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Curbing medical enthusiasm

BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39175.409132.3A (Published 05 April 2007) Cite this as: BMJ 2007;334:0-a
  1. Elizabeth Loder, research editor
  1. Boston
  1. eloder{at}bmj.com

    It's easy to feel contempt for deluded practitioners of the past who advocated bloodletting and tonsillectomies for all. Easy, that is, until one considers emerging evidence that coronary stenting and postmenopausal hormone replacement therapy may well be the contemporary equivalents of those now discredited practices. These and other cautionary tales abound in this week's BMJ, reminding us of the dangers of medical enthusiasm for interventions and treatments—however well intentioned—that have not been subjected to careful scrutiny.

    A recent study in the New England Journal of Medicine concluded that patients with stable coronary artery disease do just as well with medical therapy as they do with percutaneous revascularization procedures. Susan Mayor interviews (doi: 10.1136/bmj.39174.633403.DB) a British physician who wrote an editorial in the BMJ last month (2007;334:593-594, doi: 10.1136/bmj.39154.552280.BE) commenting on a group of BMJ papers that also cast doubt on stenting (2007;334:617, 621, 624; doi: 10.1136/bmj.39106.476215.BE, 10.1136/bmj.39112.480023.BE, 10.1136/bmj.39129.442164.55). He suggests that percutaneous techniques have been less used in Europe than in the United States principally because “there have not been the same financial incentives to carry out some stenting.”

    It's impossible to read this week's clinical review (doi: 10.1136/bmj.39153.522535.BE), on management of the menopause, without thinking of the recent dramatic shift in medical attitudes towards postmenopausal hormone replacement therapy. Unbridled enthusiasm for the presumed benefits of hormone replacement therapy has been replaced by notable caution, with the bulk of experts recommending short term, low dose use of treatment only for women with intolerable symptoms such as flushing. The use of hormonal therapy to treat almost all menopausal symptoms meant that little effort was expended to find alternative treatments. Now that the dangers of hormonal treatments have been revealed, we are left with a paucity of effective treatment alternatives. A few that have modest evidence of benefit include clonidine, some selective serotonoin and noradrenaline reuptake inhibitors, gabapentin and Vitamin E.

    What other medical orthodoxies might join hormone replacement therapy and stenting on the ever -growing list of discredited interventions? Nicola Low examines (doi: 10.1136/bmj.39154.378079.BE) the enthusiasm for chlamydial screening—ill advised, she says, in the absence of good evidence about its benefits. Once again, it seems, screening programs have been advocated in the absence of evidence that benefits exceed harms, that costs are reasonable, and that fundamental criteria for screening are met.

    A mass vaccination campaign against a common sexually transmitted disease is not the slam-dunk one might have thought, either, at least not in the United States. Enthusiasm for widespread programs to vaccinate young girls against human papillomaviruses that cause cervical cancer and genital warts has been tempered by a surprise backlash. In this case, the usual anti-vaccination types find themselves with some strange bedfellows, including those who feel that the long term harm to benefit balance has not been adequately studied. The fact remains, though, that the opposition to Texas governor Rick Perry's proposal for compulsory vaccination is less about the medical issues involved and more about perceptions of corporate influence and profiteering. Perry has ties to vaccine manufacturer Merck, and this has led to skepticism about his motives in recommending mass vaccination. (doi: 10.1136/bmj.39164.510127.AD)

    And a final cautionary tale, which may have the salutary effect of making you grateful for your current place in the medical profession: “There are jobs worse than yours.” Mary Black lists five of them (doi: 10.1136/bmj.39170.612986.59), including “head of medical services at Guantanamo Bay” and “surgeon in the commercial kidney transplant trade.” These, she says, are jobs that “are difficult to justify to your children, and are likely to be a source of regret on your deathbed.”