Ending Medical Reversal

Improving Outcomes, Saving Lives

by Vinayak K. Prasad • 2015 • 346 pages

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Key Takeaways

1. Medical reversal is common and harmful: Many accepted practices are later proven ineffective

Doctors often pursue treatments that improve survival while making patients miserable in the process. Patients usually have precisely the opposite goals—they value feeling better much more than living longer.

Prevalence of reversal. Studies suggest that 40-50% of current medical practices may be ineffective or harmful when rigorously tested. Examples include:

Stents for stable heart disease
Vertebroplasty for osteoporotic fractures
Hormone replacement therapy for postmenopausal women

Harms of reversal:

Patients exposed to ineffective or harmful treatments
Wasted healthcare resources
Erosion of trust in medical system
Delayed adoption of truly effective therapies

Medical reversals occur because practices are often adopted based on limited evidence like:

Mechanistic reasoning
Observational studies
Expert opinion
Financial incentives

2. Evidence-based medicine is crucial: Randomized controlled trials are the gold standard

The randomized controlled trial is arguably the most important medical technology of the 20th century.

Hierarchy of evidence. Randomized controlled trials (RCTs) provide the strongest evidence for determining if a treatment works. Key aspects:

Randomly assign patients to treatment or control group
Control for known and unknown confounding factors
Can prove causation, not just correlation

Other study types have limitations:

Observational studies: Subject to confounding
Case-control studies: Prone to bias
Surrogate endpoints: May not translate to clinical benefit

Importance of replication. Even well-designed RCTs can produce false positives. Replication in multiple trials provides greater confidence in results.

3. Surrogate outcomes can be misleading: Focus on meaningful clinical endpoints

Remember, we say sometimes. They are not always wrong. If they were always wrong, it would be easy—always do the opposite. Research says observational studies are wrong somewhere between 15 and 50 percent of the time.

Definition. Surrogate outcomes are measurable markers used as substitutes for clinically meaningful endpoints. Examples:

Blood pressure for heart disease
Tumor shrinkage for cancer survival
Bone density for fracture risk

Limitations. Relying on surrogate outcomes can lead to adopting ineffective or harmful treatments:

Lowering blood sugar doesn't always improve diabetic outcomes
Cholesterol-lowering drugs may not reduce heart attacks
Tumor shrinkage doesn't necessarily mean longer survival

Focus on patient-centered outcomes:

Mortality
Quality of life
Functional status
Symptom relief

4. Screening tests require careful evaluation: Benefits must outweigh potential harms

Overdiagnosis occurs when some of the cancers that are found through screening are insignificant. They are cancers that have no potential to make people sick or die.

Criteria for effective screening:

Finds disease early
Reduces disease-specific mortality
Improves overall survival

Potential harms of screening:

False positives: Anxiety and unnecessary procedures
Overdiagnosis: Treatment of disease that would never cause symptoms
Opportunity costs: Resources diverted from more effective interventions

Examples of controversial screening:

PSA testing for prostate cancer
Mammography for women under 50
Whole-body CT scans

Carefully weigh benefits and harms, considering factors like:

Age and risk factors of target population
Accuracy of screening test
Effectiveness of available treatments
Psychological impact of screening

5. Industry influence can bias medical research and practice

Trials are also paid for by agencies that do not have a vested interest in one outcome or another—agencies such as the U.S. National Institutes of Health, the Veterans Administration, and the Department of Defense.

Sources of bias:

Industry-funded clinical trials
Conflicts of interest in guideline development
Marketing to physicians and patients

Consequences:

Selective reporting of positive results
Exaggeration of treatment benefits
Downplaying of side effects
Promotion of marginally effective treatments

Strategies to mitigate bias:

Independent funding of clinical trials
Strict conflict of interest policies
Critical appraisal of evidence
Transparency in research and guideline development

6. Medical education needs reform: Emphasize empiricism over reductionism

In our quest to decrease medical reversal, time would be spent in small groups learning to critically evaluate the evidence behind every decision made during an actual patient encounter.

Current limitations:

Overemphasis on basic sciences
Insufficient training in evidence appraisal
Lack of focus on patient-centered outcomes

Proposed reforms:

Earlier clinical exposure
Integration of evidence-based medicine throughout curriculum
Training in critical appraisal of research
Focus on patient-centered care and shared decision-making

Benefits:

Improved clinical reasoning skills
Better understanding of evidence hierarchy
Increased skepticism of unproven practices

7. Burden of proof should be on new treatments: Higher standards for adoption needed

The burden of proof, in cases of newly discovered species, must be on the discoverer.

Current problem: Many treatments are adopted before rigorous evidence of efficacy exists.

Proposed solution: Require strong evidence of clinical benefit before widespread adoption.

Key principles:

Randomized controlled trials as gold standard
Focus on patient-centered outcomes
Replication of results in multiple studies
Consideration of cost-effectiveness

Challenges to implementation:

Pressure for rapid adoption of new technologies
Financial incentives for industry and providers
Patient demand for latest treatments

8. Patients can protect themselves by asking key questions about treatments

If you have been offered a treatment that is proved to affect end points you care about, you can decide whether you want it. You have considered the "number needed to treat." Now ask those questions that you wanted to ask from the start. How does it work? What are the side effects? Does my insurance cover it?

Key questions for patients:

What outcomes matter most to me?
What is the evidence supporting this treatment?
How much will this treatment help?
What are the potential harms?
Are there alternative options?

Strategies for shared decision-making:

Ask about "number needed to treat" (NNT)
Request to see relevant research studies
Discuss natural history of condition if untreated
Consider participating in clinical trials

Empowering patients:

Recognize limitations of medical knowledge
Understand that "doing something" isn't always best
Be comfortable with uncertainty in medicine

Last updated: May 8, 2025

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FAQ

1. What is Ending Medical Reversal by Vinayak K. Prasad about?

Focus on medical reversal: The book investigates the phenomenon where widely accepted medical practices are later found to be ineffective or harmful, a process called medical reversal.
Exploration of causes: It examines why these reversals occur, including flawed data, industry influence, and systemic issues in medicine.
Impact and solutions: The authors discuss the consequences for patients and healthcare, and propose reforms to reduce reversals and improve evidence-based practice.

2. Why should I read Ending Medical Reversal by Vinayak K. Prasad?

Understand medical uncertainty: The book clarifies why medical recommendations change and why some treatments are later disproved, helping readers navigate confusing medical news.
Empowerment for patients and clinicians: It provides tools to critically evaluate medical practices and become better consumers of healthcare.
Insight into systemic flaws: Readers gain a deeper understanding of how industry, guidelines, and regulation can perpetuate ineffective treatments, and how to avoid becoming victims of reversal.

3. What are the key takeaways from Ending Medical Reversal by Vinayak K. Prasad?

Medical reversal is common: A significant portion of medical practices are later found to be ineffective or harmful, often after years of widespread use.
Evidence-based medicine is crucial: The book stresses the need for robust, well-designed randomized controlled trials before adopting new therapies.
Systemic reform is needed: Changes in medical education, research, and regulation are necessary to prevent future reversals and improve patient outcomes.

4. What is medical reversal, as defined in Ending Medical Reversal by Vinayak K. Prasad?

Definition of medical reversal: Medical reversal occurs when a widely used medical practice is overturned by new, more rigorous evidence showing it is ineffective or harmful.
Contrast with normal progress: Unlike normal medical advancement, where better treatments replace less effective ones, reversal means the current practice was never truly effective.
Consequences of reversal: This leads to wasted resources, patient harm, and erosion of trust in the medical system.

5. How common is medical reversal according to Ending Medical Reversal by Vinayak K. Prasad?

Prevalence in research: The authors found that about 40% of studies testing established medical practices showed those practices to be ineffective.
Implications for practice: This suggests that a large proportion of what doctors do may not be beneficial, highlighting a widespread problem.
Variation by specialty: The exact rate may differ by medical field, but the prevalence is significant enough to demand attention and reform.

6. What are some notable examples of medical reversal discussed in Ending Medical Reversal by Vinayak K. Prasad?

Medications: Drugs like flecainide for post-heart attack arrhythmias and atenolol for hypertension were found to be ineffective or harmful.
Procedures: Interventions such as vertebroplasty for spinal fractures and stenting for stable coronary artery disease were shown to offer no benefit over placebo or standard therapy.
Screening tests: Mammography for women in their 40s and PSA testing for prostate cancer were reversed due to lack of mortality benefit and harms from overdiagnosis.

7. How does evidence-based medicine (EBM) relate to medical reversal in Ending Medical Reversal by Vinayak K. Prasad?

Promise of EBM: EBM aims to base medical practice on solid empirical evidence, primarily from randomized controlled trials, to avoid ineffective treatments.
Challenges in practice: Despite more trials, many studies avoid important questions or are biased, allowing dubious practices to persist.
Need for robust evidence: The book argues that only therapies supported by strong evidence should be adopted, to prevent future reversals.

8. What are surrogate outcomes, and why do they contribute to medical reversal according to Ending Medical Reversal by Vinayak K. Prasad?

Definition of surrogate outcomes: These are indirect measures, like blood pressure or cholesterol, used as stand-ins for meaningful clinical outcomes such as survival or quality of life.
Limitations of surrogates: Treatments may improve surrogate markers without delivering real patient benefits, leading to false assumptions of efficacy.
Examples of failure: Drugs like fenofibrate and niacin improved cholesterol but did not reduce heart attacks, illustrating the danger of relying on surrogates.

9. How do subjective outcomes and the placebo effect play a role in medical reversal in Ending Medical Reversal by Vinayak K. Prasad?

Subjective outcomes explained: Patient-reported measures like pain or quality of life are vulnerable to placebo effects, making treatments seem effective when they are not.
Placebo-controlled trials: Sham-controlled studies, such as those for arthroscopic knee surgery, revealed no real benefit beyond placebo.
Ethical considerations: The book discusses the importance of rigorous controls and the ethical challenges of using placebos in research.

10. What systemic and industry factors contribute to medical reversal, according to Ending Medical Reversal by Vinayak K. Prasad?

Industry influence: Pharmaceutical companies often design and fund studies that favor their products, selectively report positive results, and influence guidelines.
Regulatory leniency: Agencies like the FDA sometimes approve therapies without robust evidence, increasing the risk of reversal.
Systemic failures: Flawed medical education, financial incentives, and conflicts of interest perpetuate the adoption of unproven therapies.

11. What reforms does Ending Medical Reversal by Vinayak K. Prasad propose to reduce medical reversal?

Medical education reform: The authors advocate for a curriculum focused on clinical reasoning and critical appraisal of evidence, rather than just mechanistic understanding.
Academic medicine changes: They suggest rewarding replication and critique, limiting industry influence, and balancing specialization with big-picture thinking.
Regulatory and research reforms: The book calls for stricter approval standards, greater transparency, and increased clinical trial enrollment using the "nudge principle."

12. What practical advice does Ending Medical Reversal by Vinayak K. Prasad offer to patients and clinicians to avoid becoming victims of reversal?

Ask about meaningful outcomes: Patients should inquire whether treatments improve outcomes that matter, such as symptoms or survival, not just surrogate markers.
Evaluate evidence quality: Seek information on whether benefits are supported by well-designed randomized controlled trials.
Form partnerships: Engage in open dialogue with doctors, ask about their experience and the natural history of the disease, and consider participation in clinical trials to support evidence-based care.