March 20th, 2019
What does it mean to be a “medical conservative”? It’s not the same as being a political or social conservative. It also does not mean rejecting science or progress in medicine. As doctors John Mandrola, Adam Cifu, Vinay Prasad, and Andrew Foy explain in a recent piece in The American Journal of Medicine, being a medical conservative means being skeptical about new medical advances until unbiased and high-quality evidence shows a clear benefit.
Why should we take our time adopting new medical practices, when it’s possible these new developments could save lives? Here are a few reasons why we agree with the authors that medical conservatism is the ideal approach to patient care.
While advances in science and medicine have undoubtedly improved quality of life, progress in medicine is not always linear. Often, a drug, test, or procedure is adopted as the standard of care based on existing evidence or bioplausibility, but is later found to not be beneficial based on new, better evidence. This is known as “medical reversal.”
There have been many instances of medical reversal over the past ten years, including stenting for stable angina, hormone replacement therapy, antibiotics for ear infections in children, and PSA testing for prostate cancer screening in low-risk men, just to name a few. Although we tend to think of medical knowledge as decisive, reversal is common; Adam Cifu and Vinay Prasad found that 13% of articles published in NEJM in 2009 reversed previous thinking on certain medical services. The jump to adopt practices without sufficient evidence has led to significant harm; for example, safety issues in medical devices that were approved with little evidence affects millions of people worldwide.
Unfortunately, once a medical practice is established as the norm, it is very difficult to change clinician behavior and patient expectations, even when new evidence shows that the status quo is ineffective or harmful. Medical conservatism means being cautious about implementing unproven new procedures or tests, to prevent overtreatment and harm to patients.
Twitter thread coming on what @adamcifu @VPrasadMDMPH @AndrewFoy82 and I think is the BEST approach to pt care. This is …
The Case for Being a Medical Conservative. https://t.co/nZXrnvMQqP
Thanks to the @amjmed for publishing this. pic.twitter.com/PKJNHLVZwU
— John Mandrola, MD (@drjohnm) March 14, 2019
At least once a week, we hear about a new device, drug, test, or procedure that is touted as a “breakthrough” or “gamechanger” for medicine. However, very rarely do these modern medical advancements actually represent a significant improvement in survival or quality of life. Many cancer drugs are described with superlatives before they are even tested in humans!
This prevalent media hype, which is often industry-driven, “not only propagates low-value care, but it also erodes the public’s trust in medical science,” the authors write. While the authors do not oppose all private enterprise in medicine, they insist that the desire for profit cannot come at the expense of patient outcomes.
Industry influence in guidelines can also lead to recommendations that would submit more of the population to treatments that will not benefit them (for example, lowering the blood pressure target, which leads to more people being given blood pressure medication). In these cases, medical conservatives would discuss the absolute (not relative) benefits and harms with patients, rather than make a blanket recommendation.
Medical conservatives strive to see through the hype and poor science, and adopt new practices cautiously based on this simple criteria: “Would an unbiased patient, who had perfect knowledge of an intervention’s tradeoffs, voluntarily choose to adopt it, and taking into account differing patient resources, pay for it?”
This may mean that, following the principles of medical conservatism, clinicians will end up doing less. This does not mean we have “given up” on medicine’s potential for healing. On the contrary, “the conservative clinician sees it as protective against our greatest foe—hubris.”