What We Don't Know

[painmd87]

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Half a century ago, obstetricians told their patients to smoke to keep the baby weight off.

Just more than a century ago, bloodletting was all the rage in the treatment of various maladies.

We know quite a bit more now than we did before. But when we look back at those two practices, we think, "What the hell were they thinking?" It's just as important to recognize what we don't know as it is to implement therapies based on what we do know.

Most of us are young. Most of us have 30-40 years, if not more, of medical practice left to go. By the time we retire, what will we look back on and say, "What the hell were we thinking?" What will future generations look back on and say, "What a bunch of idiots!"

My money is on radiation and chemotherapy. Many of these therapies are brutal in their effectiveness. When a better treatment for cancers becomes available, we will look back and say, "Why did that seem like such a good idea at the time?"


**Disclaimer**: No homework assignment here. Just an exercise in critical thinking.

 

[st2205]

"Chiropractic really could cure everything it claimed."

 

[Kevin Baker]

Antibiotic use. Less so in the clinical sense but using them in animals is creating superbugs. And overuse in patients, noncompliance breeding resistant strains, or using them unnecessarily, is a factor. Wait till something crosses over with resistance to everything we can throw at it.

I agree with you on cancer therapy but its the best option at this time.

Overscreening is another major issue.

All in all, clinical medicine is moving, and has moved, from more of an art to an evidence based medium. There are still major changes coming (individualized medicine, electronic medicine, etc.) but most of what we do now is supported in the literature and is the best option at this given time, minus the many years it takes for new options to make it to clinical practice. Back in the bloodletting/tobacco/forced masturbation hysterical women days, the stuff wasn't EBM so you have a lot of crazy ideas supported by pseudoscience if anything.

 

[SpecterGT260]

Antibiotic use. Less so in the clinical sense but using them in animals is creating superbugs. And overuse in patients, noncompliance breeding resistant strains, or using them unnecessarily, is a factor. Wait till something crosses over with resistance to everything we can throw at it.

I agree with you on cancer therapy but its the best option at this time.

Overscreening is another major issue.

All in all, clinical medicine is moving, and has moved, from more of an art to an evidence based medium. There are still major changes coming (individualized medicine, electronic medicine, etc.) but most of what we do now is supported in the literature and is the best option at this given time, minus the many years it takes for new options to make it to clinical practice. Back in the bloodletting/tobacco/forced masturbation hysterical women days, the stuff wasn't EBM so you have a lot of crazy ideas supported by pseudoscience if anything.

the "seems to me...." argument 👍

 

[aSagacious]

I agree with you on cancer therapy but its the best option at this time...but most of what we do now is supported in the literature and is the best option at this given time, minus the many years it takes for new options to make it to clinical practice.

Agreed. Further, I think we've more or less arrived at partially understanding the most practical/common aspects of physiology. The rest will probably just be iterations of increasing precision/depth to fill in the gaps. I think Feynman articulates this point well with his chess analogy:

[YOUTUBE]http://www.youtube.com/watch?v=o1dgrvlWML4[/YOUTUBE]

 

[bleeker10]

They will be seeing a significant increase in numbers of new cancers due to all the CT's and other radiographs which are ordered, as recent studies are showing (http://www.npr.org/templates/story/story.php?storyId=121436092). This will lead to either a) a decreased use of CT/finding an alternate method of imaging with the same quality and less radiation or b) a more focused and precise order for CT scan (i.e. hepatobiliary and pancreas scan) with the patients wearing some form of lead to reduce the dosage of radiation.

We will learn that the glue/epoxy orthopods use for arthroplasty and/or bone dust will lead to lung issues/cancers. Even though I think this, I'm still going for ortho

Lastly all these steps we take in the OR such as timeouts, computerized sponge counters, wearing hospital issues scrubs only, etc will be shown to not reduce the amount of errors/infection rates enough to justify the costs of implementing them. One of the hospitals I'm at started using the SurgiCount automated sponge counter to keep track of laps because apparently you can't trust someone to accurately count. If you haven't seen this, check this site out: http://www.surgicountmedical.com/ . Basically the packages of sponges have barcodes on them and have to be scanned before they are used.

 

[scarshapedstar]

My money is on radiation and chemotherapy. Many of these therapies are brutal in their effectiveness. When a better treatment for cancers becomes available, we will look back and say, "Why did that seem like such a good idea at the time?"

You ought to read The Emperor of All Maladies. There have been radical surgeries that turned out to be no more effective than excising the tumor (the more pounds of flesh you remove, the better you've done your job!) and other similarly misplaced priorities (the more overwhelmingly you poison your patient, the better you've done your job!) but current treatments are used because they work a lot better than a placebo. You can't say the same for bloodletting, but then nobody ever asked back then.

 

[Prncssbuttercup]

So, I just had this kind of conversation with my sister. She was diagnosed with cervical cancer in 2010, and it was successfully treated without chemo/rad, just a total hysterectomy... (just is a bit sarcastic)... At any rate, she's 36yrs old, and is now dealing with bone loss issues, because she and her doctor didn't want to put her on estrogen replacement because of the issues that causes... wellllll, now the physician basically told her "you're either going to get cancer by the time you're 60 (from taking estrogen), or be in a wheelchair by 60 (from taking a bone-loss drug), you have to decide"..... UMMM are you kidding me??? We have NO idea how many things will change in 25 years, we have the girl who used nanoparticles to successfully kill tumors/cancer, we have new effective drugs and treatments being developed all the time, and this is a situation where I know in 25 years we'll look back and say "yep... who knew"?

FWIW, I think the antibiotic thing is going to be an issue sooner than we think... I really think we need to get on board with Tbilisi and phage... http://en.wikipedia.org/wiki/George_Eliava_Institute

 

[costales]

Agreed. Further, I think we've more or less arrived at partially understanding the most practical/common aspects of physiology. The rest will probably just be iterations of increasing precision/depth to fill in the gaps. I think Feynman articulates this point well with his chess analogy

That's a classic. The whole series is worth watching. Feynman was as much loved for his humility as for his brilliance. I bet most people haven't seen this letter:
http://www.lettersofnote.com/2012/02/i-love-my-wife-my-wife-is-dead.html

 

[DrWBD]

That's a classic. The whole series is worth watching. Feynman was as much loved for his humility as for his brilliance. I bet most people haven't seen this letter:
http://www.lettersofnote.com/2012/02/i-love-my-wife-my-wife-is-dead.html

Thanks for posting that, a great read.

My favorite Feynman speech: http://www.lhup.edu/~DSIMANEK/cargocul.htm

 

[DuxburyPembroke]

So, I just had this kind of conversation with my sister. She was diagnosed with cervical cancer in 2010, and it was successfully treated without chemo/rad, just a total hysterectomy... (just is a bit sarcastic)... At any rate, she's 36yrs old, and is now dealing with bone loss issues, because she and her doctor didn't want to put her on estrogen replacement because of the issues that causes... wellllll, now the physician basically told her "you're either going to get cancer by the time you're 60 (from taking estrogen), or be in a wheelchair by 60 (from taking a bone-loss drug), you have to decide"..... UMMM are you kidding me??? ...

I'm very sorry to hear about your sister. Is she at significantly increased risk genetically for breast cancer? Does she have hyperlipidemia or a family history of early heart attack? Hormone replacement is standard of care, and she might want to ask a different doctor, perhaps one who keeps more up to date.

 

[r90t]

Young person with a Stage 1B1 cervical cancer can be treated with a radical hysterectomy, not a total hysterectomy, different procedure, and it is what is usually recommended for a younger patient, with post-op high risk features that would add either rads for chemo/rads. She is within standard of care for her treatment.

As a rad onc, I don't think my field will die, but improved staging modalities will (and is) offering stage migration, which changes historic survival curves. Radiation will be delivered to higher dose (i.e. dose escalation) with smaller margins (smaller fields).

The biologic agents that have been used over the last 10 years, or so, are not without side effects, and can still result in adverse consequences. Look at what Avastin does in central lung squam.

As for hindsite in medicine, FDA regulation of supplements. Just becasue it is natural, doesn't mean it's safe. Greater use of robotic surgery, as we have seen over the last 3 years, will only become more prevalent, although, not shown in some circles to be dramatically more effective. New imaging modalities, such as PET/CT 10 years ago, or MRI in the 80s, will lead to better dx.

FYI, in the 80s, I had UV skin treatment resulting in sig. peeling for acne by a dermatologist. I don't think that is being done any more. What did that do to my skin cancer risk?? This is a prime example of hindsight.

 

[Prncssbuttercup]

The surgeon decided to do the total, not ideal, but they decided it because there were two types of cancer involved. She feels she is at increased risk for breast cancer, as she has had benign solid breast cysts/lumps/tumors removed in the past. Her father's family health history is unknown. I also told her to seek a second opinion, as well as saying I think a low-dose estrogen with exercise is her best bet... 😉

 

[painmd87]

As a rad onc, I don't think my field will die, but improved staging modalities will (and is) offering stage migration, which changes historic survival curves. Radiation will be delivered to higher dose (i.e. dose escalation) with smaller margins (smaller fields).

The biologic agents that have been used over the last 10 years, or so, are not without side effects, and can still result in adverse consequences. Look at what Avastin does in central lung squam.

Great points.

Your post made me think of another great example of my point when I started this thread:
Look at battlefield surgery during the Civil War. GSW to the leg? Bite down on this while I cut the leg off. It wasn't that they thought this was the best idea, it's just that this was the best idea that they knew of. Sterilization, anesthesia, etc. were unheard of. They simply didn't know what they didn't know. The evidence showed that people lived longer when you hacked off the limb, because they would more likely bleed out or die from infection if you don't.

Today, we look back on that as ridiculous because we know more. At some point in the future, we will know more about how cancers and other devastating illnesses develop and progress, and we will look at our current treatments as brutal and silly. We'll see the side effects of a treatment as it plays out over the long term and realize it was a terrible idea. Your UV tx for acne is a great example of that.

Thanks for sharing

 

[FrkyBgStok]

After reading Cheating Death by Dr. Gupta it has me thinking about these things. Especially the chapter on hypothermia. Him talking about these things that were horrible to help medicine really blew my mind. It talked about what is really valuable in CPR. A lot of it was counter intuitive and it had me thinking, "where are we going in medicine."