What was medical school like in the 1700's?

[Asp]

"Published for more than eighty years, The Milbank Quarterly features peer-reviewed original research, policy review, and analysis, as well as commentary from academics, clinicians, and policymakers. According to the Institute for Scientific Information, for the past two years the Quarterly’s “impact factor” (based on citations of published articles) has been the highest of the thirty-nine journals in Health Policy & Services and of more than fifty journals in Health Care Sciences & Services. Articles published in the Quarterly also had the longest citation half-life of the leading peer journals."

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[Tired]

Quote from the abstract:
"A leading example is arthroscopy for knee arthritis, which a landmark study has shown works no better than a placebo operation...Surgeons have attacked the study on questionable methodological grounds yet they have not insisted on the follow-up trials that would address the problems they claim undercut the study's unwelcome conclusions. In deference to expert opinion, the government has maintained broad coverage of the procedure under the Medicare program. These outcomes are unsurprising. Medical procedures are not subject to rigorous scientific evaluation in general. While drugs and devices are routinely tested for efficacy, there is no FDA for surgery. We argue that the systematic underevaluation of medical procedures reflects the simultaneous presence of market failures and government failures, and that this problem is not self-correcting."

Like a typical premed, you take the review of a paper at face value without ever reading the original source and critically evaluating it.

The VA study was conducted on patients with OA of the knee, and randomized them to either (1) arthroscopic debridement, (2) saline irrigation, or (3) sham surgery. There was no difference between the groups in outcome scoring.

This wasn't a shocker to very many people who actually do Orthopedics for a living, since most osteoarthritis doesn't benefit from arthoscopic debridement anyway, which is why most Orthopods don't scope arthritic knees except in very limited, specific circumstances. In fact, the main reason this paper got so much press wasn't because of its results; it was because they actually got an IRB to approve sham surgeries.

In the future, if you're going to bring up papers to prove your points, you should try reading them first.

 

[Tired]

Placebo controlled trials of surgical procedures are controversial but in several well publicized cases they have been found to be valuable in identifying treatments that are useless.

Four words: Internal mammary artery ligation

Sham surgery is a great thing.

 

[Asp]

Like a typical premed, you take the review of a paper at face value without ever reading the original source and critically evaluating it.

The VA study was conducted on patients with OA of the knee, and randomized them to either (1) arthroscopic debridement, (2) saline irrigation, or (3) sham surgery. There was no difference between the groups in outcome scoring.

This wasn't a shocker to very many people who actually do Orthopedics for a living, since most osteoarthritis doesn't benefit from arthoscopic debridement anyway, which is why most Orthopods don't scope arthritic knees except in very limited, specific circumstances. In fact, the main reason this paper got so much press wasn't because of its results; it was because they actually got an IRB to approve sham surgeries.

In the future, if you're going to bring up papers to prove your points, you should try reading them first.

And what was my point? Let me quote myself:

"I don't see how you can be so confident when so many surgical procedures aren't based on randomly controlled trials, the only ones that can reliably prove these procedures are beneficial."

I then referenced a link to and copied the abstract of a review paper about a particular surgical procedure that had received such scrutiny recently. Let me quote the first two sentences of the abstract:

"In an ideal word, doctors would choose what medical procedures to use on the basis of rigorous evidence. In reality, medical procedures may diffuse into clinical practice before they are scientifically evaluated."

Which was precisely what I was pointing out. I was just showing that my claim wasn't spurious, and could also be found in the reputable literature.

Now, you, seeing I linked to an article concerning one of your hot button issues, get your panties in a bunch because you think I've falsely accused orthopedic surgeons of doing worthless and therefore ethically unsound procedures. But in fact, I haven't. I really don't care about whether this particular procedure works or not. I'm just pointing out that it had been used in practice before proof either way. That's all.

So before you label me a premed and try to pull the authority card, why don't you try reading my posts first.

 

[Asp]

And now that I've established that you have absolutely no reading comprehension when it comes to my posts, let me also provide evidence that you have no reading comprehension when it comes to the literature. Let me quote that abstract again:

"Surgeons have attacked the study on questionable methodological grounds yet they have not insisted on the follow-up trials that would address the problems they claim undercut the study's unwelcome conclusions. In deference to expert opinion, the government has maintained broad coverage of the procedure under the Medicare program."

Look, that abstract acknowledges your point about "questionable methodological grounds." In fact, that aspect of the original study is common knowledge, not just among those high and mighty enough to do "Orthopedics for a living." Try Googling "arthroscopy for knee arthritis" -- there's an About.com article about the very argument you're making, for chrissakes.

So the authors in this paper (which, indeed, I haven't read) are trying to say that even though it could be argued that the original paper didn't establish definitively that the arthroscopy procedure was useless, no further studies had been done that provided evidence either way, so the CONSERVATIVE thing to do, in their opinion was to not do anything. Yet, the experts (people like you) convinced the government to continue funding the procedure. And they felt this was bad policy. That was all. They weren't trying to be apologists for the original study at all.

So what do you have to say for yourself? If I were you, I'd go hide in a corner, because you just got eviscerated .

 

[45408]

I'm serious. The things you cite do make a difference, but they don't add up to more than a handful of years.

Here's another reference

http://links.jstor.org/sici?sici=0160-1997(197722)55%3A3%3C405%3ATQCOMM%3E2.0.CO%3B2-6

Abstract

"Legislators, practitioners, and the public may deem it "heretical," but analysis of United States data shows that introduction of specific medical measures and expansion of services account for only a fraction of the decline in mortality since 1900. Even acknowledging that "mortality" and "health" are not synonymous, analysis of age- and sex-adjusted rates still suggests important trends and generates hypotheses for informed social action."

That article is 30 years old, and the link you posted seems to only have the first page. Got an actual article I can read?


I looked up a handful on my own, and most of them attribute the large jump in life expectancy to a significant drop in infant mortality. You say potato.....

 

[MossPoh]

In the future, if you're going to bring up papers to prove your points, you should try reading them first.

Oh snap! again

I feel like I am in the academia version of Jerry Springer

I have no idea what we're trying to prove in this argument. It isn't like one person is going to concede and go "well, you have a point there". Let it rest and we can all think the other person is a jack ass.

I haven't read the article, but going from what I've read here. Do you know what is considered a legitimate reason for the surgery? Is the author's criterion similar to the generally accepted guidelines by the surgeon? What is considered enough of a result to be considered beneficial? Why did they pick a surgery that generally seems to improve quality of life and not length of life? I am betting the data for fixing a clogged artery is different than arthritic knees. The list goes on and on. Once again, these are questions from just skimming what was posted here..not even good skimming.

 

[Asp]

That article is 30 years old, and the link you posted seems to only have the first page. Got an actual article I can read?

Heh, I thought your school's library would have access to JSTOR? Unfortunately most of the scholarly articles I might cite would also not be in the public domain. But I copied some of the most relevant paragraphs for you and anyone else who's interested:

Employing the data and techniques of historical
demography, McKeown (a physician by training) has provided a
detailed and convincing analysis of the major reasons for the decline
of mortality in England and Wales during the eighteenth, nineteenth,
and twentieth centuries (McKeown et al., 1955, 1962, 1975).
For the eighteenth century, he concludes that the decline was largely
attributable to improvements in the environment. His findings for
the nineteenth century are summarized as follows:​

.

. . the decline of mortality in the second half of the nineteenth

century was due wholly to a reduction of deaths from infectious

diseases; there was no evidence of a decline in other causes of death.
Examination of the diseases which contributed to the decline suggested
that the main influences were: (a) rising standards of living, of which
the most significant feature was a better diet; (b) improvements in
hygiene; and (c) a favorable trend in the relationship between some
micro-organisms and the human host. Therapy made no contributions,
and the effect of immunization was restricted to smallpox which
accounted for only about one-twentieth of the reduction of the death​

rate. [Emphasis added. McKeown et al., 1975, p. 3911​

....​

As for the twentieth century (1901-1971 is the period

actually considered), McKeown argues that about three-quarters of
the decline was associated with control of infectious diseases and the
remainder with conditions not attributable to micro-organisms. He
distinguishes the infections according to their modes of transmission
(air- water- or food-borne) and isolates three types of influences
which figure during the period considered: medical measures (spec-
cific therapies and immunization), reduced exposure to infection,
and improved nutrition. His conclusion is that:
the main influences on the decline in mortality were improved
nutrition on air-borne infections, reduced exposure (from better hygiene)
on water- and food-borne diseases and, less certainly, immunization
and therapy on the large number of conditions included in the
miscellaneous group. Since these three classes were responsible respectively
for nearly half, one-sixth, and one-tenth of the fall in the death
rate, it is probably that the advancement in nutrition was the major​

influence. [McKeown et al., 1975, p. 4221​

....​

It is clear from column b that only reductions in mortality from

tuberculosis and pneumonia contributed substantially to the decline
in total mortality between 1900 and 1973 (16.5 percent and 11.7
percent, respectively). The remaining eight conditions together accounted
for less than 12 percent of the total decline over this period.
Disregarding smallpox (for which the only effective measure had
been introduced about 1800), only influenza, whooping cough, and
poliomyelitis show what could be considered substantial declines of​

25 percent or more after the date of medical intervention.​

.....​

In general, medical measures (both chemotherapeutic andprophylactic)

appear to have contributed little to the overall decline in
mortality in the United States since about 1900-having in many
instances been introduced several decades after a marked decline
had already set in and having no detectable influence in most
instances. More specifically, with reference to thosefive conditions
(influenza, pneumonia, diphtheria, whooping cough, andpoliomyelitis)
for which the decline in mortality appears substantial after the
point of intervention-and on the unlikely assumption that all of
this decline is attributable to the intervention-it is estimated that at
most 3.5 percent of the total decline in mortality since 1900 could be
ascribed to medical measures introduced for the diseases considered​

here.​

......​

But, if it can be shown convincingly, and on commonly accepted

grounds, that the major part of the decline in mortality is unrelated
to medical care activities, then some commitment to social change
and a reordering of priorities may ensue. For, if the disappearance
of X is largely unrelated to the presence of Y, or even occurs in the
absence of Y, then clearly the expansion and even the continuance
of Y can be reasonably questioned. Its demonstrable ineffectiveness
justifies some reappraisal of its significance and the wisdom of​

expanding it in its existing form.​

In this paper we have attempted to dispel the myth that medical

measures and the presence of medical services were primarily responsible
for the modern decline in mortality. The question now
remains: if they were not primarily responsible for it, then how is it
to be explained? An adequate answer to this further question would
require a more substantial research effort than that reported here,
but is likely to be along the lines suggested by McKeown which were
referred to early in this paper. Hopefully, this paper will serve as a
catalyst for such research, incorporating adequate data and appropriate
methods of analysis, in an effort to arrive at a more viable​

​

​

alternative explanation.​

I looked up a handful on my own, and most of them attribute the large jump in life expectancy to a significant drop in infant mortality.

Let's see them.

​

 

[RySerr21]

Let's see them.

asp the prowler is correct. there are many ways to look at the data to make it seem much better than it is. for example....

in the 1900s the life expectancyc for a 45 year old was 70 years.... in 2004 the life expectancy for a 45 year old was 75 years....

thats your proof that the reason it has increased 30 years in the last century is laregely due to the decrease in infant deaths. if you compare middle aged men....medical advancements have only given us 5 more years.......hmmmmm that doesnt really make sense does it?

i dont have an exact source but as i am sur eyou will request it will do my best to find it.

 

[Drogba]

I don't see what else it could be. Let's start early - and all of these are things that have been implemented due to medical advances or public health measures - when your mother was pregnant, she took enough folic acid to ensure you didn't get a neural tube defect. She was vaccinated against rubella, which prevented you from getting birth defects. She was screened for the Rh antigen, so you didn't get fetal hydrops. She was then monitored for pre-eclampsia so she didn't die and bring you with her. Then she was monitored for group B strep, so you didn't get infected during birth. Then when you were born, you had antibiotics put on your eyes, so you didn't go blind from maternal gonorrhea, and you were supplemented with vitamin K so you can synthesize clotting factors. Then you were screened for metabolic disorders (PKU, MSUD, etc) that could cause mental ******ation if not caught within a few weeks of birth. Then you were vaccinated against a number of diseases that kill people at a young age all around the world, and you were saved by herd immunity of other diseases. Furthermore, other diseases like tuberculosis, leprosy, malaria, etc. are all very low risk in this country because they're aggressively eradicated.And that's within a year or two of birth. Five years, seriously? I can't even believe you're serious.

False. Almost all significant infectious diseases had begun a steady decline before treatment was available.

McKeown's publication is a landmark and apparently one that very few premeds and/or doctors know about. I can't find the other graphs right now.

It's fairly well accepted that biomedicine had a fairly negligible impact on the demographic transition and the vast increase in life expectancy over the past 100-200 years. As much as medicine would like to take credit for contributing to a vast increase in population health, its really not a reasonable claim.

 

[Asp]

asp the prowler is correct. there are many ways to look at the data to make it seem much better than it is. for example....

in the 1900s the life expectancyc for a 45 year old was 70 years.... in 2004 the life expectancy for a 45 year old was 75 years....

thats your proof that the reason it has increased 30 years in the last century is laregely due to the decrease in infant deaths. if you compare middle aged men....medical advancements have only given us 5 more years.......hmmmmm that doesnt really make sense does it?

i dont have an exact source but as i am sur eyou will request it will do my best to find it.

Maybe if you substitute "1 year old" or maybe "2 year old" for "45 year old" you might have a case. You were trying to defend prowler's assertion about "infant mortality" I presume?

 

[Asp]

McKeown's publication is a landmark and apparently one that very few premeds and/or doctors know about.

I think the RAND study should go in this category as well of almost unknown but extremely important studies on the impact on medicine on human life and health.

Especially with the focus on health care this election cycle.

 

[Drogba]

I think the RAND study should go in this category as well of almost unknown but extremely important studies on the impact on medicine on human life and health.

Especially with the focus on health care this election cycle.

You are going to have to link me to the study you are talking about. It sounds familiar but I can quite remember what you might be referring to.

 

[Asp]

Of course. See the massive, seminal RAND Health Insurance Study

http://www.rand.org/pubs/reports/2006/R3055.pdf

and see economist Robin Hanson's blog post at

http://www.overcomingbias.com/2007/05/rand_health_ins.html

for the correct interpretation of this study.

I warn you: the links I gave could change your view of medicine drastically! It did for me.

From earlier in the thread.

 

[KeyzerSoze]

Nice, an unsourced chart from a whacko anti-vaccine website.

 

[45408]

Heh, I thought your school's library would have access to JSTOR? Unfortunately most of the scholarly articles I might cite would also not be in the public domain.

Sure, a CURRENT subscription that goes back 10 years. You posted a 30-year old article. Those are rarely online, dude.

It is clear from column b that only reductions in mortality from tuberculosis and pneumonia contributed substantially to the decline in total mortality between 1900 and 1973 (16.5 percent and 11.7 percent, respectively).

okay, 16.5% and 11.7%

at most 3.5 percent of the total decline in mortality since 1900 could be ascribed to medical measures introduced for the diseases considered here.

oh, okay, 3.5%, got it


Which one is it?

 

[45408]

False. Almost all significant infectious diseases had begun a steady decline before treatment was available.

You didn't disprove what I just said. Read it again. I said aggressive ERADICATION. As in quarantines, draining swamps, mosquito netting, etc. Not medication.

 

[45408]

From earlier in the thread.

Um, yeah, the study is comparing different types of health care, not health care versus no health care, and it's definitely not an analysis on the increase of life expectancy.

 

[RySerr21]

Maybe if you substitute "1 year old" or maybe "2 year old" for "45 year old" you might have a case. You were trying to defend prowler's assertion about "infant mortality" I presume?

i defended him by agreeing with what he was saying.... then i said a new topic that wasn't related to infant mortality. sorry if i blurred those togehter.

 

[Asp]

Source
McKinlay, J., & McKinlay, S. (1977). The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century.

Milbank Quarterly, 55, 405–428.​

Why 1977?
Because the topic of this paper is so damn established now that there's no reason to rehash it. The topic might have been controversial in 1976, but not in 2008.​

Nature doesn't need to republish the fact that DNA is a double helix, for instance.​

Validity of source
"Published for more than eighty years, The Milbank Quarterly features peer-reviewed original research, policy review, and analysis, as well as commentary from academics, clinicians, and policymakers. According to the Institute for Scientific Information, for the past two years the Quarterly's "impact factor" (based on citations of published articles) has been the highest of the thirty-nine journals in Health Policy & Services and of more than fifty journals in Health Care Sciences & Services. Articles published in the Quarterly also had the longest citation half-life of the leading peer journals."​

KeyserSoze, I hope I made your day, or at least your evening.​

 

[Asp]

Sure, a CURRENT subscription that goes back 10 years. You posted a 30-year old article. Those are rarely online, dude.

My university has access all the way back to 1934. I guess yours took the cheaper subscription?

okay, 16.5% and 11.7%


oh, okay, 3.5%, got it


Which one is it?

Wow we have budding Tired in the making here; I'm getting tired of showing people how to read. It's fairly clear from the passages I provided, even though I didn't provide the context of the entire article, that the 16.5% and 11.7% refer to reductions in total mortality primarily due to tuberculosis and pneumonia being less prevalent in the period 1900-1973, whereas the 3.5% is not disease-specific and refers to the reduction in total mortality from the application of medicine, both therapeutic and prophylactic, in the period 1900-1973. As Monica Vitti would say, capiche?

 

[Asp]

You didn't disprove what I just said. Read it again. I said aggressive ERADICATION. As in quarantines, draining swamps, mosquito netting, etc. Not medication.

TheProwler, I'm not going to let you get away with a different standard of proof than me. Show me a good paper from a reputable source that demonstrates that "quarantines, draining swamps, and mosquito netting" are the main reason diseases like pneumonia and tuberculosis declined in prevalence in the West in the 20th century. Please.

 

[Asp]

Um, yeah, the study is comparing different types of health care, not health care versus no health care...

The study indicated that the marginal benefit of medicine was effectively zero. Which is quite an unexpected result, with deep repercussions, wouldn't you say? Of course you haven't really bothered to read what I've said about it earlier in the thread, have you?

...and it's definitely not an analysis on the increase of life expectancy.

I agree.

 

[Asp]

i defended him by agreeing with what he was saying.... then i said a new topic that wasn't related to infant mortality. sorry if i blurred those togehter.

Apology accepted.

 

[Samus Aran]

hmm, i'm not sure insults are really necessary here. please try to play nice

 

[Drogba]

You didn't disprove what I just said. Read it again. I said aggressive ERADICATION. As in quarantines, draining swamps, mosquito netting, etc. Not medication.

Certainly none of those had an affect on TB incidence. TB was afterall the number one killer at that time. In fact its very difficult to argue that any one specific intervention led to this decline. As you can see from the McKeown publication the best theory he could come up with was an improvement in nutrition. The point here is that improved mortality is likely linked to improve social conditions much more than any specific medical or public health intervention.

Now there are some cases where you can see a direct link between intervention and improved mortality but these there are very few examples. Small pox is really the poster child for this, and produced a great deal of optimism for disease eradication. What happened with smallpox has NEVER been replicated and it is unlikely that it ever will be. Malaria was pegged for eradication by the WHO as one of its founding goals. As you can see it is still a top killer.

Also, prevalence of a causative agent need not translate to disease. TB is the prime example here too. In england back in the 1800s some 90% of people whose deaths were unrelated to TB had evidence of TB infections upon autopsy. Thus preventing the exposure and transmission of the bacillus is certainly not really the issue here. At some points in time and in some areas of the world laten TB was present in a majority of a population, yet only a fraction of these cases turned active. The only thing you can really attribute this to is the overall health status of the patient which is closely linked to their social condition and not any public health intervention.

Finally, your examples really only reference diseases with non-human vectors which, aside from malaria, don't really compare in terms of mortality to other IDs. Thats as true today as it is historically (aside from the bubonic plague which never established endemicity in the areas I'm familiar with).

Sorry, if this post is a little disjointed I'm typing between classes.

 

[Drogba]

KeyserSoze, I hope I made your day, or at least your evening.​

Asp, thanks alot for finding those for me. I didn't have the time to search for an online source to an incredibly well known publication (among the public health community). Keyser's assumptions are pretty funny though. I did atleast state it was from McKeown.

As far as RAND goes, I really think that a 3-5 year time horizon limits the conclusions we can draw from it. The value of access to care is more of a lifetime cumulative effect than something that would show up in such a study. Also, I think there are other problems with that specific study that I don't have the time to discuss right now.

 

[45408]

hmm, i'm not sure insults are really necessary here. please try to play nice

If my posts are going to get deleted, you should at least edit out Asp's sarcastic and condescending remarks.

 

[Asp]

I apologize if I hurt your feelings, TheProwler.

 

[45408]

I apologize if I hurt your feelings, TheProwler.

I'm not hurt, and I responded how I felt, but they apparently didn't like it.

 

[Samus Aran]

If my posts are going to get deleted, you should at least edit out Asp's sarcastic and condescending remarks.

it wasn't me...

 

[bcat85]

Beyond all these graphs... this is an artist's depiction of medical school in the 1700's

 

[Drogba]

I thought we were having a cool conversation, what happened

 

[coldweatherblue]

mmmmm drama drama..

Statistics can be used to prove almost anything.

I think that there are many causes of the increased life expectancy in the 20th century; for medicine to claim all the credit would be presumptuous.

However, I think anyone who makes a big deal about the pointlessness of medicine is being overly controversial. Also there are certain tones used in this thread that shouldn't be used in conversation with other people, especially considering that we will one day be in a professional environment.

If you had a brain tumor in the 1850's it was inoperable and you died. Today many things made possible through medicine that both increase patients quality of life and prolong their lives. Whether or not in the grand scheme of things medicine played a more important role than food/demographics, etc in overall population health isn't really a doctors concern, imo.