Integrator Advisor Speaks: Irishman Mannahan on the Tests and Surgeries Lacking Evidence
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
Spiro
DM, et al. Wait-and-see
prescription for the treatment of AOM: a randomized controlled trial. JAMA Sept. 13, 2006;296:1235-41
McCormick
DP, et al. Nonsevere AOM: a
clinical trial comparing outcomes of watchful waiting versus immediate
antibiotic treatment. Pediatrics
2005;115:1455-65
Little
P, et al. Pragmatic randomized
controlled trial of two prescribing strategies for childhood AOM. BMJ 2001;322:336042
Also:
Treatment of Strep Throat to Prevent Acute Rheumatic
Fever
Treatment of Bronchitis and Sinusitis with Antibiotics
Episiotomy during childbirth
Circumcision
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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