"Ending Medical Reversal" is an essential book for medical students, physicians, and anyone even peripherally involved in medicine; for everybody else, it's merely highly recommended. The core of the book, paraphrasing, is that sometimes physicians decide to do things to patients without great evidence. These practices are, later on, 'reversed' by well-done trials, often to the great surprise of thought leaders and experts in a specialty. This is "Medical Reversal", which doesn't sound all too exciting, but is actually super important.
To understand why, the underpinnings of the evidence-based medicine community need to be examined, and the books lay them out in understandable and lucid prose, with lots of examples for people unfamiliar with medical practice. The most important of them is the following: medical theory, in the sense of scientific models that allow for accurate prediction of real-world outcomes, is very poor. Another way of saying this: biology is very complex, and predicting real-world outcomes in biological systems with any precision is mostly impossible.
The second most important assumption is that the vast majority of modern medical interventions, even when they do work, have modest effect sizes. A new cancer drug, if you're lucky, might increase survival by an average of a month, a new weight loss drug might let you lose another 5-10 lbs, and a surgery might save 79% of patients instead of 77%. These are made-up numbers, but the point stands: on average, when new drugs works, which is itself rare, they tend to be incremental improvements over the old standard of care.
There are exceptions, but they're rare in the modern era: for instance, you didn't need RCT's to see that antiseptic techniques improves surgery, because the effect sizes were enormous-- for instance, operating on the peritoneum, previously a death sentence, became possible. Amputation mortality rates fell by more than 50%. The effects were so powerful they could be seen with practically any study design.
The third tenet of EBM is that most interventions, even the best funded and most plausible candidates, fail when tested in the real world. As the authors put in their book, this means that the prior probability of any given intervention working is very low, even in the late phases of drug development. This has implications for the types of evidence that physicians should require to shift their guess on whether a given drug works. Importantly, developing medical interventions is incredibly hard and expensive, and seems to be getting harder over time, giving rise to the reverse Moore's Law that has been termed "Eroom's Law" .
As a result of these 3 factors, to really know if a medical intervention is effective, you need randomized controlled trials where the effects of a single intervention are tested on roughly similar groups of patients and outcomes are tracked in a rigorous manner. RCT's are onerous, slow, and require immense coordination-- but they've overturned many pet theories and biologically plausible interventions. The fact that these theories and interventions turn out to not work is not the problem-- after all, false starts and experimentation are how science progresses-- the problem is that they're often implemented prematurely, before rigorous testing, and only later, as doubt builds, are they truly tested.
This is "Medical Reversal". There are other important arguments in the book, but they're mostly subsidiary to these 3 key arguments. Among them is a critique of surrogate endpoints, criticism of sloppily and hastily implemented 'systemic' interventions in hospital systems, the profusion of observational studies purporting to show harmful or beneficial effects of lifestyle factors, and the supplement industry. All of these other criticisms could be short books on their own, but they're woven in to this book in a seamless way. If I could pin the critique of systemic interventions with only preliminary evidence on the wall of every major hospital chain, I would!
There's a more radical part of the book, which I think is underappreciated: the call to action in the later half of the book. The authors argue for a new era in medicine, wherein a large fraction of patients will be enrolled in RCT's, constantly testing medical dogma, even for simple questions that are currently poorly understood. They want an easier and more seamless way to recruit patients in clinical trials, which would be done at lower cost than current methods, and think this can be done partly by viewing RCT's as the default.
Any practice in medicine that is currently understudied would be subject to this "RCT by default, opt out if you want" framework. Since RCT's would be testing treatments that are, theoretically, in equipoise, this is far more ethical than our current era, in which many medical interventions are only tested rigorously AFTER being used on patients in uncontrolled settings. As they correctly point out, the "safest way to receive a new drug is in a trial with a control arm. The randomized-controlled-trial design provides a built-in safeguard—trials are stopped if the treatment turns out to be harmful".
As they acknowledge, this radical change is a big ask, but "evidence-based medicine...is the only rational way to provide care" and in my view, is the only ethical way to practice medicine. They make this radical change seem like the self-evidently obvious thing to do...
Later in the book they critique medical education for it's elevation of purported drug mechanisms and biological minutiae over a better understanding of medical evidence, landmark clinical trials, and more contact with patients in clinical settings. They call for an overhaul of medical education. A nice quote on this: "The primacy of the basic sciences is the reason that cardiologists could not accept the finding that niacin did not save lives. It is why radiologists could not accept that vertebroplasty did not help back pain. It is the reason orthopedists could not accept that repairing torn menisci did not help knee pain."
The book isn't perfect. There are some relatively minor factual stumbles which don't affect the core arguments.
For example, it uncritically cites "Nudge" by Sunstein and Thaler, which is based in large part on Behavioral Economics-- but at least some of that work has not fared well in the replication crisis, as Kahneman himself has pointed out in a blog post. So that's pretty ironic. Very little of their argument rests on these points, merely a few throwaway paragraphs, so it's a very minor misstep.
I also think its slightly deceptive to say that supplements don't have to admit to a lack of evidence, as they claim. They do. Every supplement I've ever purchased has had, in clear writing, "This product is not approved....to treat or prevent any disease". Of course, these same supplement bottles claim benefits, so its a mixed message, but supplements certainly have labeling to indicate they're not approved. I would certainly agree with them, that, as a whole, the supplement industry is mostly a waste of consumer money for little purpose.
The authors also repeatedly criticize pharma-funded trials and influence, but my understanding is that pharma-funded trials generally comply with reporting regulations better than academia funded trials, and may, in fact, be more trustworthy than the average academic study. I'm not sure about this, but I vaguely recall a high-profile article showing this. Not sure.
Then there are the ideological disagreements one can have with the book. I wonder what the authors would think of cosmetic surgery when they write "The list of medical practices that improve outcomes among healthy individuals is a very short one." They're right about medical outcomes, but individuals have goals besides health, and cosmetic surgery can occasionally help achieve those goals. They do mention quality of life as an outcome of importance, and I would certainly agree with them that cosmetic surgery should be rigorously tested, but it would be an interesting debate to have...
In regards to supplements, individuals often have goals besides health as well: performance in the gym, aesthetics, etc. There are a small handful of supplements with RCT evidence of efficacy: creatine is probably the best example. It works pretty reliably, though with a modest effect, on increasing muscular endurance and likely muscle growth. Caffeine is another example. Both are used by millions, with very good safety profiles. Would the authors propose that all non-medical usage of supplements be banned? I would love to hear their thoughts on that.
More controversially, plenty of people would make trade-offs between quality of life and lifespan. How would a clinical trial be run on these questions? They could theoretically be done, but as it stands I think any trial that, for instance, allowed healthy middle-aged men access to exogenous testosterone in supraphysiological doses, would struggle to get run. Since most of medicine doesn't fall into these cracks, their argument is still a very solid one-- these are more just wrinkles of disagreement I'd be interested in hearing about.
Cosmetic surgery and supplement use for non-medical purposes both push on an interesting corner of their argument: freedom. For the clinical trial infrastructure to work, participating in a trial has to be the main way that drugs get approved and patients get access to experimental medications. If alternative pathways to drugs are available in large numbers, and enrollment in trials is threatened, this whole RCT structure falls apart. Medical freedom is not exactly compatible with "RCT's for all".
To their credit, the authors sort of touch on this: they focus on the pull side of RCT incentives-- if clinical trials are much easier to run, if inclusion criteria for new drugs were not so strict, if many more patients were enrolled, etc. then patients would have much fewer incentives to try to get drugs outside of approved protocols. And yet, with urine and blood testing of drugs, medical tourism, and patients sharing information about side effects with each other over social media, it is becoming increasingly possible for patients to figure out who is in a control/experimental arm and get drugs outside of approved channels. These are real threats to RCT's, and I'm very curious what the authors think of these developments.
My final disagreement is with optimism in medicine. I'm not even sure the authors would disagree with this, since they're not really aiming their critique at drug researchers per se, but just in case: while drugs with large effect sizes are rare in medicine, they're not unknown. In the modern era, perhaps only HIV and Hep-C drugs, along with immunotherapy in some cancers and Gleevec meet this benchmark of large effect sizes. While most medicines will be incremental advances of the state of the art, I hope we continue looking for moonshots. We should be properly skeptical of anybody who claims to have found one, but rejoice if a good RCT shows them to be right. Expect failure or incremental advance, rejoice when we're wrong!
Overall, I can't recommend this book enough!
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- Reviewed in the United States on April 26, 2020
- Reviewed in the United States on November 12, 2015
Top reviews from other countries
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FaustoReviewed in Spain on August 16, 2019
Obliga a repensar las certezas que hoy ofrece indistintamente la práctica médica
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Cliente AmazonReviewed in Brazil on June 13, 2018
Ending medical reversal - excelent !
- Mr. L. De PaorReviewed in the United Kingdom on January 6, 2020
Everyone should read this book
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