Chapter 5

A medical reversal occurs when a better-designed study contradicts an accepted medical practice, such as a medication, diagnostic test, or procedure. Medical Reversal Over 50 years of medical practice, I have prescribed many well-established treatments that were the uniform standard of practice at a particular point in time. OB-GYN and primary care practitioners prescribed estrogen…


A medical reversal occurs when a better-designed study contradicts an accepted medical practice, such as a medication, diagnostic test, or procedure.

Medical Reversal

Over 50 years of medical practice, I have prescribed many well-established treatments that were the uniform standard of practice at a particular point in time. OB-GYN and primary care practitioners prescribed estrogen replacement therapy (ERT) widely to improve women’s life quality, and not prescribing them was considered an uncaring attitude on the doctor’s part and even substandard practice. Hormonal replacement therapy was widely used worldwide as OB-GYN Society recommended Estrogen Replacement Therapy (ERT) in the 1980’s, 1990’s and 2000’s for most women after menopause. However, a big shift regarding ERT occured in recent years, with a growing caution around long-term hormonal therapy after the publication of Women’s Health Initiative trial which began in 1992 and ended in 2015.The study enrolled 160,000 menopausal women and focussed on strategies to prevent heart disease, breast disease and colorectal cancer. Not only did the study demonstrate any benefits from lifelong ERT, but it had signficant side-effects and risks. These included increased clots ( venous thromboembolism), strokes, and a heightened risk for invasive breast cancer.This landmark study led to a re-evaluation of the risks and benefits of ERT, as well as a better understanding of the potential long-term effects. Primary Care providers and gynecologists previously ( before the publication of WHI trial) were all convinced that estrogens helped maintain a woman’s vitality after menopause, improved bone health, and provided protection from the progression of atherosclerotic heart disease and dementia. In the epidemiology of coronary artery disease, females in general developed heart problems ten years later than men during their postmenopausal years, and practitioners believed estrogens protected women until menopause and a decline in estrogen levels in menopause exposed them to the risk of coronary artery disease. Based on this belief practitioners prescribed estrogens on a long term basis after menopause. Pharmaceutical companies used aggressive marketing tactics, with dinners and educational events by experts for doctors to promote drugs like Premarin ( Conjugated estrogens ).  In his heavily researched book PHARMA, Gerald Posner says that Prempro ( combined estrogen/progesterone) became a best seller in the 1970s (Wyeth-Ayerst won FDA approval without conducting a randomized clinical trial). There were a total of 90 million hormonal prescriptions annually at its peak. Thelma Wilson, a registered nurse, was the wife of Robert Wilson(gynecologist). Dr. Wilson was a passionate proponent of long-term hormonal therapy for women. It is a sad irony that Thelma died of breast cancer. She had breast cancer ten years previously and had a mastectomy.  Despite that, Thelma continued taking hormones until her death ten years later from a recurrence of breast cancer with metastases. She confessed to her son just before her death that she, her husband, and the men at Wyeth did not want their children to know about this and for the story to become public!!

After the Final Evidence Review on November 1, 2022, The USPSTF  recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons. 
The widespread prescription of hormones by practitioners has now ceased. The current practice is to use hormones based on the balance of benefit versus potential harm in an individual patient for a limited period of time around menopause. This is a huge departure from the previous practice of lifelong therapy.

The second most prominent medical reversal occured in the management of coronary artery disease with balooning and stenting.
Through the 1990s and 2000, coronary artery stenting was done routinely for blocked coronary arteries in patients with stable angina. It was routine practice to open the blockages with balloon angioplasty and put stents on the premise that this would improve coronary blood flow and thus reduce the risk of future heart attacks. ( see clinical perspectives in case history illustrated below).
The COURAGE TRIAL, a large randomized trial published in 2007, was a turning point in our understanding of the role of stenting. This trial showed that stented patients performed no better than patients who received optimal medical therapy, significantly challenging our approach to coronary artery disease treatment with invasive stenting.
During an extended follow-up of up to 15 years since 2007, researchers found no difference in survival between an initial strategy of stenting plus medical therapy and medical therapy alone in patients with stable ischemic heart disease. These findings have significant implications for our current treatment strategies.

When researchers presented the above trial’s findings, a reporter attended the American College of Cardiology’s annual scientific meeting. After the presentation and discussion among panelists, this reporter interviewed several cardiologists during the lunch break. The majority of the doctors interviewed still believed that stenting was like an “insurance” against future heart attacks, and indeed, some of the doctors had the procedures themselves. It’s crucial to note that these procedures are risky. As revealed by the research, the potential complications from stenting should raise concerns and prompt a reevaluation of such practices.

My patient, who was 64 years old, had severe chest discomfort lasting almost 18 hours over the Easter weekend and ended up having a fatal heart attack and cardiac arrest on Easter day. He had a large family spending Easter at my patient’s home. He had a normal stress test a week previous to his heart attack. Because he had a normal stress test, the family wanted an autopsy to confirm that a myocardial infarction was indeed the cause of his demise. The autopsy showed evidence of acute myocardial infarction. But there was an interesting twist to the autopsy findings. There were more than 90% blockages, considered critical narrowings, in left anterior descending and circumflex arteries ( arteries to the front and lateral portions of the heart), but only (non-critical) 60% narrowing in the inferior portion of the heart. The area of heart damage (myocardial infarction) was in the inferior portion of the heart, NOT the front and lateral portion of the heart as expected i.e. heart damage should have occured in the areas of the heart with critical coronary arterial narrowing, not the area of the heart with non-critical narrowing. As I explained to the family, the area served by the most narrowed branches of coronary artery tree had developed extensive collateral circulation ( ” natural bypasses ” ) which protected the heart muscle in that area. Contrarily, the area served by the non-critical narrowing of coronary artery branches did not have enough collateral circulation to protect the heart muscle in that area.

Just before the passing of my patient, a small study was published in the American College of Cardiology that examined the areas of heart muscle damage (infarctions) at autopsy. All these patients had a prior heart catheterization within 3 months of their demise. In all the patients, the areas of heart muscle damage ( infarctions ) were in areas served by non-critically narrowed arteries. The areas served by the critically narrowed arteries were protected from heart muscle damage. The authors concluded that the protected areas had developed collateral circulation, while the non-protected areas had NOT developed collateral circulation. In coronary artery disease, the best scenario for future cardiac events is to have a heart with extensive collateral circulation in all the areas served by three coronary arteries and their branches.

(Cautionary Note: Coronary artery stenting is of undoubted value in unstable angina patients and  patients with  acute symptoms of impending heart attack.) So, these circumstances are quite different from patients with stable heart conditions such as stable angina.

Drs. Vinayak Prasad and  Dr.Adam Cifu narrate numerous examples of medical reversal -when doctors start using a medication, procedure, or diagnostic tool without a robust evidence base―and then stop using it when it is found not to help, or even to harm, patients. One example is a procedure called kyphoplasty in which medical cement was injected in a collapsed vertebra in patients with severe osteoporosis. Hundreds of patients went through these procedures until a high quality trial demonstrated that this procedure did not help control pain any better than a control group who did not have cement injected.

According to Vinay Prasad’s study, “A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices,” 146 medical practices were reversed in 363 articles published in the New England Journal of Medicine between 2001 and 2010, equivalent to 40.2% of the articles. So, medical reversal is quite common.

A recent NYT Magazine article on April 13, 2025 ( New Research on ADHD) highlights new approaches to the diagnosis of ADHD and there should be a medical reversal as the condition has widespread impact in America.

Summary of the article in bullet points:

  1. The roots of the current treatment started in 1937 with amphetamines and have remained the same in 1999.

      DSM makes the diagnosis based on subjective criteria.

  1. 3% of Americans had amphetamine prescriptions in 1966; this has dramatically increased to 20%
  2. Russell Barkley, researcher, labels it as “Diabetes of the Brain i.e a chronic medical condition lasting throughout life
  3. British & Australian Reserarchers have noted that 75% have co-existing diagnoses of depression, anxiety disorder, dyslexia and autism.
  4. Enigma organization, in a consensus statement, have stated that “less brain electrical activity and spotty brain scan defects” were inconclusive for those taking amphetamines and for those on placebo
  5. Paul Tough summarizes the article after talking to experts like Sonuga-Barke that ADHD is a continuum with fluctuations as compared to hypothesizing defects like defective personality trait,(as compared to somebody being different rather than defective) wrong environment, wrong context.

It is astonishing that the U.S Army gave it to the military forces fighting in World War II. In the private sector, long haul drivers were prescribed amphetamines.

The old concepts of ADHD diagnoses lead to stigmatization, at best, and isolation, depression,suicide, and other drug and alcohol addictions.

Much of the above information was based on randomized trials. Some readers suggested that including clinical cases might make it more interesting for them.

I might add that in 1960, as a first-year medical student at Guy’s Hospital (University of London, UK), I spent 3 months (required surgical rotation) with Sir Hedley Atkins (1904-1983), a world-renowned surgeon at his time. He advocated aggressive modified radical mastectomy with the entire removal of the breast, underlying muscular tissue ( pectoral muscles), and removal of nearby lymph nodes ( axillary nodes). While Atkins was famous in England, William Halstead (1852-1922 )was a pioneer breast surgeon at Johns Hopkins Hospital. He also advocated aggressive modified radical mastectomy. There were large galleries atop the surgery room for visiting surgeons from all over the world to learn Atkin’s surgical techniques.

Sir Hedley Atkins specialized in the scientific treatment of breast cancer, and the Hedley Atkins Breast Unit at New Cross Hospital acknowledges his contribution to the field. He was elected a fellow of the Royal College of Surgeons in 1934, became vice-president from 1964 to 1966, and President from 1966 to 1969.

Although Sir Hedley Atkins strongly believed in “cutting out” as much cancer as possible, he followed his patients meticulously for breast cancer relapses and published his findings in peer-reviewed Journals. His attitude and approach led to the current practice of breast conservation and the rejection of dehumanizing mutilating breast surgery procedures of the past.

In summary, scientific advances will always lead to medical reversals when better procedures and technologies become available.

During my practice in Kenya in late 1969, my first patient was a 34-year-old primary care physician. He came to my office with the complaint of crushing chest discomfort in the center of his chest, lasting throughout the previous night. It was clear that he had anginal discomfort. He had no family history of coronary artery disease. Clinical examination revealed that he had tachycardia with a heart rate of 120/mt, and his blood pressure was low, with a reading of 102/62. There were no signs of congestive heart failure. There was no pericardial friction rub. EKG showed massive anterior wall myocardial infarction with large q waves in leads 1, avL, and v1-v6. There were reciprocal tall R waves in leads 2, 3, and avF. The family was understandably shocked by my findings, and I was also worried. He was hospitalized immediately, and in those days, the treatment was complete bed rest and the use of morphine to alleviate chest discomfort.
At that time, a team of cardiologists came to start a cardiology program at Kenyatta Hospital in Nairobi, Kenya. I took my patient’s EKG tracings and showed it to all the three cardiologists in the Glasgow team. They all agreed that he had sustained a transmural anterior myocardial infarction ( massive heart attack in the front wall of the heart). Even in advanced countries like the USA and the UK, there were no cardiac catheterizations and, for that matter, no ICUs for monitoring heart rhythm. The team postulated a congenital abnormal coronary artery system, such as a stenosis ( narrowing ) of the main coronary artery, as the possible etiology of a heart attack.

A few weeks later, I discussed the case with an eminent cardiologist from Harvard Medical School. He had come to Kenya for a wildlife safari vacation. Kenya Medical Association had arranged a lecture by him for local physicians. I showed the tracings to him, and he offered the same explanations as the Glasgow Cardiologists for his heart attack. After six weeks of bed rest, my patient stabilized. Six months ( around June 1970 ) after his heart attack he started having episodic exertion induced and nocturnal central chest discomfort. EKG showed new findings waves in the inferior heart wall ( q waves in leads 2,3 and AFV). The family, as well as I, were extremely worried about his prognosis. There were no approved statins at the time that he could have used. I migrated to Canada in June 1972, and we remained in touch. From 1972 to 1994, he remained symptom free until he relocated to the UK. He underwent cardiac catheterization in London in 1994 and triple vessel bypass surgery. He also started taking lovastatin at that time. He practiced in London and led an active life until he died from a massive stroke in 2004. He was 68 years old when he died and had lived for 34 years since his first heart attack.
Contrary to his family’s and my expectations, he survived 24 years symptom-free without any specific treatment. Why was he symptom-free? Almost certainly, he developed extensive collateral coronary artery circulation, bypassing all the blocked coronary artery segments.

When I was practicing medicine in Milwaukee in the early 1980s, Dudley Johnson, a pioneering cardiac surgeon, popularized the notion of complete myocardial revascularization and typically took 8 hours of operating time to accomplish this. So, this iconic surgeon established the concept of myocardial revascularization, and generations of cardiologists followed his thinking on this subject.


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