Six times when medicine completely changed what it was doing due to new evidence.

There is a tale, told by many an alternative medicine proponent, that scientific (read: real) medicine is close minded, old-fashioned and doesn’t adapt to change. They tell us they’re the cutting edge, though in actuality not once has any alternative practice change when proven ineffective or dangerous.

But real medicine, being a scientific field, adapts to new information. When something works we embrace it. When something doesn’t – we toss it away.

So today, I wanted to bring you 6 cases of when scientific medicine completely changed what it was doing because of new information. This is not a conclusive list, of course, doctors change practice due to new information daily, but I tried to bring some milestone cases. Feel free to send me any other interesting cases I missed here.

Alright. Let’s go!

1. That time we stopped doing the mammary artery ligation surgery. Before 1960 there was a procedure called internal mammary artery ligation to alleviate the symptoms from angina pectoris (chest pain due to clogged arteries supplying blood to the heart). The mammary arteries are small vessels supplying the front chest wall, and in this operation they were surgically closed, without significant damage to the patient – these arteries have natural bypasses. This operation was deemed efficient in alleviating the symptoms, though the process by which that was accomplished was not clear. In this, rather early and crude (before Helsinki and informed consent laws) example of evidence based medicine, patients were receiving the operation but were randomized to either close or not close the mammary arteries. The results: There was no difference. The practice of the operation stopped, it was deemed ineffective and was not kept for “placebo value”.

2. That time we stopped doing arthroscopies on people with osteoarthritis. Osteoarthritis is a degenerative disease of joints which involves changes in the bone and cartilage and causes pain and disability. Usually associated with old age, injuries to the joint and overuse, it is a common and debilitating illness and the major cause for knee replacement surgery. But before 2002, one of the treatments offered was performing a procedure to wash and smooth out the cartilage in the joint using arthroscopy. In this study, with adequate blinding and placebo control, it was shown that this procedure is ineffective and provides no benefit. It was removed from common practice, and somehow no one said “well, we need to see if maybe this operation is good for something else”, like, say, acupuncturists or chiropractors do.

3. That time when we took a good look at hormone replacement therapy for post-menopausal women and realized it’s not all perfect and became reluctant to use it, but then looked at it again and found out there’s a smart way to use it to help patients. HRT is a supplemental hormonal therapy for post menopausal women that aims to ameliorate the symptoms of menopause and give post-menopausal women some of the protective qualities of higher estrogen levels. This therapy makes common sense, but when tested in 2002 the Women’s health initiative came to the conclusion that it was riskier than placebo and the treatment became widely unpopular. When new data came in and practices changed, it was shown that if you stratify women by risks and age, there are groups where this treatment is definitely beneficial and the harms minimal. Now this treatment is given in an evidence based manner, to those who will benefit the most.

4. This, the essential beginning of the clinical trial, is a description of a trial of blood-letting, a common practice of non scientific medicine. In the early 1800’s, a physician by the name of Pierre Louis conducted a non-blinded, primitive randomized controlled trial of two very homogeneous groups of patients with pneumonia and had shown that early blood-letting is lethal. Medicine as we see it today is a new thing, and evidence based medicine is newer still. Before medicine was rigorously tested and treatments verified – we were no better than the alternative crowd. Let these lessons from history show us where the path of “integrative medicine” might lead us, we must not integrate unbased, unscientific treatments into medicine.

5. The story of the discovery of helicobacter pylori, the stomach bacterium that is a major cause of pepetic ulcer disease and stomach cancer, is a fine example of the triumph of systematic research over preconceived notions. Here is a physician that recognized a disease causing pathogen where none was thought to exist, stood up to the challenges by his peers to prove his hypothesis, published reproducible research and finally got his hypothesis accepted. I love this story because it shows how silly the medical conspiracies are – here’s a lone (pretty much) scientist proposing a hypothesis that goes against what the medical world knows. What happens when he shows actual results? Why, his findings get accepted and suddenly we’re curing peptic ulcers and preventing stomach cancer. How did big pharma let us?

6. This one is not exactly like the others, but I think this is a wonderful example of what intelligent medicine actually is. Chronic myeloid leukemia is a blood cancer that has in almost all cases a very specific genetic cause, called the “Philadelphia chromosome”. It’s a hot spot (a fragile zone in the DNA) fracture of the DNA that brings two proteins together into a complex that causes uncontrolled proliferation of white blood cells in the body. This disease was lethal in almost all cases until 15 years ago. Here is the first clinical study of a drug that was intelligently designed (wink wink) to block the effect of this very specific protein. Lo and behold, suddenly there was a drug that cures cancer. Well, A cancer, but it gives a complete cure rate of around 95%. This drug, this amazing piece of medicine was developed by a guy sitting in a small room with funny smelling bottles and the hindu sign transcribed as “ohm” on the wall. Wait! Nope, sorry! It was created by fucking Novartis, which is as big pharma as it gets. And you know why? Because curing cancer is a way to earn ridiculous amounts of money while helping people, so this company, when they found a drug that works against cancer, what did they do? Hide it? Tell only tinfoil hatted quacks? Fuck no! Published results in the fucking NEJM and got it out to save people and earn money. And you know what, they completely deserved getting a metric fuck-ton of money for this medicine.

This is a slight side step from my usual format, but I think it is extremely useful to know the history of medicine and the way medicine actually works, so as to not be influenced by quackery and conspiratorial fear mongering. Please remember, what separates evidence based medicine from alternative (nothing-based) medicine is that EBM changes and adapts to new information. Real medicine is open minded, but skeptical, employing pre-test probability to assess claims before testing them to see if they even make sense, and testing them to see if perhaps they work anyway. It is a mutable, complex field of knowledge, that requires people to invest years upon years of study in order to be considered specialists and then continue studying and adapting to stay with current practice. To replace this evolving body of knowledge with superstitious bullshit is to return to the years of blood-letting, of plague and of mass graves from vaccine-preventable illnesses. I sincerely hope we will outgrow the superstitions inside and those encroaching on scientific medicine as soon as humanely possible.

I am, as always,

A wide eyed Skeptic

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