An epidemic of unnecessary and unhelpful medical treatments
The article gives an introductory example of a patient that was referred to two different cardiologists, both of whom wanted to do an angiogram. The article doesn&#x27;t mention of course that the cardiologists get paid per angiogram performed. The remuneration per unit time for seeing the patient in clinic and carefully discussing the options and evidence is drastically less than just doing the angiogram. Some cardiologists will also have a target number of angiograms they need to perform every year specified by arrangements with the angiogram facility.<p>So although it is widely known that doing angiograms and inserting stens in patients with stable coronary artery disease is a waste of time, perverse incentives in a fee for service model result in these outcomes. As such it isn&#x27;t a good example of evidence-free medicine. In Australian public hospitals, the cardiologists are paid the same salary regardless of whether they do zero or 1000 angiograms a year. They are very happy not to do unnecessary angiograms in line with the current evidence. If anything, this introductory example shows that a health system needs to be set up to facilitate and encourage evidence-based practice.<p>Otherwise this article rehashes many points about clinical trials and interpreting medical evidence, without a really coherent theme, except maybe to (yet again) criticise doctors.<p>Things have improved in the last 10 - 15 years. Clinical trials come under more scrutiny, trial pre-registration has become more common (although not strictly enforced), health systems gather more and more data about patient outcomes outside of clinical trials and manipulative marketing practices by pharmaceutical companies have been curtailed drastically.<p>In my opinion, the challenges for evidenced based medicine in the next decade are:<p>1. Getting some decent data about nutrition. There are really remarkably few useful things we can say about how nutrition relates to health.<p>2. Reducing unnecessary interventions towards the end of life in an ageing population. Healthcare and healthcare research is not well suited to de-escalating care.<p>3. Transitioning from a one-size-fits-all approach doing clinical trials in 1000s of undifferentiated patients, to collecting 1000s of data points about each individual patient (blood and metabolic variables, genome sequencing, immune profiling, microbiome etc) and using that data to get them healthy and keep them that way. Needless to say, the difficulties in doing this will make doing a randomised controlled trial look like a walk in the park.<p>4. Fighting pseudo-scientific diagnostic tests and treatments. Examples of this are everywhere - Theranos, gene therapy clinics in undisclosed locations in South America, quantified self services that have no proven health benefits, virtually every supplement ever sold, multivitamins...<p>5. Fighting the politicisation of health care. This is a very worrying trend that can easily render all our scientific efforts irrelevant - eg anti-vaxxers, far-right intolerance of harm minimisation measures like abortion and decriminalising drug use.