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Integrator Advisor Speaks: Irishman Mannahan on the Tests and Surgeries Lacking Evidence PDF Print E-mail
Written by John Weeks   

Integrator Advisor Speaks: Irishman Manahan on Tests and Surgeries Lacking Evidence

Summary: Integrator advisor and (sometimes ire-filled) Irishman Bill Manahan, MD, read Money is Not the Cure: Controversies in Healthcare by Seymour Handler, MD in the week before St. Patrick's Day. Manahan, faculty member at the University of Minnesota medical school and past-president of the American Holistic Medical Association, has four decades of practice informing his observations about US healthcare. So on the eve of St. Patrick's Day he was compelled to compile a short list of those medical procedures and tests most likely to inflame his ire due to their lack of supporting evidence ...
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The evening before St. Patrick's Day I spent a little time writing on the way those of us who are involved in efforts to integrate complementary, alternative and integrative practices into the hospitals and health systems may self-censor our activities. (
Does the power of hospitals promote self-censorship in the US integrative medicine movement?)  We sometimes don't consider evidence or approaches when they challenge our economic model.

Bill Manahan, MD
The morning of St. Patrick's Day, I woke to an e-mail note from Irishman, Integrator advisor Bill Manahan, MD. Manahan had been writing on a not unrelated theme that very evening. His viewpoint on the prism of medicine-as-we-know-it took him into the places where we continue to do things, often very expensive things, when evidence suggests otherwise. Manahan excused himself with a note at the end. He stated
that he was writing on "the eve of St. Patrick's Day - a time that the blood of all Irishmen is boiling just a wee bit."

Alas, though my spouse is full-blooded Irish and we had plans for a March 17th corned beef and cabbage dinner with the family of a very good friend, one James D. Regan, I am not sure that any theory of the inheritance of proximal characteristics can explain my particular focus on the eve of St. Patrick's Day. I did ask Manahan if I could pass on to you the product of his ire. He agreed and here it is.


"Dear Friends and Family,

"I just finished reading Money is Not the Cure: Controversies in Healthcare by Seymour Handler, MD (2006).  Dr. Handler was a pathologist in a community hospital in the Twin Cities for over 40 years, and he taught basic pathology to medical students at the U of MN.  He knows his stuff.

"After reading his book, I made up a list (below) of some of the treatments, procedures, tests, and exams that we routinely do in our medical practices that in the past or the present lacked good evidence for doing them.  I wanted to share this list with you because I believe it is important that more people understand how many of our present medical practices are not actually based on good science.  Frequently, the 'facts' that the medical system tells you may not be what is best for you. 

"My other concern is how much effort is being spent trying to figure out how to PAY for our health care system.  Unfortunately, almost no money is being spent attempting to educate everyone so that the medical system does only those things that have been proven to truly make a difference in the lives of people.  I believe that this type of education would cut health care costs significantly.

"Some of you may be surprised at this list.  Many of my colleagues would argue with it.  Some of the items I have mentioned are certainly open for debate.  Unfortunately, again, there really is no debate about what is occurring, and we, therefore, all go on performing most of these treatments, procedures, tests, and exams.

"So that is what I am doing on the eve of St. Patrick's Day - a time that the blood of all Irishmen is boiling just a wee bit."

Bill Mannahan, MD
Twin Cities, Minnesota



Examples from the Past (& Present) of a Lack of Evidence-Based Medicine

Bill Manahan, MD

Internal Mammary Artery Ligation for Angina
C. Walton Lillehei at the University of Minnesota

Doctors Cobb and Thomas at the University of Washington (NEJM 260; 1950: 1115)

Gastric Freezing for Treating Peptic Ulcers

Refrigerated solution was circulated through coils placed in the stomach.  Unfortunately, some stomachs and abdominal walls froze and the stomachs ruptured.  Owen Wangensteen, MD, invented this procedure

Bone Marrow Transplant to Augment High Dose Chemotherapy in Breast Cancer

Because of the high cost, insurance companies insisted on a good study that eventually showed no difference between those having BMT/HDC and the controls.

Knee Arthroscopy for Osteoarthritis

Lavage or debridement of the rough or torn cartilage surfaces was done as a way to delay or avoid total knee replacement.  Millions of these procedures were done until a multi-center controlled trial was performed by J. B. Mosley et al and published in the NEJM 347, No 2, July 11, 2002: 81-88.  Both groups had identical pain relief and function in the long-term with the placebo group actually having less postoperative problems.

Imaging of the Spine for Back Pain Problems & Surgery for Chronic Back Pain

M.C. Jensen, et al authored MRI of the Spine in People Without Back Pain, NEJM 331, No. 2; July 14, 1994: 69-73 and S. J. Atlas et al authored Long-Term Outcomes of Surgical and Non-Surgical Management of Sciatica Secondary to Lumbar Disc Herniation, Spine 30; 2005: 29

Hormone Replacement Therapy
A discussion of HRT is probably not needed because of recent publicity about this

Treatment with Antibiotics of Otitis Media
  1. Spiro DM, et al.  Wait-and-see prescription for the treatment of AOM: a randomized controlled trial.  JAMA Sept. 13, 2006;296:1235-41
  2. McCormick DP, et al.  Nonsevere AOM: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment.  Pediatrics 2005;115:1455-65
  3. Little P, et al.  Pragmatic randomized controlled trial of two prescribing strategies for childhood AOM.  BMJ 2001;322:336042
Treatment of Strep Throat to Prevent Acute Rheumatic Fever

Treatment of Bronchitis and Sinusitis with Antibiotics

Episiotomy during childbirth


Examples from the Past and Present of Routine Screening Tests that Lack Good Evidence-Based Research

  • Routine yearly chest x-rays
  • Routine yearly upper GI x-rays
  • Routine yearly barium enema x-rays
  • Routine self-breast exam
  • Routine yearly annual exam by a physician
  • Routine blood chemistry panels
  • Routine CT lung scan for smokers
  • Routine PSA test for men
  • Routine mammography for women
  • Routine fecal occult blood test
  • Routine use of flexible sigmoidoscopy
  • Routine follow-up for solid tumor cancers after surgical resection

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