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C wk THE BANDWAGONS OF MEDICINE Lawrence Cohen ` Henry Rothschild Department of Medicine Louisiana State University Medical Center New Orleans, La. 70118

r f Cohen and Rothschild THE BANDIrlAGONS OF MED'ICINE...2 Although medical progress has been extraordinary, its path has often been directed by the overwhelming acceptance of unproved but popular ideas - the bandwagons of medicine. Some of these ~ ideas eventually prove valid, and their uncritical acceptance is belatedly justified. More often, however, they are disproved and 'abandoned, or replaced by another bandwagon. A new idea can frequently help overcome stagnation and inertia, but, unfortunately, an object in motion tends to remain in motion, and the bandwagon becomes an overwhelming force. How do ideas attaTn acceptance among physicians without rigorous proof of their validity? Moreover, how do valid ideas become extended beyond their proper limitations? The development of a bandwagon is a dynamic process, involving a number of social and scientific factors. A single advocate or group of advocates may be able to generate the interest necessary to launch~the idea. Once other investigators become enthusiastic, preconceived notions blur the distinction between quality and quantity of evidence. Clinicians, laymen, the media, and various interest groups all have a role in sustaininy unproved'ideas. Physicians often accept a new idea because it offers a simple solution to a complex problem. Pressured by their profession into keeping abreast of current trends, physicians must absorb an abundance of new material. Therefore, they may read uncritically or concentrate their reading on~non-technical journals and abstracts. The public, in search

C Cohen and Rothschild THE BANDWAGONS OF MEDICINE..,3 of a panacea, exerts further pressure on the clinician. The mass media give the idea momentum by publishing opinions, conclusions, and extrapolations as data. Research foundations, government agencies, and private industries may each have a vested interest in the idea, endowing it with official sanction and monetary support. Once a hypothesis is generally accepted, further investiga- tion is considered perfidious, and is curbed by the reluctance to fund dissidents. Though the idea may become orthodoxy, doubts persist among an unconvinced minority, because the evidence is not conclusive. Eventually these doubts lead to a critical reevaluation of the hypothesis. The gap left by the decline in popularity of an idea is filled by either a more viable idea or by a newly emerging bandwagon. All sciences are subject to the bandwagon effect, but medicine is particularly susceptible to both the social and scientific determinants. The'design and execution of long-term controTled clinical studies are difficult. The evaluation of studies is affected by the subjectivity of.both a patient's response and a clinician's interpretation of that response. The data in support of a theory may be unconsciously affected by the selective choice of subjects. Also, the battle against disease is accompanied by a feeling of urgency, a feeling that motivates physicians to endorse

Cohen and Rothschild THE BANDWAGONS OF MEDICINE...4 new but inadequately tested techniques. Most unfortunately, medical research that questions orthodoxy is restricted by professional ethics. For example, Chalmers et al. (1) stated, in reference to a possible trial of low-dose heparin in the treatment of myocardial infarction: "...the results of the six random control trials reviewed above would make further use of a placebo questionable fromian ethical point of view." Because of the pervasiveness of bandwagons, the dynamics of the phenomenon are best seen in examples from various stages of its development. Each past, present, or possible future bandwagon .exemplifies a different aspect.of the dynamics of the phenomenon. * * The bandwagon syndrome did not begin with modern medicine. This history of medicine is largely the history of this phenomenon; both had roots in the serpent cult of Aesculapi'us. Often the primary impetus to a bandwagon's development is its identification vtith a powerful personality. Aseculapius is an extreme example of this identification, Worshipped as the god of healing in Roman times, Aesculapius was imported from Greece in the hope of ridding the city of a plague. In Aesculapius' temples, sacred f snakes licked the diseased to effect a cure, His tenets were never

Cohen and Rothschild THE BANDWAGONS OF MEDICINE.,.5 ~ questioned by ancient physicians until the cult lost its popularity with the decline of the Roman gods. The scope of a bandwagon is not limited by time or national boundaries. Phlebotomy was a standard practice around the world, from the earliest recorded times to the nineteenth century. In medieval times the Greek concept of the four humors, blood, phlegm, and yellow and black bile, determined health and medicine. Backed by the Church, bloodletting was used to balance the proportions of , these fluids in the body. In the 1800's, leeches replaced veni- section as the primary method of removingithe "'bad blood." This procedure was so common that "leech" became a synonym for physician. Even the weakened patients confidently accepted the beneficence of bloodletting. The four essential fluids did not lose credibility until alchemy transmuted into chemistry, but even then the phlebotomy bandwagon did not decline. This indiscriminate procedure ended only when the introduction of more sophisticated types of therapy allowed those fortunate enough to avoid blood- letting to outlive those treated by this barbarous practice. At the beginning of the nineteenth century one bandwagon, Brunonianism, was superseded by another one, homeopathy. Both are examples of the role of the initial proponent in establishing a bandwagon, as both were founded and backed by powerful men, whose theories rose and fell with their owminfluence. From a

Cohen and Rothschild THE BANDWAGONS OF MfDI'CINE...6 1-W r historical viewpoint, it is clear that neither was adequately substantiated, if, indeed, any attempt at scientific verification was undertaken. The Brunonian system of the Scotch physician, John Brown, was a drastic philosophy of therapy that employed massive doses of stimulants and depressants, to counteract the pathological imbalance of the body's "excitement." Alcohol and opium were his favorite clinical tools, and he himself died of an overdose of laudanum. In his time Brown gathered~a large following, was approved by the French National Convention, and was enthusiastically accepted by the medical establishment of Europe for 25 years. The historian, Johann Baas, stated that the Brunonian system was responsible for more deaths than the French Revolution and the Napoleonic Wars combined (2). At the turn of the century, the German physiciamSamuel .Hahnemann was able another bandwagon, giving a patient a disease, Hahnemann drug that produced began in France at across Europe, and to transform the decline of Brunonianiism into homeopathy. Directly opposed to the method of drug to counter the sjpposed cause of a advocated the treatment of every disease with a the same symptoms as the disease, His theory the turn of the century, held widespread respect even today has proponents. A corollary of homeopathy was: the smaller the dose, the more effective the drug. Since at that time drugs were commonly prescribed in massive doses, this practice, which amounted to giving almost no treatment,

Cohen and Rothschild THE BANDWAGONS OF MEDICINE,.,7 .W proved to be beneficial to patients. Nevertheless, the acceptance of homeopathy and its triumph over Brunonianism created a readiness to ascribe the success to this system of therapy, Occasionally the disregard of the scientific method is deliberate andla bandti•ragon's proponent unscrupulous, For example, the Russian fraud, Lysenko:, was able to control Soviet-Science for thirty years. Lysenko's-ungrounded rejection of Mendelian heredity and Darwinian evolution, backed~by his flamboyant nationalism~and Stalin's support, caused a stagnation of science in the USSR, The DNA research of Watson and Crick was not published in Russia until several years after its appearance in the West, after Lysenko fell from power. * * * In the recent past, many bandwagons have takem the form of the extension of a new practice to a wide range of applications beyond its proper limits. Thus, even the hasty acceptance of a valid technique may be harmful. This is the paradox of'medical. progress, The overuse of tonsi'.llectomy provides a good example of the extension of a:valid procedure into an overwhelming bandwagon. Previously indicated only for quinsy, in the beginning of the twentieth century tonsillectomy became routine for almost all throat infections. The sources of this:transition were new techniques, false assumptions, the pressure of anxious laymen,

Cohen and Rothschild THE BANDWAGONS OF MEDICINE.,.8 .Q economic factors, and the acceptance of inadequate studies as conclusive. The ancient Greeks and Hindus performed primitive tonsillec- tomies, but the development of new techniques of anesthesia and surgery triggered the mass acceptance of tonsillectomy. In 1907, S. J. Crowe at Johns Hopkins Medi~cal School revamped the procedure, making it safer, more comfortable, and less likely to be followed by a recurrence of infection (3). The blanket acceptance of throat infection as indication for surgery was furthered by two related assumptions: first, that the frequency and severity of throat infections in the past is generally predictive of their frequency in the future; second, that even when morbidity from throat infection is mild, the benefit of tonsillectomy outti•reighs•its cost andirisk. During the years that tonsillectomy was considered the most effective treatment for repeated throat infection, neither of these assumptions was ever adequately tested(4-7). Laymen also had a role in the overextension of tonsillectomy. A number of factors--anxiety, impatience with the inconvenience and ~ cost of frequent visits, concern over a repeated course of antibiotic treatment, preconceptions or wishful thinking concerning the effects of tonsillectomy--led many patients or parents of young patients to consciously or unconsciously exaggerate previous morbidity. Naturally, the patients appeared to improve when

Cohen and Rothschi ld THE BANDWAGONS OF MEDICIrJE... 9 observed postoperatively by physicians, as compared with pre- t , operative observation by the parents, Unquestionably, personal gain is a motivating factor in the overuse of some medical procedures, including tonsillectomy, Many studies show that Parkinson's law prevails in the practice of surgery; wherever there are surgeons, operations abound. The United States has twice as many surgeons per capita as Great Britain and twice the number of operations per capita (8). One survey showed that Canadian surgeons, who are paid by the procedure, performed roughly twice as many operations as did surgeons in Great Britain, who draw a fixed salary whether they operate or not. This discrepancy was most noticeable in the case of elective operations, such as tonsillectomy (9). The efficacy of tonsillectomy was considered to be evidenced by the large number of persons who improved after the operation. That evidence is clearly inadequate, without a control group of patients who had similar symptoms but were not operated on. However, an experiment involving such a control group would have been considered heretical in the heyday of tonsillectomy. Because tonsillectomy was the standard treatment, all of these factors were r generally glossed over when indication for surgery was determined. There were and still are indications for tonsillectomy, but- millions of tonsils and adenoids have been removed needlessly, in ~ spite of the lack of conclusive evidence of the operation's ~ . W - tV C!t . ~D - M+

Cohen and Rothschild THE BANDWAGONS OF MEDICINE.,,10 efficacy in treating many conditions (7), Who is to say whether the 300 deaths per year due to this operation in the 1950's (3) were the result of necessary surgery or a runaway bandwagon? Though now anticoagulation, like tonsillectomy, has only a limited number of applications, at one time it was extended to a wide range of thromboembolic phenomena because of the over- zealousness of its advocates. Most notably, in the 195Ws, long- term anticoagulation became routine in the treatment of acute myocardial' infarction and high risk of infarction. The Food and Drug Administration had authorized limited testing of anticoagulants under strict supervi'sion, but physicians began administering them ind'iscriminately. Soon anticoagulation became the treatment method of choice for a wide range of indications. The abundance of studies supporting anticoaguiants, along with the promise of a miracle drug to combat man's leading~ killer, compensated for the inconclusiveness of those studies. Unable to rely on sol1d evidence, bandwagons have a tendency to take the form of a holy cause. In a 1959 symposium on the history of anticoagulants, Irving Wright (10) pays "tribute to those who did not concern themselves with the past but who pressed forward into the unknown, facing the risks of failure, even after years of work...." The symposium is intended to inspire young investigators; the authors are confident in the immortality of