Remember that thing that we said was good for you, then we changed our minds telling you it’s now bad for you. And now? We’re changing our minds again…umm, maybe it is good for you again.
Medicine that claims to be ‘evidence-based’ is never static. It changes. Sometimes quickly and sometimes slowly and so too do our doctor’s suggestions about what they think is right to keep us healthy.
In that light, sometimes medical recommendations around screening, surgery, or treatments like drugs or vaccines follow a certain pattern: widespread Enthusiasm based on promising early evidence, a Reversal when rigorous trials reveal limited benefits or unexpected harms, and then a Revival driven by new interpretations, technological tweaks, manufacturer greed, or good old advocacy. Here are six examples of ERRing, which no doubt confuses patients and clinicians alike:
Tonsillectomy (Especially in Children)
Enthusiasm: For about 40 years, from the 1930s to the 1970s millions of tonsillectomies were done annually, often bundled with adenoidectomy and was viewed as a near-standard childhood rite. I am old enough to remember feeling envious when many of my friends in elementary school were getting their tonsils removed. This was the early 70s where tonsillectomy was one of the most common surgeries worldwide, routinely performed for recurrent sore throats, enlarged tonsils, or even preventive reasons. After all, better safe than sorry, right? Sure my brother and sisters and I went through bouts of sore throats but my mother, a nurse, didn’t buy into the tonsillectomy hype, so we all still have them. Here’s how that worked out…
Reversal: It wasn’t until the PARADISE study, (PAtient-centered outcomes Research and ADvanced Intervention for the Surgical treatment of Ears, Nose, and Throat diseases), a randomized trial published in the New England Journal of Medicine in 1984 found the surgery might have some benefit for kids suffering recurrent and severe infections, but overall most kids improve spontaneously. Surgery-related complications which are rare were manageable. Soon tonsillectomies were history, falling by more than 50% in many countries and guidelines became highly restrictive.
Revival: In the 2000s it was recognized that obstructive sleep apnea could be treated with tonsillectomy so there was a major revival. Today about 500,000 tonsillectomies are performed annually on US children alone, and widely promoted for quality-of-life and neurocognitive benefits. Let’s just say, even today, doing tonsillectomies can be lucrative for those doing them, whether they are warranted or not.
Hormone Replacement Therapy (HRT) for Menopausal Women
Enthusiasm: In the 1980s through early 2000s, systemic estrogen (often with progestin) was widely prescribed for menopausal hot flashes. Pharma-funded campaigns pushed HRT as an anti-aging elixir that could also help prevent heart disease, osteoporosis, and dementia. Observational studies and heavy pharmaceutical marketing positioned HRT as essential for women’s health. That was until real science stepped in.
Reversal: One of the largest and best randomized trials ever conducted of HRT, the Women’s Health Initiative (WHI), was published in 2002 and found increased risks of breast cancer, heart attack, stroke, and blood clots, with no net preventive benefit in older postmenopausal women with the exception of slightly reduced osteoporotic fractures. Prescriptions plummeted more than 50%, and guidelines shifted against routine use. There was a lot of major ass-covering and finger-pointing in drug company circles, but at least we had some high-quality science to point to.
Revival: In the last five years, no doubt aided by Big Pharma trying to revamp markets, the WHI was ‘reanalyzed’ and women are now told that the benefits of HRT may outweigh risks if started near menopause for moderate-to-severe symptoms. Newer guidelines and women’s health advocates are now pushing individualized low-dose, short-duration HRT as firstline for symptom relief. Fair enough, but does that renewed enthusiasm go too far? I agree with those who are knowledgeable about the importance of a high -uality RCT like the WHI and think this revival is nonsense. Clearly there’s an unexploited market yet the estrogen pushers are just putting more lipstick on a pig.The very real harms related to breast cancer, blood clots, and heart attacks are not to be dismissed and journalists reporting on the HRT revival should do their homework and “Follow the money, honey.”
Hellbound and Down 