THE DIGITAL REVOLUTION
Strong Convictions , Loosely Held
Every day we face uncertainty about which medical truths will be overturned or ridiculed in the future ( Ioannidis ). Despite the inertia that prevents hasty adoption of novel approaches , medicine still has an issue with “ reversals ,” see these two articles and one book ( Prasad , Herrera-Perez , Prasad ). The title of the first paper says it all : “ Medical reversal : why we must raise the bar before adopting new technologies .”
Low value medical practices are “ either ineffective or cost more than other options but only offer similar effectiveness ” ( Herrera-Perez ). Medical reversals represent a subset of low value practices “ that have been found , through randomized controlled trials , to be no better than a prior or lesser standard of care .” The 2019 paper in eLife reviewed trials in JAMA , NEJM and Lancet and found 396 instances of reversals . The majority were classified as medications ( 33 %), procedures ( 20 %) and vitamins / supplements ( 20 %). Only 9 % involved devices ( plus 2 % diagnostic instruments and 2 % screening tests ).
14 LOUISVILLE MEDICINE by MARTIN HUECKER , MD
Technology is anything that wasn ’ t around when you were born . - Alan Kay , computer scientist
Trials should compare newly proposed diagnostics and therapeutics to current standards , not to an absence of alternatives . Always beware of industry-sponsored studies of a new treatment compared to an outdated one or placebo . In assessing novel data , we must consider not just the financial cost , but the opportunity cost of transitioning to something new .
So we have good reasons for hesitancy to change practice . The oath to “ first do no harm ” drives us to seek bulletproof evidence of safety ( and efficacy ). But should physicians and health care systems incorporate new technology more rapidly ? Do the FDA and NIH really prioritize and facilitate novel experimental approaches ? Does the current reimbursement architecture produce stagnation ?
My research team has entered this environment of tightly controlled grant funding , top of the food chain gatekeepers , and a roughly 10 % funding award rate . It all started when a nonlinear dynamics genius ( John Heironimus ), who hangs out at the pool with the father of a UofL ER part-timer ( small town Louisville ), approached our team with his vision for a novel diagnostic technology . He wanted to use highly sophisticated mathematics to analyze