Dr. Vinay Prasad: Medical reversal is harmful, avoidable and much too common

Oct 20, 2018

When it comes to medicine, the understanding of what is best for a patient can change over time due to new advances made in research, clinical trials and the like. Even so, many practices and products are adopted with little testing, leading to what a hematologist-oncologist at Oregon Health & Science University (OHSU) described as a vast amount of medical reversals.

Dr. Vinay Prasad joined us to discuss medical reversal on "Take Care," he's an associate professor of medicine at OHSU and co-author of the book “Ending Medical Reversal: Improving outcomes, saving lives.” In his book, he wrote that there are a lot of practices in medicine that are adopted quickly and used for long periods of time when, in fact, they are ineffective or even harmful.

“Many of us wish and think of medicine as a series of incremental advances…and I think, for many things, that narrative is correct,” Prasad said. “But…[there] are practices that we deploy, we extol, we use for many, many years that, in retrospect, are found to be no better or even worse than a prior standard of care or, in some cases, doing nothing.”

Prasad defined medical reversal as “missteps in medicine,” or when doctors start using a medication, procedure or diagnostic tool without evidence to back its success and then stop using it when it's proven inadequate or damaging.

This problem of frequent haphazard adoptions and subsequent reversals has been there throughout all of medical practice, Prasad said, and it persists to this day.

“In recent years, we still continue to see some new drugs and devices and surgeries being deployed, lacking good evidence,” Prasad said. “We still see some practices that we recently adopted being contradicted.”

That continuity is the focus of Prasad’s research -- to find out why it remains a problem. According to Prasad, some physicians will not adopt better practices despite research because they get a lot of anecdotal results that convinces them of a procedure’s effectiveness. In additon, the doctors may get a financial incentive to continue the harmful practice.

“We see tremendous reluctance among providers who have done things for a long period of time to let it go even when faced with very clear, indisputable, very strong evidence that it doesn’t work,” Prasad said. “And simply generating better and more credible evidence is often not enough to break that addiction.”

Another reason Prasad identified for why it is so difficult to make a reversal is the lack of consensus to test the practices -- a task that he said is arduous and can take years. Even if it can get tested, it is still an uphill battle.

“Then, you have to get people to believe the contradictory study, to change their practice patterns, and that often requires some nudges,” Prasad said. “Getting those nudges requires the work of politics -- changing minds and changing attitudes -- and that’s very difficult. So, at every step along the way, there is resistance to medical reversal.”

The main root of this problem, Prasad said, is that humans are too quick to accept new therapies before the necessary studies have been conducted, which happens because of eagerness and a system that rewards such recklessness.

“We do [it] in part because we’re enthusiastic about new things,” Prasad said. “We also do it because all of the for-profit motives in the system encourage the rapid and hasty adoption of new therapies.”

Pharmaceutical companies also benefit from deploying a product without testing it rigorously, so there is no interest among the bio-medicine industry to test the products, Prasad said. Even regulatory agencies can be influenced by the pressure to innovate.

“We want the U.S. Food and Drug Administration, we want third parties, to hold these products to that standard,” Prasad said. “But we see regulatory agencies under tremendous pressure to approve more and more products.”

Prasad said that medical reversal is unavoidable, as science always goes through growing pains, but the amount of reversals today is well above what it could and should be.

“Not everything we do will be perfect, but the current rates of reversal that we’re tolerating…are far higher than the uncertainty of science and statistics,” Prasad said.

To help that number go down, Prasad said products need to consistently go through rigorous testing before being released to the market. Doing so can help decrease the adverse effects of frequent reversals, like loss of trust in biomedicine and science in medicine.

“We live at a time where there are so many people that are quick to question science…but we can’t give them ammunition by failing to test our own hypotheses rigorously,” Prasad said.