More Medical Flip-Flops: Leeches, Lobotomies, and Learning the Hard Way

In “Medical Flip-flops: Is It Flip to Call Them Flops?” I wrote about the flip-flops that signal advances in medicine. The bottom line: don’t flip out about flip-flops that aren’t really flops, but signify progress.

But what about the flip-flops that occur because of real flops?

“Impending lobotomy, butterflies in stomach” – illustration by Sadie Levine, @sadiesartthings

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Weight lost, found again

The history of diets is full of flip-flops. How many times over the years did I work with patients to lose weight by reviewing their caloric intake, and telling them to exercise more? It turns out that isn’t the entire picture. Counting calories was the accepted wisdom of the day; evidence now suggests it may be a waste of time.

We also accepted the common wisdom that breakfast was “the most important meal of the day.” Now it turns out that skipping breakfast may aid in weight loss.

No wonder that weight loss with diets is often elusive. Lost weight is often found again.

I think of patients who started their diets with great determination, and in six months had lost exactly half a year.

Serious obesity has long been viewed as personal failure, deserving of shame and guilt. But fortunately for its sufferers, science is now teaching us that it is a disease, not a moral lapse; in addition to exercise and a healthy diet, weight-loss drugs can be very helpful. Serious obesity is better treated with medication than willpower.

Jumping on the bandwagon

The discovery that aspirin can protect our hearts was huge, a truly exciting moment in medicine. Aspirin is protective in people who have angina or who have had previous heart attacks or strokes.

Doctors jumped on the bandwagon. Since aspirin worked after heart attacks and strokes to prevent more attacks, maybe it would also work before the attacks, to prevent them from happening in the first place.

(Treating before the fact is called primary prevention; treating to prevent recurrences is called secondary prevention.)

So doctors went along with our patients who had no heart disease treating themselves with unproven aspirin therapy. And what happened? Some of them began coming to us with serious stomach bleeding, caused by their aspirin. The bleeding was caused even by teensy-weensy, “baby aspirin,” only one-fifth the normal dose. And even when this “baby aspirin” was enteric-coated, to protect the stomach. Eventually studies confirmed that in primary prevention, aspirin has real risks— and no benefits. 

The hype

Sometimes new drugs are just overhyped. When the tranquilizer Valium (diazepam) first came out, it was a breakthrough. Our tense and anxious patients loved it. It became the most-prescribed drug in North America. It was heralded as “non-habit forming”; later it turned out that people became addicted to it. By prescribing it to be taken regularly, rather than just  occasionally as needed, we were unwittingly turning our patients into addicts.

Halcion (triazolam) was another blockbuster. Everybody was prescribing it for insomnia; it worked wonderfully. Until the neuropsychiatric reactions piled up, and it was taken off the market in many countries. Today it is prescribed rarely, and only for severe insomnia, and very cautiously for no more than a week or two.

We’ve learned, the hard way.

Leeches and lobotomies

But some flip-flops make us smile. 2,000 years ago, leeches were the latest and greatest thing in medicine. They were used to cure diseases by bloodletting, “balancing the humors.” They stayed state-of-the-art until the nineteenth century. (They’re making a very limited comeback in plastic surgery, but no longer as a cure-all.)

In psychiatry, from the 1920’s to the 1950’s there was enthusiasm for lobotomies for a whole array of psychiatric disorders. Lobotomies to treat mental illness were supplanted by the discovery of antipsychotic and antidepressant medications that were much more effective, and safer.

And looking back, I’m amazed that my psychiatry textbook in medical school classified homosexuality as mental illness.

I’m sure that in the future, people will look at many of today's ideas and treatments with the same, head-shaking smiles.

Are doctors too quick to jump on the bandwagon when exciting new therapies are discovered? Too influenced by pharmaceutical promotion? Or, like many people, maybe just too eager to embrace new things in general?

It usually requires considerable time to confirm the benefits of a new method of treatment; still longer to determine the harmful effects. Experience has taught me to be more conservative when new treatments come out. To sit back, wait things out. See where the dust settles.

Being wrong

Meanwhile, however, some patients are breathing down their doctors’ necks. They’re watching TV and surfing the internet and social media for the latest medical discoveries. Wanting to jump aboard. I can only tell them what I’ve learned: some of yesterday’s blockbuster drugs had to be removed from the market. Don’t rush to embrace exciting new theories and claims. Be sceptical of miracle cures.

Our patients expect us to know everything and make no mistakes. But medicine is complex,  constantly evolving. Some of our assumptions have turned out to be false, in medicine as in any other human enterprise. We have to be prepared to be wrong. 

We can only be as wise as our current knowledge. The advice I give is the best we have at any given moment, but it may change. That is the nature of science and medicine.

We have to be humble: today’s breakthrough may be tomorrow’s great flop.

Leeches and lobotomies seem incredibly barbaric today. But when they were truly the latest and greatest, the doctors prescribing them were wise… for their times.

Peter

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PS Feel free to leave your comments on this or past posts— I love hearing from you.