Brown, the Washington University cardiologist, says that once doctors get out of training, "it's a job, and they're trying to earn money, and they don't necessarily keep up. So really major changes have to be generational."
Data compiled by QuintilesIMS, which provides information and technology services to the health-care industry, show that atenolol prescriptions consistently fell by 3 million per year over a recent five-year period. If that rate holds, atenolol will stop being prescribed in just under two decades since high-quality trials showed that it simply does not work.
Just as the cardiovascular system is not a kitchen sink, the musculoskeletal system is not an erector set. Cause and effect is frequently elusive.
Consider the knee, that most bedeviling of joints. A procedure known as arthroscopic partial meniscectomy, or APM, accounts for roughly a half-million procedures per year at a cost of around $4 billion. A meniscus is a crescent-shaped piece of fibrous cartilage that helps stabilize and provide cushioning for the knee joint. As people age, they often suffer tears in the meniscus that are not from any acute injury. APM is meant to relieve knee pain by cleaning out damaged pieces of a meniscus and shaving the cartilage back to crescent form. This is not a fringe surgery; in recent years, it has been one of the most popular surgical procedures in the hemisphere. And a burgeoning body of evidence says that it does not work for the most common varieties of knee pain.
Something like the knee version of the oculostenotic reflex takes hold: A patient comes in with knee pain, and an MRI shows a torn meniscus; naturally, the patient wants it fixed, and the surgeon wants to fix it and send the patient for physical therapy. And patients do get better, just not necessarily from the surgery.
A 2013 study of patients over 45 conducted in seven hospitals in the United States found that APM followed by physical therapy produced the same results as physical therapy alone for most patients. Another study at two public hospitals and two physical-therapy clinics found the same result two years after treatment.
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