Tuesday, December 07, 2010

Why did medical progress slow after 1984?

From 1910 to 1984 medical progress was extremely swift. After 1984, not so much. As I wrote in 1998 ...

Gordon's Notes: Challenges to medicine and science – medication invention hits a brick wall

... I can vouch for the lack of progress. I’m wrapping up a review of roughly the last 7 years of changes in medical practice.

To put it delicately, progress has sucked. If you put a good physician to sleep 7 years ago, and woke her up today, she’d be reasonable competent on day one. A week later she’d be fully up to speed.

My med review conclusions are:

  • Lots of new combinations of old drugs, maybe due to co-pay schemes Many new drugs have suicidal ideation as a side-effect.
  • Lots of failed immune related drugs re-purposed with limited focal impact on a few disorders. Probably some improvements in seizure meds.
  • Lots of new Parkinson’s and diabetes meds, but they’ve had limited value. (metformin was a home run, but that was more than 7 years ago).
  • Really lousy progress in antibiotics; there are fewer useful therapies now than 7 years ago. Actually, fewer every year...

Twenty-five years ago it was reasonable to criticize physicians for failing to keep up with a rapidly expanding medical literature. I used to lecture on that topic in residency and beyond, teaching "Grateful Med" [1] use with MEDLINE [2] before the internet went public.

By 1992 though I was getting suspicious. Many exciting journal findings were being reversed within 2-3 years. I planned out a small research study, looking at ten year success measures for novel therapeutic recommendations published in leading journals.

I never did that study, instead I moved from academic to industry. Later John Ioannidis did something similar [3]. Writing in 2010, he demonstrates that modern medical progress is slow with many reversals and lateral moves. The era of rapid progress in medicine is over.

Some of the consequences of slow progress are obvious. Nobody in 1984 would have predicted that by 2010 we still wouldn't be able to cure or prevent multiple sclerosis, rheumatoid arthritis, Alzheimer's disease, or diabetes mellitus. Even as recently as 2000, nobody would imagine the near total failure of clinical genomics. Such negativity would have been considered irrational pessimism.

Other consequences are less obvious. True innovation produces bigger results for less effort. In the absence of innovation there's only raw effort. That translates to more money spent on health care to achieve smaller results. Without genuine innovation, health care cost control is exquisitely painful.

So why has medical progress slowed so much?

One can imagine a lot of cultural explanations, but it's not just US health care innovation that slowed. It slowed everywhere.

I suspect it's more like what happened to aeronautical or automotive engineering or cars or, with the death of Moore's Law, CPUs. The period of medical progress from 1910 to 1984 was an anomaly, an explosive renaissance arising from a "perfect storm" of emerging technologies and cultural receptivity. It was wonderful, but it's been over for a while. The gasoline engine gets a little better every year, and so does medicine.

One day there will be another renaissance in medicine. We just can't predict when.

There's a silver lining of course. Physicians needn't feel guilty about not keeping up with the literature.

See also:

-- footnotes

[1] A terrific DOS and Mac Classic app, named by a terrific National Library of Medicine project leader who was also a Grateful Dead fan. It was the successor to today's PubMed, but I think it was, in several ways, better than PubMed. Grateful Med was a graphical shell over a terminal interface; in 1996 Internet Grateful Med took over. The 1993 version was the best though.

[2] I am just entropic enough to remember the vast shelves of paper-bound "Index Medicus"; dozens of yards of books listing research publications.

[3] Thinking is easy. Doing is hard.

1 comment:

Anonymous said...

It's just maybe no one tries to understand anymore ... I had several health issues, and physician just tell you the same thing you can find yourself on google .. and sometimes less...

There's a huge gap between technology progress and medecine progress. Today most people are unaware of that, and there is a kind of taboo about it. When my mother get sick(cancer) i was one of them. I thought that medecine could beat any disease, "hey man, we are in the 21th century!"

Organs transplant ! Kind of a joke ! You think maybe you'll have a new kidney and everything is ok ??

Well, first you'll have to wait(if you don't die before), but worse, the drug they give you to prevent you body from rejecting the organ destroys it ! So if you are really lucky you can keep it 20 years...