"Maybe 40% of what doctors do is mistaken."
That was one of the first of many OMG! zingers medical provocateur Vinay Prasad, MD MPH, flung at us at today's Salem City Club presentation, rather drily titled Evidence Based Medicine: Weighing the Evidence for Effective Health Care.
But not one moment of his talk was boring. In fact, it was one of the most interesting and entertaining City Club talks I've experienced. And I've been to many of them. Prasad is a great speaker: funny, caustic, informed, blunt, spontaneous.
I found what appears to be a very close version of his talk on You Tube. So if you find my summary of what Prasad told us today piques your interest, check this video out. His talk starts at about four minutes in.
Later in his talk Prasad noted that there's no way to know exactly what percentage of medical care is ineffective. So it could be less or more than 40%. Regardless, it's a lot.
If you're thinking that this makes him less than universally popular among his fellow doctors, you'd be correct. After his talk I asked him how his presentation is received by other MDs. He told me that in Europe and Canada he gets a standing ovation. But in Texas, say, speaking to cardiologists, Prasad said he'd get boos.
Which speaks volumes about the sorry state of our American health care system. Or more accurately, non-system. As is well known, we spend way more on health care than other comparable countries yet have health outcomes that are worse.
There are many reasons for this, but paying for costly medical services that don't provide any real benefit is a major contributor.
Prasad noted that we have a bias toward believing in continual technological process. He showed a slide of an old Model T next to a Tesla Model T. Now, this was the only error I recognized in his talk, since I couldn't find any sign via the Great God Google that a Tesla model with that initial actually exists or is planned.
But it is conjecture, so some apparent Prasad literary license is fine with me.
His point with the auto analogy is that we can see how much cars have progressed since the Model T era. Ditto with computers, cell phones, televisions, and so much else. But with health care we can't discern progress with the naked eye. Controlled studies are necessary.
And these frequently demonstrate what the title of a book he's co-authored refers to: Medical Reversal. This is when doing something is found to be no better or worse than a prior standard of care.
Examples: routine hormone replacement therapy for post-menopausal women and steroid injections for certain spinal problems. Regarding the latter, a a controlled study where half the patients got a salt water injection revealed that both groups felt better.
Which points to the power of placebos. And a question I asked during the Q & A period.
It went like this: "If both steroid and salt water injections benefit patients with back pain, please comment on the ethical issues surrounding placebos, since doing away with ineffective treatments seems like doing away with a witch doctor a tribe believes in, and who makes them feel better."
Prasad's answer made sense, though it raises additional questions. He said that a medical treatment shouldn't be more costly than a placebo, and also shouldn't be any riskier than a placebo.
And he correctly pointed out that bottles of pills marked "Placebo" can be bought on Amazon, since it has been found that even when people know a treatment is a placebo, it still provides benefits to many.
Publication bias is one reason why ineffective treatments get so much attention. Journals like to publish reports of positive findings involving new forms of medical practice. So studies that show something doesn't work, or is a review of the effectiveness of an established medical practice, don't get as much publicity.
Prasad said about doctors, "A lot we learn because someone senior to us taught that it works." In other words, doctors believe in their own experience -- much of which surely shouldn't be trusted, because it isn't based on solid science.
Again, the 40% figure is just a guesstimate. But Prasad told us that the actual percentage of ineffective treatments in medicine is much more like snow in Chicago than a massive California earthquake. Meaning, it happens frequently, not rarely.
Even randomized clinical trials came in for some criticism, since companies funding them often hope to make billions of dollars by getting a new drug, device, or whatever approved. So they put considerable effort into increasing the odds that a clinical trial will show that their innovation is effective.
I'm vague on how this is done. But if you peruse Prasad's impressive web site, you'll find countless (almost) papers, articles, and other material to read on a wide variety of subjects. The News and Media page has some profiles of Prasad.
I enjoyed "Did he really just tweet that? Dr. Vinay Prasad takes on Big Pharma, Big Medicine, and his own colleagues -- with glee." Here's how it starts out:
Dr. Vinay Prasad is a professional scold: He takes to Twitter each day to critique this cancer drug as ineffective, or blast that one as overpriced, or dismiss the clinical trial of another as completely irrelevant.
So it’s a bit of a surprise to catch him at the bedside of an elderly man with lymphoma, laughing gently with his patient as he inquires about his day — and painstakingly explains a potent drug’s unpleasant side effects.
Prasad’s empathic bedside manner — and generally affable mien — is at stark odds with his digital persona as a caustic crusader for the principle that solid scientific evidence, not hope or hype, should guide how we as a society spend $700 billion a year on health care.
Just 34, Prasad has become an influential voice in the medical community through his prolific, high-impact publishing, a steady stream of media cameos, and — of course — his vociferous Twitter presence. Among his main arguments: Drug costs have spiraled out of control. Conflicts of interest run amok in health care. We don’t have any idea how well new cancer drugs and diagnostics work, thanks to ill-designed clinical trials. And more than half of all practiced medicine is based on scant evidence — and possibly ineffectual.
Needless to say, such positions haven’t won him many close friends among pharma companies — or even among some fellow doctors. He doesn’t much care.