This post originally appeared on The Timmerman Report.
I have a new favorite TV show: Join or Die with Craig Ferguson. Ferguson is a irreverent, sometimes raunchy Scottish comedian who used to host the Late Late Show alongside his skeleton puppet sidekick Geoff. Join or Die airs Thursdays at 11 pm on the History Channel, which is your first clue that this isn’t your run of the mill late night talk show.
The premise of Join or Die, named after Ferguson’s tattoo, is that four people, a random assortment of comedians, actors, historians and scientists plus Ferguson, debate a historic question of the day. The first show asked “What Was History’s Biggest Political Blunder?” (Answer: Elliot Spitzer’s hooker indiscretions). The most recent show determined that history’s greatest “Frenemies” were Bill Gates and Steve Jobs. But the show I have liked the best so far, naturally, was the one that focused on, “What Was History’s Worst Medical Advice?” You can watch the entire episode here.
Ferguson was joined by guests Chris Hardwick (podcaster, comedian, Nerdist), comedian Jordan Carlos, and “ScienceBob” Pflugfelder in this episode. Clearly none of these people are doctors, which makes the show more interesting. If one is going to look back on the worst medical advice in history, I’d definitely think the consumer’s view is more interesting. In fact, Ferguson admonishes the audience not to let the show change their feelings about doctors since doctors always have different opinions from each other anyway. A good point, and exactly why we need clinical analytics in the form of decision support tools that bring evidence-based medicine to the fore, but I digress.
The candidates for Join or Die’s worst medical advice in history were these:
- Smoking is good for you
- Bloodletting is a cure-all
- Lobotomies cure mental illness
- Pulling random teeth combats depression by stimulating the brain (!)
- Mercury is an excellent intervention for irregularity, syphilis and other diseases (Ferguson calls it the “coconut water of its day”
- Drinking urine purifies the body
Well, that is a nasty bunch of medical recommendations. All were designed, to make people feel better. All, in fact, result in more harm than good. Smoking and urine imbibing were dismissed quickly as candidates for “the worst” as they create some suffering, but don’t lead directly to the grave. Mercury and bloodletting, while damaging, were eliminated next.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
The tooth pulling option was particularly reviled, alongside the lobotomies, because those two were the only ones where you are looking into a human face and defiling it nonetheless. According to trivia from the show, Henry Cotton was the famous tooth guy; Walter Freeman was Mr. Lobotomy. He even had a mobile lobotomy service which today’s telemedicine advances could have made highly scalable if the practice still persisted. Both of these types of treatment were widely publicized and hailed as progressive by famous doctors with dynamic personalities. In other words, marketing was a big part of the program. Evidence of scientific efficacy was scant.
The winner of this dubious honor? The lobotomy. An estimated 18,000 of these were performed for “medical reasons” between 1939 and 1951 and the results were pretty medieval. The practice included sticking sharp objects through the area around the eye, mutilating brain tissue and noting that the patient felt a lot better when it stopped. Patients were also usually incapacitated and incapable of resuming a normal life.
But here’s the thing. As I watched the show, I couldn’t help thinking about what else might be on the list if the show were being televised 50 years from now. What advances in science, technology and common sense will we have in the near future that will render current medical practices as future “worst medical advice” candidates? What are we widely marketing to patients today despite those practices being highly painful, life-altering (in a bad way) and ineffective?
There are some simple ones to consider because they are probably meaningless, but not immediately harmful. A big one in this category is our endless supply of evidence-free nutritional advice (Don’t eat fat! Eat fat! Don’t eat gluten no matter whether you are celiac or not! Juice cleanse! Kale is the cure for all evil!). Don’t get me wrong, good nutrition is essential to good health, but simple fixes and anointing kale as the best thing since, well, Mercury, is probably not evidence-based. I’m not seeking to offend anyone, but faith-based cures are also in this category in my view. They may not kill you now, but they may kill you later by causing you to avoid something more medically effective.
I personally worry that injecting things into your face to mitigate wrinkles and to create Betty Boop lips will ultimately prove out to be dangerous and ill-advised, if for no other reason than that they make you look like Jocelyn Wildenstein does now.
As I scanned my own knowledge and also polled a cast of characters who I think to be pretty smart about this stuff (actually mostly doctors who have more significant medical knowledge but who have much less fun than a bunch of comedians), here’s what came up as the most likely to be nominated as the future worst medical advice we are currently giving patients:
- Opiates for pain in post-acute settings
- Prescribing antibiotics for the common cold and everything under the sun
- Avoiding vaccinations to mitigate risk of autism
- Unspecified chemotherapy to treat cancer
- Localized radiation to treat cancerous tumors
All of us have heard about the danger of opiates and the horrifying addictive behavior they are driving. Yet we are still prescribing them all the time for people with pain; over 200 million such prescriptions were written in 2013 in the US and elsewhere. It is estimated that more than 2.5 million people in the US currently have opioid addictions or related heroin addictions. Costs of treatment, not to mention societal costs and criminal justice costs, are in the tens of billions. Over 16,000 overdoses leading to death occurred in 2013 and the numbers are rising. We had to sit though Super Bowl commercials about opioid-induced constipation, for God’s sake. This is clearly a travesty of the medical system and is my top pick for what needs to go and fast if for no other reason than to take the jaw-dropping horror away from sports viewing experiences.
And if you think opioids are overused, antibiotics are right up there as a drug we need to stop over-prescribing. We have prescribed them so much they don’t work anymore to cure the diseases that are now going to kill us. The CDC calls antibiotic resistance, “one of the world’s most pressing public health problems.” They note that every year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a direct result of these infections. Another quarter million or so are hospitalized for C. difficile infections largely caused by antibiotic overuse. While it is sometimes difficult to tell a virus (where you wouldn’t use antibiotics) from a bacterial infection (where you might), there are now many tests available to help narrow down the uncertainty. Too often patients demand the drugs for no evidence-based reason and too often doctors accede to these wishes to get the patient out of their office or avoid conflict. It’s a disaster.
Living in Marin County, CA, unofficial home of the anti-vaxer crowd, it’s amazing to see the damage wrought by publicity and celebrity in the name of bad science. Is there any evidence that withholding vaccinations from children has led to less autism? I don’t think so. Is there any evidence that withholding vaccinations leads to pain, misery and death. Why yes there is. One trip to Disneyland last year cost 125 kids a diagnosis of measles that they could have largely avoided by getting properly vaccinated. Measles is one of the largest killers in the world in places where people are not vaccinated. In the US in 2015 we had the first death from measles in over 12 years and the risks are growing due to actual doctors and others suggesting that the risks outweigh the benefits.
Many of the doctors I informally polled felt that the medical advice we would most regret in the future is around the way we use chemo and radiation to treat cancer today. There was much discussion about the long-term systemic damage done to patients by largely unspecified chemotherapy administration (cardiovascular damage, lung damage, endocrine problems) or high dose radiation therapy (brain and nerve problems, soft tissue/bone damage, digestion problems). These risks are particularly worrisome since the efficacy of chemotherapy and radiation therapies are mixed. It is true that some patients survive and thrive after cancer treatment, but it’s still a bit of a crap shoot. Sometimes the radiation arrests the tumor’s spread and sometimes it metastasizes anyway. Sometimes the chemo saves a life and sometimes the cure is worse than the disease – just ask a cancer patient. We can only hope that the precision medicine efforts gaining steam today will lead us to better specificity and sensitivity and that we will no longer be “forced to break eggs with a sledgehammer” as my friend Roy Smythe, MD, so accurately put it.
Join or Die, while a silly and non-scientific show, contained this interesting observation: “Medical advice is wrapped up in human shame…once we used religious thinking to make medical decisions. When humans don’t know anything, they guess and they guess badly….The basic human idea is sort of logical -there’s something in you we don’t understand so let’s take things out ‘til you feel better.” To summarize: when there is no evidence, buyer beware.
Celebrity doctors and regular ones alike have tools to work with and not all are good. As a consumer, it is essential to understand the pros and cons of treatment and to recognize that what we see trending on Twitter may not be the best state of medical knowledge. One can only hope that the emerging data sciences can help us do a better job of more rapidly throwing treatments on the garbage pile as they prove to be entirely useless or worse. Learn or Die!
