How does modern medicine work

Slice a pie into five pieces, and remove one piece. That slice represents the roughly 20 percent of clinical-care practices for which solid randomized, controlled trial evidence exists. The remaining four-fifths represent medical care delivered based upon a combination of less reliable studies, unsystematic observation, informed guesswork and conformity to prevailing treatments and procedures used by most other clinicians in a local community.

To illustrate how little scientific evidence often exists to justify well-established medical treatments, David Eddy researched the scientific evidence underlying a standard and widely used glaucoma treatment designed to lower pressure in the eyeball.

He searched published medical reports back to and could not find one randomized, controlled trial of the treatment. That was despite decade after decade of confident statements about it in textbooks and medical journals, statements which Eddy found had simply been handed down from generation to generation. The kicker was that the treatment was harmful to patients, actually causing more cases of blindness rather than fewer. Similar evidence deficits exist for other common medical practices, including colorectal screening with regular fecal-occult-blood tests and sigmoidoscopy; annual chest x-rays; surgery for enlarged prostates; bone-marrow transplants for breast cancer; and common approaches to pain control, depression, immunizations, cancer screening, alcohol and drug abuse, smoking and functional disabilities.

The problem is rampant across medicine; a huge amount of what physicians do lacks a solid base of scientific evidence. In the past, many standard and accepted practices for clinical problems were simpler and more straightforward than those that today's clinicians face—and these practices seem to have worked, despite the paucity of good research evidence.

Physicians simply made subjective, intuitive decisions about what worked based on what they observed. The problem today is that the growing complexity of medicine bombards clinicians with a chaotic array of clinical choices, ambiguities and uncertainties that exceeds the inherent limitations of the unaided human mind.

As a result, many of today's standard clinical practices bear no relation to any evidence of effectiveness. Instead, physicians frequently base their decisions on shortcuts, such as the actions of the average practitioner "if everyone is doing it, the intervention must be appropriate" ; the commonness of the disease "if the disease is common, we have no choice but to use whatever treatment is available" ; the seriousness of the outcome "if the outcome without treatment is very bad, we have to assume the treatment will work" ; the need to do something "this intervention is all we have" ; and the novelty or technical appeal of the intervention "if the machine takes a pretty picture, it must have some use".

Drug prescribing is another blatant example of medical practice that is often evidence-free. Drugs that are known to be effective may work well for only 60 percent of people who take them. But about 21 percent of drug prescriptions in the United States are for "off-label" use, that is, to treat conditions for which they have not been approved by the U.

Food and Drug Administration. That's more than million prescriptions per year. Off-label use is most common among cardiac medications 46 percent and anticonvulsants 46 percent. Here's the real punch line: in 73 percent of the cases where drugs are used in unapproved ways, there is little or no evidence that they work. Physicians prescribe drugs well over a million times a year with little or no scientific support. These are fighting words, saying that such a big chunk of medical practice is not based on science.

To illustrate just how provocative this topic is, look at what happened in the s when the Federal Agency for Health Care Policy and Research now the Agency for Healthcare Research and Quality released findings from a five-year investigation of the effectiveness of various treatments for low back pain—one of the leading reasons that Americans see physicians. Led by back expert Richard A. Deyo, MD, MPH, the team included orthopedic surgeons, primary-care physicians, physical therapists, epidemiologists and economists.

Together, they examined the relative value of various diagnostic tests and surgical procedures. They conducted a comprehensive review of clinical literature on back pain. They exhaustively examined variations in the rates at which different procedures were being used to diagnose and treat back pain. Their chief finding was deeply disturbing: what physicians thought worked well for treating low back pain doesn't. The implication was that a great many standard interventions for low back pain may not be justified.

And that was immensely threatening to physicians, especially surgeons who perform back operations for a living. Among the researchers' specific findings: no evidence shows that spinal-fusion surgery is superior to other surgical procedures for common spine problems, and such surgery leads to more complications, longer hospital stays and higher hospital charges than other types of back surgery. Disgruntled orthopedic surgeons and neurosurgeons reacted vigorously to the researchers' conclusion that not enough scientific evidence exists to support commonly performed back operations.

The surgeons joined with Congressional critics of the Clinton health plan to attack federal funding for such research and for the agency that sponsored it. Consequently, the Agency for Healthcare Policy and Research had its budget for evaluative research slashed drastically. The back panel's guidelines were published in Since then, even though there are still no rigorous, independently funded clinical trials showing that back surgery is superior to less invasive treatments, surgeons continue to perform a great many spinal fusions.

The number increased from about, in to , in What are physicians to do? They need a great deal more reliable information than they have, especially when offering patients life-changing treatment options.

Before recommending surgery or radiation treatment for prostate cancer, for example, physicians and their patients must compare the benefits, harms and costs of the two treatments and decide which is the more desirable. One treatment might deliver a higher probability of survival but also have bad side effects and high costs, while the alternative treatment might deliver a lower probability of survival but have no side effects and lower costs.

Without valid scientific evidence about those factors, the patient may receive unnecessary and ineffective care, or fail to receive effective care, because neither he nor his physician can reliably weigh the benefits, potential harm and costs of the decision. Recognizing that the quality and reliability of clinical-research information vary greatly, entities like the U. The strongest evidence is the scarcest and comes from systematic review of studies randomized, controlled trials that are rigorously designed to factor out biases and extraneous influences on results.

Weaker evidence comes from less rigorously designed studies that may let bias creep into the results for example, trials without randomization or cohort or case-control analytic studies. The weakest evidence comes from anecdotal case reports or expert opinion that is not grounded in careful testing. There are a lot more "maybes" than "do's. Guidelines are not rigid mandates or "cookie-cutter" recommendations that tell physicians what to do.

They are intended to be flexible tools to help physicians and their patients make informed decisions about their care. Even guidelines that are rooted in randomized, controlled trial research do not make clinical decisions for physicians; rather, they must be applied to individual patients and clinical situations based on value judgments, both by physicians and their patients.

Clinical decision-making must entail value judgments about the costs and benefits of available treatments. What strong guidelines do is to change the anchor point for the decision from beliefs about what works to evidence of what works. Declaration This is my original unpublished piece, not under consideration for publication elsewhere.

Questions That This Paper Raises What needs to be done to bring about the paradigm shift from control and palliation to prevention and cure? Is cure at all possible? Will mainstream medicine ever be able to incorporate the beneficial findings of CAM? What needs to be done to promote wellness with longevity?

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A Lancet analysis revealed that if rising life expectancy means years in good health, then health expenditure is expected to increase by only 0. The greatest stress on the NHS comes from managing almost entirely preventable chronic conditions such as heart disease, high blood pressure and type 2 diabetes. Yet rather than address the root cause of these conditions through lifestyle changes, we prioritise drugs that give — at best — only a marginal chance of long-term benefit for individuals, most of whom will derive no health outcome improvement.

The reality is that lifestyle changes not only reduce the risk of future disease, their positive effects on quality of life happen within days to weeks. However, those patients unlucky enough to suffer side effects from prescribed medicines may find their quality of life will deteriorate in order to enjoy small longer term benefits from the medication. But more than saving money, it will be about redistributing resources within the system to where they are needed most, in acute and social care.

If it were not for the discoveries of these companies, many of the people reading the Atlantic as well as this blog would not be here today. The efforts of the industry should not be sacrificed for the ideals of better care from physicians. As noted above, changes in care are more about the reimbursement system, and less about the 10 cents of every dollar spent on health care in America.

Ultimately, if it were not for the declines in death rates from heart disease and stroke, created by the drug device industry, we would lose 1 million more Americans every year. Just ask yourself, what are the chances that you or someone you loved would be in that 1 million, this year or the next. Thomas Sullivan is Editor of Policy and Medicine, President of Rockpointe Corporation, founded in to provide continuing medical education to healthcare professionals around the world.

Prior to founding Rockpointe, Thomas worked as a political consultant. Its impossible to those who did not knowabout to judge the others culture or belives. Nevertheless if they were professors in modern sscinces! Here comes the golden say: The best medicine, is that covers nutrition needs , and the best food, is that covers medication needs. Finally , Bees honey deveoped out of herbal sources! If others are of nothing in such belifth or knowledge,this will not means the current medicine is the best or the bioneer one ,For Islamic culture historically came first … But the progress,preference or Excellence will cot be of fair justice valus if other compititors are excluded.

Leave A Reply Cancel Reply. Save my name, email, and website in this browser for the next time I comment. Home Media Modern Medicine vs. Alternative Medicine: Different Levels of Evidence. Modern Medicine vs. By Thomas Sullivan Last updated May 6,