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First, do harm...

MagazineDecember 2010 (Vol. 21 Issue 9)First, do harm...

It has become the stuff of urban myth: when doctors go on strike, the death rate falls

It has become the stuff of urban myth: when doctors go on strike, the death rate falls. However, unlike most myths, this happens to be true.

One study has analyzed mortality rates in seven areas where doctors have been on strike in the recent past. Indeed, although researchers expected to see death rates rise when doctors downed tools, they discovered that the rate stayed the same or, in the majority of cases, fell. As the researchers were forced to conclude, "Reductions in mortality may result from these strikes" (Soc Sci Med, 2008; 67: 1784-8).

Conversely, when doctors are fully employed, they are the third cause of death in the US after heart disease and cancer (JAMA, 2000; 284: 483-5).
More medicine might at least suggest greater life expectancy among its survivors, but this is not happening. Indeed, in spite of today's medicine being more aggressive and interventionist than at any time before in history, the general life expectancy is declining. After climbing slowly over the past two centuries, it is beginning to fall and looks likely to continue its downward trend throughout the 21st century (N Engl J Med, 2005; 352: 1138-45).

While modern medicine may not kill you or even extend your life, it can certainly make you ill. In those parts of the US that have the best healthcare coverage, the residents are sicker than in populations where healthcare facilities are poor or inadequate (Ann Intern Med, 2003; 138: 273-87). This could be because so much of medicine truly does cause harm. Adverse reactions to medical treatment result in 116 million extra physician visits, 77 million additional prescriptions, 17 million emergency hospital visits and $77 billion in extra costs every year in the US (JAMA, 2000; 284: 483-5).

Worse, some of the treatments that cause so much harm are also useless, and shouldn't be carried out in the first place. America's medical industry has started a process of identifying pointless and harmful procedures in an effort to reduce its annual costs of $2 trillion, especially in the light of President Obama's healthcare reforms. Professor Howard Brody of the University of Texas has invited each medical specialty to put forward its 'top five' list of tests or treatments that are most commonly ordered by physicians and among the most expensive and, yet, offer "no meaningful" benefit.

"In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit," he writes (N Engl J Med, 2010; 362: 283).

Response to Brody's invitation has been mixed, ranging from dermatology's "we do no unnecessary care" to emergency medicine's "only five?" Stephen Smith, of Brown University's Medical School, is taking the challenge seriously and is preparing a list from the usual practices of internal medicine. "I hate to say it, but it's true: doctors sometimes do things that do not benefit patients and can even be harmful," he said (Newsweek, March 5, 2010).

Taking up the theme, Deborah Grady, at the University of California at San Francisco, is launching a 'Less is more' column in the Archives of Internal Medicine medical journal that will be focused, twice each month, on a medical practice that is pointless or even harmful (Arch Intern Med, 2010; 170: 749-50).

Here is WDDTY's contribution to the debate, with our list of the medical treatments, practices and tests in which we believe the risks outweigh the benefits.

o Angioplasty. This has become the wonder treatment for anyone with angina or stenosis (narrowing of the arteries). It is a simple procedure whereby a tiny inflatable 'balloon' is threaded into blocked arteries. When it is then expanded, it forces the plaque 'plug' up against the arterial wall, thus opening up the vessel's lumen. However, major studies have consistently demonstrated that the technique is no better than heart drugs (N Engl J Med, 1996; 335: 1253-60; Harv Heart Lett, 2008; 19: 7). In addition, in the emergency room, it is more often than not a killer. The technique is supposed to be performed within 90 minutes of the patient's admission-any later, even by just a few minutes, and angioplasty may kill the patient. A Canadian study discovered that, in 68 per cent of all emergency procedures, angio-plasty is carried out well outside of the recommended time, thereby doubling the chances of the patient dying (JAMA, 2010; 303: 2148). In addition, more than 500,000 non-emergency angio-plasty procedures are performed in the US alone every year-and the specialist is paid $51,000 for each one.

o Arthroscopic surgery. This procedure is carried out around 650,000 times a year in the US alone, and is the last option before knee-replacement surgery for osteoarthritis sufferers. Around half the patients say they feel a big improvement in pain levels and movement afterwards (Arthritis Rheum, 1993; 36: 289-96), although there has never been any evidence to suggest that the procedure either cures or arrests the osteoarthritic process.

In a study of 180 patients, researchers discovered that the surgery was no better than a placebo. In other words, patients who underwent 'dummy' surgery, during which nothing was done to them, reported the same benefits as those who had received the full arthroscopic treatment (N Engl J Med, 2002; 347: 81-8).

o Bilateral oophorectomy. This routine procedure involves removal of the ovaries at the same time as the womb is removed (hysterectomy). It is entirely a just-in-case measure, and it's supposed to prevent the development of ovarian cancer. It is carried out on around 300,000 women in the US every year, which represents 55 per cent of all hysterectomies.

However, William Parker at the St John's Health Center in Santa Monica, CA, argues that the procedure's risks outweigh any benefits. Oestrogen deficiency, which invariably arises after the ovaries have been removed, results in higher risks of coronary artery disease, stroke, hip fracture, Parkinson's disease, dementia, cognitive impairment and depression (J Minim Invasive Gynecol, 2010; 17: 161-6).

o Biopsies. These tests involve taking tissue samples, usually to detect cancer in the skin or with-in organs. The tests, however, may be inaccurate. A prostate biopsy has a 25-per-cent failure rate, and this poor rate is improved only slightly even when repeated samples are taken (Mol Urol, 2000; 4: 93-7). Automated needle biopsy, one of the techniques used, gets it wrong 40 per cent of the time (Eur J Cancer, 2003; 39: 1676-83), while lung biopsy produces a false-negative rate of around 30 per cent, thus suggesting a clean bill of health when cancer is actually present (Resp Care Clin North Am, 2003; 9: 51-76).

Not only are biopsies inaccurate, but they can also be dangerous. Lung biopsies can cause the lungs to collapse, and prostate biopsies sometimes cause blood clots, preventing urination, but the greatest risk is the spread of cancer cells. Cases have been reported where a biopsy caused the spread of prostate cancer (Urology, 1976; 8: 513-5), while malignant cells are spread in around 30 per cent of all breast biopsies (AJR Am J Roentgenol, 1999; 173: 1303-13). Liver biopsy causes a 'significant risk' of cancer spread in up to 16 per cent of cases (Dis Colon Rectum, 2003; 46: 454-8).

o Coronary calcium scans. This screening test for coronary artery disease looks for specks of calcium-or calcifications-in arterial walls, using a radiology technology known as 'computed tomography' (CT) scanning.

However, the information it provides the heart specialist is useless. In a patient at low risk of coronary disease, high levels of calcification are not a significant marker on its own, whereas a high-risk patient needs treatment irrespective of the amount of calcification present (N Engl J Med, 2009; 361: 990-7, 2490-2).

But this useless information can come at a high cost to the patient. A CT scan emits radiation levels that are equivalent to 74 mammograms and 442 chest X-rays (Arch Intern Med, 2009; 169: 2078-86). Put another way, a CT-scanned patient is exposed to radiation levels that are 21 times higher than was released at Hiroshima when the atom bomb was dropped. Overall, 2 per cent of patients have an increased risk of developing cancer due to repeated CT radiation exposure (AJR Am J Roentgenol, 2009; 192: 887-92).

o ECG (electrocardiography). This test is supposed to detect signs of heart disease by monitoring the electrical signals of the heart at rest or during and after exercise. However, it doesn't appear to work with women. One study discovered that women are often misdiagnosed even when there is an actual heart problem (N Engl J Med, 1991; 325: 226-30). ECG is also far more likely to record a false-positive result in women following exercise (Arq Bras Cardiol, 2001; 76: 540-4), causing a great deal of unnecessary worry. Neither does it fare much better in men. In one study of 8176 male and female patients with suspected angina, the test was unable to detect heart problems whether the patient was resting or after exercise (BMJ, 2008; 337: a2240).

o Inhalers. These devices for asthma and lung problems such as emphysema and bronchitis are usually seen as lifesavers, yet the truth may be the very opposite. Emphysema and bronchitis sufferers double their risk of a fatal heart attack when they use an inhaler, and the risk is greatest when the drugs ipra-tropium bromide and tiotropium bromide are involved. Also, the risk of stroke is increased if the drugs are used for more than six months (JAMA, 2008; 300: 1439-50).

Indeed, America's Food and Drug Administration (FDA) has decided that the risks outweigh any benefits in children aged four to 11 years who use a long-acting beta-agonist (LABA) drug (N Engl J Med, 2009; 360: 1592-5).

Although inhalers can offer immediate relief, their long-term use can make asthma even worse, a study from the University of Leicester has concluded (see Telegraph.co.uk, 14 Jan 2010, and box, page 12).

o Mammograms. Every woman over the age of 50 or so is encouraged to have regular mammography screening to detect early signs of breast cancer. However, researchers have concluded that the risks outweigh any benefits. The Cochrane Collaboration says that doctors are dramatically downplaying the risks of mammography X-rays while overstating the benefits. Overall, say the researchers, there's no evidence that mammography saves lives (J R Soc Med, 2010; 103: 14-20). The reason could be that mammograms are not sensitive enough to pick up the aggress-ive, fast-growing tumours that can be life-threatening. Instead, the tumours they are able to detect are invariably slow-growing and possibly even benign. Yet, a positive reading inevitably launches an aggressive treatment protocol that includes chemotherapy and even mastec-tomy. Mammograms can also be inaccurate, a problem that is compounded by inexperienced technicians. For every genuine case of cancer detected, a mammogram also picks up 10 times the number of false-positives (N Engl J Med, 1998; 338: 1089-96).

o MRI scans. Magnetic resonance imaging is one of the newer, and more impressive, screening technologies. Rather than using radiation, it employs a magnetic field, which makes it sensitive to changes in the body's soft tissues. It is especially useful for detecting changes in the brain, and in the cardiovascular and musculoskeletal systems, and for identifying cancerous tissue.

However, because it is so very impressive, it is overused. It is prescribed, for example, for anyone with lower back pain. A guidance paper from the American College of Physicians "strongly recommends" that physicians stop all routine imaging and diagnostic tests, as they are pointless and expensive (Ann Intern Med, 2007; 147: 478-91).

o Pap tests. Sexually active women are supposed to have a regular Papanicolau, or Pap, smear to detect the early signs of cervical cancer. The tests should begin at the age of 21 at the very latest, but studies confirm that it has little positive benefit for any woman under the age of 30. Researchers found that the test only starts to detect cervical cancer in women aged 34 or older (Women's Health, 2009; 5: 613-6). Pap smears also detect benign changes that would invariably disappear on their own and without intervention.

o PSA screening. Just as every woman over the age of 50 is urged to have a mammogram, so every man of similar age is recommended to have a serum prostate-specific antigen (PSA) test for prostate cancer. How-ever, as with mammography, the PSA test risks appear to outweigh its benefits. Prostate cancer develops slowly, and only 8 per cent of deaths occur in the under-65s, yet aggressive treat-ment of the cancer often results in a dramatic reduction in the quality of life, including impo-tence and urinary incontinence (Am Fam Physician, 1998; 58: 432-8).

o Spinal fusion. This procedure, also known as 'spondylodesis' or 'spondylosyndesis', is a surgical technique in which two or more vertebrae are fused together, or combined. This immobilizes the vertebrae, and is designed to reduce pain in those with degenerative disc disease or other spinal conditions. How-ever, it is useless in all cases other than fractures or spinal cancer. Nevertheless, around 351,000 of these useless procedures were performed in the US alone in 2007, costing $26.2 billion, or $75,000 per person.

As medical researcher and author Shannon Brownlee points out: "We doctors are extremely good at rationalizing. Somehow we manage to figure out how the very best care just happens to be the care that brings us the most money" (Brownlee S. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. New York, NY: Bloomsbury USA, 2007).

o Thyroid tests. Around 10 million thyroid tests are carried out in the UK each year for an annual cost of lb30 million. As there are around 600,000 people in the UK with an over- or underactive thyroid, this suggests that many healthy people are being tested unnecessarily. Doctors maintain that thyroid disease can have non-specific symptoms but, if this is so, then the tests should be picking up more than the 0.45 per cent of problems it's detecting ('Signs and symptoms predict thyroid disease', online at www. medicine.ox.ac.uk/bandolier/band46/ b46-5.html).

o Vertebroplasty. This surgical technique injects cement into the spine. This is supposed to stabilize the vertebrae, and is a common procedure for osteo-porosis sufferers with back fractures. Around 170,000 of these procedures are carried out in the US every year, at a cost of $5000 per operation. However, it is useless, and any benefits are all in the patient's mind, as two studies have confirmed. In one, the benefits of a sham procedure were maintained for up to six months afterwards; in the other, 131 patients were given either
a vertebroplasty or a dummy procedure, and the results were similar in both groups (N Engl J Med, 2009; 361: 557-68, 569-79).

o X-rays. Standard radiographs are among the most basic items in the doctor's diagnostic toolbox. Astonishingly, seven out of 10 Americans have at least one X-ray every year, which suggests that there cannot always be a valid reason for the test.

In fact, the detection abilities of standard radiography are limited: chest X-rays are unable to detect tuberculosis (TB) (Lancet, 1999; 353: 319-20), and they cannot pick up intracranial bleeding (J Neurol Neurosurg Psychiatry, 2000; 68: 416-22), for example. They are also now becoming recognized as a major possible cause of cancer. In one experiment on mice, 62 per cent developed cancer following X-rays (PNAS, 2008; 105: 12445-50). In people, those who have had more than 10 dental X-rays are far more likely to develop thyroid cancer (Telegraph.co.uk, 4 June 2010; www.telegraph.co.uk/health/ healthnews/7802609/Dental-X-ray-link-to-thyroid-cancer.html).

Bryan Hubbard

The drugs that do more harm than good

Every pharmaceutical drug can cause an adverse reaction, but sometimes the effects are so significant-or the drug just doesn't do what it is supposed to-that the risks far outweigh any benefits. Here's a list of some of those drugs.

o ADHD drugs. Many parents watch with relief as their ADHD (attention-deficit/hyperactivity disorder) child takes a drug such as Ritalin and his behaviour improves almost immediately. However, this usually means that the child then takes the drug for the remainder of his adolescence and possibly even into early adulthood. Yet, one study has discovered that the drugs have a beneficial effect only for the first 14 months; thereafter, any improvement is down to natural causes. The researchers tracked two groups of ADHD children: one group was taking a drug such as Ritalin, Adderall or Concerta, and the other group had never taken a drug. After 14 months, the non-drug group suddenly displayed marked improvement, while the drug group maintained the same level of inattention and hyperactivity (J Am Acad Child Adolesc Psychiatry, 2009; 48: 240-8).

o Alzheimer's drugs. A family of drugs known as 'cholinesterase inhibitors' are commonly prescribed for dementia and Alzheimer's disease. However, several studies have questioned their effectiveness in slowing cognitive disorders, and a later study from the Institute for Clinical Evaluative Sciences in Toronto discovered that they also cause a range of serious side-effects. These drugs-Aricept (donepezil), Exelon (rivastigmine) and Razadyne (galantamine)-increase the risk of fainting, bradycardia (slowing of the heart rate to dangerously low levels) and hip fracture. Patients may also need a pacemaker as a direct result of taking one of these drugs (Arch Intern Med, 2009; 169: 867-73).

o Antibiotics. Although antibiotics have been lifesavers, they are so overprescribed-and often inappropriately for viral conditions-that they are now considered to be one of the most dangerous families of drugs around today. About 20 per cent of all drug-related visits to accident and emergency units are due to an antibiotic. Over a two-year period, 142,000 Americans reacted so badly to an antibiotic that they had to be admitted to hospital (Clin Infect Dis, 2008; 47: 735-43).

The drugs can also make bacterial infections worse. In a study of 119 children, 71 were given amoxicillin, a moderate-spectrum penicillin. Within two weeks, many of the children had developed antibiotic-resistant bacteria (BMJ, 2007; 335: 429).

o Antidepressants. People with clinical depression are not helped by antidepressants. The new generation of drugs is not targeted at the cause of most depression-a brain protein called 'monoamine oxidase A' (MAO-A)-and time is the best healer, say researchers at the Centre for Addiction and Mental Health in Toronto (Arch Gen Psychiatry, 2009; 66: 1304-12). Not only are they ineffective, but they also dramatically increase the risk
of suicide. The worst culprit was Effexor (venlafaxine), one study discovered (BMJ, 2007; 334: 242). Anti-depressants also increase your chances of stroke and of death by any cause if you are a postmenopausal woman (Arch Intern Med, 2009; 169: 2128-39).

o Aspirin. Around 100 billion aspirin pills are taken every year, usually as part of a health regime to ward off heart disease. Although it's recognized that the NSAID (non-steroidal anti-inflammatory drug) causes gastrointestinal (GI) bleeding, the extent-and severity-has only recently come to light. Researchers now reckon that the drug is killing around 20,000 Americans and sending another 100,000 to hospital every year. Worldwide, aspirin is killing around 100,000 every year due to GI reactions (Proceedings of the Annual Scientific Meeting of the American College of Gastroenterology, 15 October, 2007). It also increases the risk of stroke in the over-75s, according to a study that looked at population clusters during 1981-1986 and 2002-2006 (Lancet Neurol, 2007; 6: 487-93).

o Proton pump inhibitors (PPIs). Around lb2 billion ($2.86 billion) is spent each year around the world on these indigestion drugs. Studies reveal that they don't work, and that most people who take them don't need them in the first place. PPIs stop the backflow of stomach acid, thus stopping heartburn. If they don't work, the view is that they won't harm you, but this is also not the case. They can cause stomach infections, and can double the risk of Clostridium difficile infection (JAMA, 2005; 294: 2989-95). This is because PPIs block the production of gastric acid, the body's natural defence against harmful bacteria. The drugs can also increase the risk of pneumonia (Arch Intern Med, 2007; 167: 950-5) and hip fracture (JAMA, 2006; 296: 2947-53).

o Statins. These cholesterol-lowering drugs are among the most popular drugs on the market. Around 36 million Americans take one every day, and annual sales revenues total $15.5 billion. Two statins-Lipitor and Zocor-are the two best-selling drugs in the US. Although there is evidence that people with an existing heart condition derive benefit from the drugs, that accounts for only 8 per cent of users. The rest are taking the drug as a just-in-case remedy, but the evidence doesn't suggest that the drugs are doing any good for healthy people. Harvard researchers analyzed eight studies and concluded that statins don't save lives-and even their benefits for heart patients are marginal. Worse, the drugs can have a paradoxical effect, causing the very heart conditions they are supposed to protect against. They have also been cited as a cause of Parkinson's disease (Lancet, 2007; 369: 268-9).

The drugs even doctors won't take

Doctors probably know better than most of us the drugs that are harmful. Here are the 'top eight danger drugs' listed by doctors when asked to list the prescription and over-the-counter (OTC) remedies that they would avoid.

o Advair (salmeterol). Advair is an asthma drug that contains salmeterol, a long-acting beta-agonist (LABA). One study found that regular use of a LABA could increase the severity of an asthma attack. Salmeterol has also been linked to the 5000 asthma-related deaths in the US every year.

o Avandia (rosiglitazone). This diabetes drug can cause a heart attack. One study has found that the drug increases the risk of heart failure by 109 per cent and of heart attack by 42 per cent among those who have taken the drug for more than a year.

o Celebrex (celecoxib). As with other NSAIDs, Celebrex causes stomach bleeding. However, one study also discovered that it comes with an extra kick: it can also lead to kidney problems and kidney damage. Worse, a twice-daily dose of the 200-mg tablet can double your risk of death from cardiovascular disease, while the 400-mg dose triples the risk.

o Ketek. This antibiotic can cause severe liver problems, and the risk is so high that its use in the US has been restricted to the treatment of pneumonia.

o Prilosec, Nexium. These acid-reflux digestion aids can cause heart problems, although there is some controversy over the link. However, they can also increase your risk of pneumonia, and of osteoporosis and bone loss. If you regularly take one of these drugs, your risk of a fracture increases by 40 percent.

o Visine Original. This OTC remedy is supposed to get rid of 'red eyes'. However, if you use Visine too often, its active ingredient, tetrahydrozoline, can cause even more eye redness.

o Pseudoephedrine. This decongestant is found in many OTC cough remedies that you can buy in any pharmacy. However, it is linked to increases in blood pressure and in heart rate, which can lead to heart attack and stroke. It can also worsen prostate disease and glaucoma.
Source: MSN Health, 8 July 2008

WDDTY VOL. 21 ISSUE 4


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