It is always interesting when established medical practices shift from standard to refuted, or even obsolete. As a women's health care practitioner, I continually strive to improve standards of care for my patients, and that is usually an expectation of medical providers in general. But when an article in the Mayo Clinic Proceedings was published earlier this year reversing 146 established medical practices, it gave me pause for thought. Medicine is not static, we know that. But how do we wrap our heads around the periodic reversals that come when studies show alternative answers to practiced norms?
This is a question many of my patients face on a regular basis when considering things such as menopause management. Hormone Replacement Therapy -- or HRT -- was, until 2001, considered a standard practice for post-menopausal women to help protect against heart disease.  Clinical trials conducted by the Women's Health Initiative (WHI), formed in 1991 by the National Heart, Lung and Blood Institute of the National Institutes of Health (NHLBI-NIH), eventually reversed that practice when their studies not only showed little proof of effectiveness, but increased risk of other afflictions.  The WHI offers suggestions for women who wish to consider postmenopausal hormone therapy, including customizing appropriate therapies to provide the most benefits. But as we relook at this study we see that the findings are subject to some interpretation as the results varied if one was just beginning menopause at the time of use or years post menopause.
But like with HRT reversal, according to the researchers conducting the recent investigation reported in the Mayo Clinic Proceedings, it may take a decade for clinicians to fully understand if a practice works. And many practices gain acceptance through faith that the evidence is sound.  This specific study evaluated 1,344 articles published between 2001 and 2010 in the New England Journal of Medicine. Of the 363 articles investigating established medical practices, 146 were found to be ineffective. On the flip side, 138 reaffirmed the practices, and 79 were found inconclusive. However, when there are any contradictions in current practices, this may undermine patient's confidence in established medical care -- a huge consideration.
Other significant examples of reversals include using stents for the treatment of stable coronary artery disease, using surgically implanted tubes for ear infections in children, utilizing stem-cell transplantation in women with advanced breast cancer, urging people with diabetes to adhere to very strict blood sugar targets, and here's a good one -- advising patients with dust-mite allergies to buy impermeable mattress covers. According to Vinay Prasad, M.D., Medical Oncology Branch of the National Cancer Institute and also head of the investigation reported in the Mayo Clinic Proceedings, the mattress-cover recommendation launched a $26 million-a-year industry until New England Journal of Medicine reports debunked it. That's a pretty big differential for the average American consumer.
But let's get back to the basics. What should patients do to understand and effectively choose their treatments and meet their personal health care needs? And how should clinicians help? Dr. Prasad advises that patients focus on the endpoints of treatment: Is the treatment's effectiveness based on hard evidence proof? Patients must ask questions and not just assume a therapy is beneficial because it is prescribed. Clinicians have a moral and ethical obligation to be honest and provide the most sustainable and reasonable treatment options available. And what about the cost? Our nation faces an economical crisis rooted in health care costs, and the Mayo Clinic Proceedings article shows that reversals contribute to those costs. Another significant factor.
So what's the big picture here? Modern medicine has offered many amazing and wonderful advances. And as a functional medicine practitioner, it's important for me to stress that lifestyle also matters: eating the right foods, participating in enjoyable exercise, getting enough sleep, and being happy. But there are many modalities to healing. Combining experience and knowledge, gut instinct, lifestyle and, most importantly, the individuality of each patient will help counter medical reversals and better our health.
1. The University of Chicago Medicine, 5841 S. Maryland Avenue Chicago, IL 60637 URL: http://www.uchospitals.edu/online-library/content=P00564
2. NHLBI Health Information Center, P.O. Box 30105 Bethesda, MD 20824 URL: http://www.nhlbi.nih.gov/whi/
3. Mayo Clinic Proceedings, August 2013,88(8),790-798, published by Elsevier Inc. URL: http://www.mayoclinicproceedings.org/article/S0025-6196(13)00405-9/abstract