March 22, 2015

Putting the Genie Back in the Bottle

You can’t put the toothpaste back in the tube. You can’t put the genie back in the bottle. You can’t turn back the clock. We have lots of expressions denoting the irreversibility of certain actions. Getting patients to stop taking a particular medication or to abandon a procedure—and persuading doctors to stop prescribing it—seems to be in the same camp. Unless something comes along that’s much better, or at least that the pharmaceutical or device manufacturing company says is much better, we are extremely reluctant to change. A series of articles in JAMA Internal Medicine
discuss this phenomenon, calling it “the undiffusion of established practices.”

One article reports that physicians gradually adopted the practice of tight control of blood sugars in the ICU after a single study showed that patients did better when their blood sugars were as close to normal as possible, but then abruptly gave up the practice after a later study drew the opposite conclusion. A second article describes how physicians jumped on the bandwagon of ordering noninvasive  screening for coronary disease in patients scheduled for non-cardiac surgery, only to discover later that the screening was not beneficial—and the routine use of such testing decreased. A third article discloses that professional medical societies tend to continue to support practices that have been challenged or even debunked if their members believe the practices to be useful.

What does all this tell us about “undiffusion?”  How do we change behavior? One answer is that we should move slowly to adopt something new, whether a medication, a procedure, or a process. We should exercise caution, given the reality that the best new thing often turns out not to be the best. A second answer is to design studies that are better at looking for subgroups that may benefit from a new approach—even if the approach doesn’t make sense for everyone. But I think there’s a lot more to be said about putting the genie back in the bottle, particularly as we begin to recognize that less may be more.

It’s instructive to look at the cases where the genie did go back in the bottle and compare them to the cases in which he didn’t. Consider, for example, the process of tightly controlling blood sugars in the ICU, a practice that physicians readily abandoned. What’s striking about this is that controlling blood sugars very tightly is a nuisance—it means checking the blood sugar four times a day and adjusting insulin doses every time. That’s labor intensive—someone has to do the tests and someone else has to respond to the results. And there’s nothing sexy about pricking a patient’s finger to get a drop of blood. It’s not nearly as exciting as seeing the patient’s organs in color on a CT-scan image—a test that was not so readily abandoned. Finally, there’s no drug company or device manufacturer that stands to gain from widespread use of fingersticks, though there is from diffusion of 128-slice CT scanners, not to mention 256-slice machines.

What about the recent example in which use of antidepressants in young people decreased after the FDA issued a black box warning about potential side effects? Some critics argue that in this instance, putting the toothpaste back in the tube was wrong-headed: many more people suffered from not being treated than from the side-effects of treatment. Whether or not it was a good idea to cut back on antidepressant use, the major driver of the behavioral change appears to have been the media. Newspapers reported that antidepressants were bad; they were dangerous; they killed people. They presented a far less nuanced picture than the original article. But the combination of publicity and fear-mongering was effective and antidepressant prescribing rates fell significantly.

Finally, the most dramatic, if obvious, examples of turning back the clock occur when the FDA orders a drug company to recall its drug. When Vioxx was taken off the market, after revelations that it significantly increased the risk of heart attacks, use of Vioxx plummeted. In a similar vein, when health insurance companies decide not to pay for something, use generally falls. Bone marrow transplantation for the treatment of metastatic breast cancer ceased when, based on revelations that an earlier study had been fraudulent, coverage was halted.

Going back is hard. Commenting on the articles in JAMA Internal Medicine, Frank Davidoff quotes David Hume: “Men generally fix their affections more on what they are possessed of, than on what they never enjoyed. For this reason, it would be greater cruelty to dispossess a man of any thing, than not to give it to him.” Likewise, research in cognitive psychology confirms that people are far more distressed by what they perceive to be losses than they are ecstatic about what they see as gains. So reversing course is likely to require a multi-pronged approach. We need to have more solid evidence to adopt change in the first place and we should be looking more carefully at subgroups of the population when we draw our initial inferences about efficacy and we need more measured and judicious reporting by the news media and we need to use the nuclear option—removing ineffective or harmful interventions from the market or from third party coverage. Only then will we gain control over the phenomenon of persistent use of established but suboptimal treatment.

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