- Medical reversal is the phenomenon of a new superior trial arising that contradicts current clinical practice.
- Many claims that specific treatments have a benefit have turned out not to be true.
REASONS FOR MEDICAL REVERSAL
The initial claim may have been:
- made from a flawed understanding of pathophysiology
- based on poor quality studies
- based on studies using surrogate outcomes rather that patient-orientated outcomes that matter
- affected by publication bias and selective reporting of results due to the publication process (see Dogma and Pseudoaxioms for how the publication process distorts science)
— high profile journals may be more likely to publish articles with more ‘sensational’ claims that, even if their methodologies are sound, are more likely to be aberrations and subsequently reversed
— trials with positive results are more likely to be published, and more likely to be published in high profile journals
- made by dishonest investigators (e.g. Joachim Boldt)
- based on publications subject to the malign influence of Big Pharma or other conflicts of interest
EXAMPLES OF MEDICAL REVERSAL
Flawed theory or small trials
- stress and hyperacidity as a cause of peptic ulcer disease (PUD) replaced by the central role of Helicobacter pylori in PUD
- steroids and prophylactic hyperventilation for traumatic brain injury
- military anti-shock trousers suit for hypovolaemic shock
- aggressive volume resuscitation for shock associated with penetrating truncal trauma
Positive results from trials based on surrogate measures (i.e. disease-oriented outcomes) subsequently overturned by trials based on patient-oriented outcomes
- high-dose steroids for spinal cord injury
- calcium in cardiac arrest
- cyclo-oxygenase-2 enzyme (COX-2) inhibitors
- early decompressive craniectomy in traumatic brain injury
- vest CPR for out-of-hospital cardiac arrest
- drotrecogin alfa for sepsis
HARMS FROM MEDICAL REVERSAL
- patients potentially harmed by being exposed to treatments incorrectly thought to be beneficial until further research provides a correction
- ongoing exposure of patients to treatments until ‘medical reversal’ enters clinical practice (typically about 10 years)
- patients’ loss of trust in the medical system from recurrent medical reversal
- A study by Prasad et al 2013 found that out of the 2004 ‘Original Articles’ published in the New England Journal of Medicine from 2001 to 2010, 363 articles tested an established therapy. Of these 146 (40.2%) reversed that practice, whereas 138 (38.0%) reaffirmed it.
References and Links
- Fatovich DM. Medical reversal: What are you doing wrong for your patient today? Emerg Med Australas. 2013 Feb;25(1):1-3. doi: 10.1111/1742-6723.12044. PubMed PMID: 23379445. [Free Full Text]
- Ioannidis JP. Why most published research findings are false. PLoS Med. 2005 Aug;2(8):e124. Epub 2005 Aug 30. PubMed PMID: 16060722; PubMed Central PMCID: PMC1182327.
- Ioannidis JP. How Many Contemporary Medical Practices Are Worse Than Doing Nothing or Doing Less? Mayo Clin Proc. 2013 Jul 10. doi:pii: S0025-6196(13)00403-5. 10.1016/j.mayocp.2013.05.010. [Epub ahead of print] PubMed PMID: 23871231. [Free Full Text]
- Prasad V, Gall V, Cifu A. The frequency of medical reversal. Arch Intern Med. 2011 Oct 10;171(18):1675-6. doi: 10.1001/archinternmed.2011.295. Epub 2011 Jul 11. PubMed PMID: 21747003. [Free Full Text]
- Prasad V, Cifu A, Ioannidis JP. Reversals of established medical practices: evidence to abandon ship. JAMA. 2012 Jan 4;307(1):37-8. doi: 10.1001/jama.2011.1960. PubMed PMID: 22215160.
- Prasad V, Vandross A, Toomey C, Cheung M, Rho J, Quinn S, Chacko SJ, Borkar D, Gall V, Selvaraj S, Ho N, Cifu A. A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices. Mayo Clin Proc. 2013 Jul 12. doi:pii: S0025-6196(13)00405-9. 10.1016/j.mayocp.2013.05.012. [Epub ahead of print] PubMed PMID: 23871230. [Free Full Text] (includes a video commentary by the lead author)
- Young NS, Ioannidis JP, Al-Ubaydli O. Why current publication practices may distort science. PLoS Med. 2008 Oct 7;5(10):e201. doi: 10.1371/journal.pmed.0050201. PubMed PMID: 18844432; PubMed Central PMCID: PMC2561077.