidence that physicians should reuire to shift their guess on whether a given drug works Importantly developing medical interventions is incredibly hard and expensive and seems to be getting harder over time giving rise to the reverse Moore's Law that has been termed Eroom's Law incidentally this may have reversed slightly in the last decade but this is a preliminary finding • As a result of these 3 factors to really know if a medical intervention is effective you need randomized controlled trials where the effects of a single intervention are tested on roughly similar groups of patients and outcomes are tracked in a rigorous manner RCT's are onerous slow and reuire immense coordination but they've overturned many pet theories and biologically plausible interventions The fact that these theories and interventions turn out to not work is not the problem after all false starts and experimentation are how science progresses the problem is that they're often implemented prematurely before rigorous testing and only later as doubt builds are they truly tested • This is Medical Reversal There are other important arguments in the book but they're mostly subsidiary to these 3 key arguments Among them is a critiue of surrogate endpoints criticism of sloppily and hastily implemented 'systemic' interventions in hospital systems the profusion of observational studies purporting to show harmful or beneficial effects of lifestyle factors and the supplement industry• There's a radical part of the book which I think is underappreciated the call to action in the later half of the book The authors argue for a new era in medicine wherein a large fraction of patients will be enrolled in RCT's constantly testing medical dogma even for simple uestions that are currently poorly understood They want an easier and seamless way to recruit patients in clinical trials which would be done at lower cost than current methods and think this can be done partly by viewing RCT's as the default • Any practice in medicine that is currently understudied would be subject to this RCT by default opt out if you want framework Since RCT's would be testing treatments that are theoretically in euipoise this is far ethical than our current era in which many medical interventions are only tested rigorously AFTER being used on patients in uncontrolled settings As they correctly point out #uotes the safest way to receive a new drug is in a trial with a control arm The randomized controlled trial design provides a built in safeguard—trials are stopped if the treatment turns out to be harmful • As they acknowledge this radical change is a big ask but evidence based medicineis the only rational way to provide care and in my view is the only ethical way to practice medicine• Later in the book they critiue medical education for it's elevation of purported drug mechanisms and biological minutiae over a better understanding of medical evidence landmark clinical trials and contact with patients in clinical settings They call for an overhaul of medical education A nice uote on this The primacy of the basic sciences is the reason that cardiologists could not accept the finding that niacin did not save lives It is why radiologists could not accept that vertebroplasty did not help back pain It is the reason orthopedists could not accept that repairing torn menisci did not help knee pain• The book isn't perfect There are some relatively minor factual stumbles which don't affect the core arguments • For example it uncritically cites Nudge by Sunstein and Thaler which is based in large part on Behavioral Economics but at least some of that work has not fared well in the replication crisis as Kahneman himself has pointed out in a blog post So that's pretty ironic • I also think its deceptive to say that supplements don't have to admit to a lack of evidence as they claim They do Every supplement I've ever purchased has had in clear writing This product is not approvedto treat or prevent any disease Of course these same supplement bottles claim benefits so its a mixed message but supplements certainly have labeling to indicate they're not approved • The authors also repeatedly criticize pharma funded trials and influence but my understanding is that pharma funded trials generally comply with reporting regulations better than a

free read Ending Medical Reversal

Ending Medical ReversalHow they are harmful and what can be done to avoid them They explore the difference between medical innovations that improve care and those that only appear to be promising They also outline a comprehensive plan to reform medical education research funding and protocols and the process for approving new drugs that will ensure that of what gets done in doctors’ offices and hospitals is truly effectiv. Great overview of the topic Medical Reversal is apparently the term for when a standard practice in medicine gets stopped due to data showing it is either worthless or actively harmful Novelty in medicine gets attention and love than verifying and we as humans are really good with coming up with reasons why something might work I was surprised to see a chapter on alternative medicine here but it was well placed The same combination of crappy to non existent date plus wishful thinking drives both the adoption of novel medical treatments and snake oil like acupuncture and homeopathy We all do it The FDA is in a no win situation even before this current administration gutting every regulatory agency take the time to really test to see if a drug works better than what’s already out there and prove that it won’t cause harm and people complain that approval takes too long Approve a drug uickly based on surrogate endpoints and you approve a treatment that ends up needing to be taken off the market because of its harmsThe authors are optimistic that things can be changed and lay out a rational proposal for doing so including changing med school education and focus I’m not sure I share that optimismThere is even a chapter at the end on how as a patient to navigate your own health care There are great suggestions of uestions you can ask your doctor to help you clarify the best way forward with your treatment This books is a must read for everybody

Vinayak K. Prasad Ù 3 free read

review Ending Medical Reversal Ð eBook or Kindle ePUB µ ❰Download❯ ✤ Ending Medical Reversal Author Vinayak K. Prasad – We expect medicine to progress in an orderly fashion with good medical practices being replaced by better ones But some tests and therapies are discontinued becausOus or useless What Dr Vinayak K Prasad Ending Medical PDFEPUB or and Dr Adam S Cifu call medical reversal happens when doctors start using a medication procedure or diagnostic tool without a robust evidence base and then stop using it when it is found not to help or even to harm patientsDrs Prasad and Cifu narrate fascinating stories from every corner of medicine to explore why medical reversals occur. While in the early stages of my career before even starting my undergraduate degree I worked as a phlebotomist and medical assistant and spent much of my time off immersed in the skeptics community reading and talking about the never ending debunkings of often mechanistically implausible interventions like homeopathy and reiki and infuriated by the regulatory failures that contribute to this robust industry These are indeed concerns worth addressing but the time I spent in the community the I found myself disheartened by its most popular collective blindspots Many of course not all skeptics readily railed against alternative practitioners while gesturing vaguely at a supposedly evidence based system they left largely unexamined Meanwhile increasingly involved in the provision of healthcare I started critically appraising the decisions being made around me and began to understand to my horror the depth of what we do not know and perhaps damningly what we know and ignoreFast forward about five or six years I picked up this book after stumbling upon a wonderful and succinct journal article from 2011 by Drs Prasad and Cifu also on the subject of medical reversal I am always thrilled to find healthcare providers who do the hard work of uestioning their own dogma as opposed to the dogma of others and this book does an excellent job of that In fact while I was reading it I felt compelled to take notes specifically because it provides especially in the first three parts such a well laid out and well sourced summary of the thoughts and feelings I've had swimming around my head and slowly taking shape in that intervening time period I predict these notes will prove handy for guiding my ongoing discussions with colleaguesAside from a few minor editorial changes I would make my main uibble with the book is that at times I wish it had gotten into the weeds in discussing specific reversals and perhaps incorporated of the appendix ed examples into the main text but I understand why such choices were made in terms of maintaining the appeal for both lay and professional audiences as well as keeping the book to an easily digested lengthThis last paragraph is a bit of an aside but I also feel compelled to note that my feelings on the alternative practices so heavily scorned by skeptics have changed somewhat over time This is not to say that I now believe in interventions for which RCTs suggest no effect I don't but I do think that understanding the context of patient decisions is much complex and worthy of consideration than the skeptics community tends to give it credit for being The skeptics community not always the public figures but often the community at large seems to encourage a harsh response to anyone who chooses such therapies with no consideration of literacyeducation and the influencing social factors desperation culture legitimately terrible personal andor intergenerational interactions with the western healthcare system and so on Not to mention the therapeutic draw of providers willingable of course there are major system constraints for most providers to spend lots of time with patients especially time listening Finally and somewhat controversially I have come to the conclusion that some degree of inclusion of alternative care can be a form of harm reduction in cases where the patient would otherwise not access any care whatsoeverI am still in the early stages truly