The People's Perspective on Medicine

Show 1035: How to Understand Medical Flip-Flops

How often have you been frustrated by medical flip-flops? It isn't just eggs and butter; doctors also contend with reversals on screening and treatment.
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How to Understand Medical Flip-Flops

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Why can’t the medical experts make up their minds? That’s a question we hear often when the guidelines for eating a healthy diet, treating high blood pressure or lowering the risk of heart attacks suddenly change. Many people complain about medical flip-flops.

How Medical Flip-Flops Affect Medical Practice:

It isn’t only patients who become frustrated about medical reversals. Physicians also become upset when they discover that a treatment they have been using is not supported by strong evidence. But sometimes it takes a surprisingly long time for that problem to come to light.

What Is Evidence-Based Medicine and How Could It Help?

Are reversals an inevitable part of the scientific process, or is there a way to avoid the whiplash? Find out what types of scientific research are least likely to result in reversals and what changes might be able to minimize such medical flip-flops. The website our guests mentioned that can be useful in sorting out which studies make sense and which might need to be confirmed before anyone accepts the findings is

This Week’s Guests:

Adam Cifu, MD, is a general internist and professor of medicine at the University of Chicago School of Medicine.

Vinay K. Prasad, MD, MPH, is assistant professor of medicine in the Division of Hematology Oncology in the Knight Cancer Institute. He is also a Senior Scholar in the Center for Health Care Ethics in the Department of Public Health and Preventive Medicine at Oregon Health and Sciences University. The photograph is of Dr. Prasad. His website is

Drs. Cifu and Prasad are co-authors of the book, Ending Medical Reversal: Improving Outcomes, Saving Lives.

Listen to the Podcast:

The podcast of this program will be available the Monday after the broadcast date. The show can be streamed online from this site and podcasts can be downloaded for free for four weeks after the date of broadcast. After that time has passed, digital downloads are available for $2.99. CDs may be purchased at any time after broadcast for $9.99.

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I am so very grateful that we continue to have truth seekers among us. Thank you for your work. Peace.

Excellent show. Thanks.
I have been following a low carbohydrate, high fat diet for some years and I feel great.
A few years ago I would think this was a bad choice.
Thanks to good medical reversals (dietary cholesterol is not a problem anymore, nor saturated fat), I can follow this diet and be sure that it is an acceptable option.

There are, however, some overwhelming truisms that just can’t get no respect, even with regard to the documentation whether the “truism” is being used or not in subsequent studies.

In Jan 2000 the HOPE trial was published online (for the first time ever for the NEJM – New England Journal of Medicine) before it was published in print because of its almost unbelievable results:

Ramipril (an ACE Inhibitor anti-hypertensive) at moderate doses (5 to 10 mg) dosed at BEDTIME in patients with hypertension PREVENTED vs placebo strokes, heart attacks, onset of diabetes and some complications of diabetes by 20% (twenty percent). This study was hard to believe because blood pressure was minimally affected overnight and hardly at all during the daytime.

In 2011 there were THREE randomized controlled trials published that asked the question: If an anti-hypertensive is dosed in the am versus at bedtime does it make any difference in outcomes such as stroke and heart attack. The overall conclusion for all three studies: about 70% (SEVENTY PERCENT) of the 20% decrease in hard core clinical outcomes is due to the BEDTIME dosing.

In 2000 the HOPE trial gave hope that the timing of anti-hypertensive dosage can make a huge difference in clinical outcomes. A promising spotlight was shone on the concept of CHRONOTHERAPY in 2000. A blazing confirming spotlight was shone on the concept in 2011.

Yet if one looks at the NEJM and tries to discern the time of day that an anti-hypertensive is being dosed, one has great difficulty in knowing when it was dosed.

When one asks internists (and other primary care providers) whether they dose at least one non-diuretic anti-hypertensive at bedtime, one will very likely find that is NOT routinely done. This represents, in my opinion, a major lapse in care.

In fact there is evidence that when indapamide is used as the diuretic AND perindopril is used as the ACE inhibitor the decrease in stroke and heart attacks (in patients with diabetes) was by 30 to 40%! Indapamide is a sparsely used diuretic as compared to the standard diuretic, HCTZ or hydrochlorothiazide. It works as an anti-hypertensive for a much longer time than does HCTZ (Hydrochlorothiazide). This is another form of the use of the concept of “chronotherapy”.

Chronotherapy just can’t get no respect.

There is a study underway again testing this concept out of the U. of Iowa and Duke U. When will they ever learn?

This is, I believe, the opposite of the concept of “flipping” highlighted in this presentation. I suggest a Radio Show that illustrates this concept that probably is not saving 100,000’s from having stroke and heart attack that could be prevented by the simple, simple act of advising patients to take at least one anti-hypertensive (probably best an ACE-I or an ARB) at bedtime AND that indapamide is a H–L of a better anti-hypertenive than HCTZ AND that African American men and hispanic men are very likely to have hypertension in the middle of the night even if theri blood pressure is controlled during the daytime, highlighting this concept especially for these important cohorts having disparities in certain cardiovascular outcomes that are not well explained otherwise.

Blood pressure control in the middle of the night, out of sight out of mind to most clinicians, but oh so important.

When will they ever learn? When will they ever learn?

For those who would like an update out of the medical literature on Dr. Charles’ excellent lesson, check out this 2015 review:

When they told us butter, eggs and many other things were bad for us, I ate them anyway. God said they were good and man said they were bad!!! I believe God knows what is best for us and I will take His advice any day over that of men.

The problem with evidence based medicine is that the people in charge of the industrialized health care complex are writing and re writing the evidence in order to prosper! When the cost of medical based healing based on medical science reaches close to 18% of GDP yet the number three cost of mortality and or morbidity is caused by hospital visits its time to change the system. It appears that the only way to change the system is to cut off the money.

Hi, I started athletics in 3rd grade and end up playing 13 sports in High School. At 19-23 my BP was 165/ 90 and remained so till present. This year I took down a 239/90 HBP to 170/80 by stopping milk and switching to tea, green and oolong tea. Nothing lowered my 170mmHg BP.

Being an athlete, I guessed it might be catecholamine problem and had a blood level and a urinary out put tests done; the 2nd one by my endocrine MD. Both tests showed a 2 reading on my epinephrine level, 5 times lower than spec 10-230 and a 636 reading on my norepinephrine level higher than the max 520 level limit ~23% higher than normal.

I believe that accounts for my 170 mmHg systolic level that won’t decrease with 7 different antihypertensives. The mild norepi tumor has yet to be identified and removed. I found and identified a different cause of HBP due to athletics. An IVP and volume urinary output level of 2163 mls/urine per 24hrs. ruled out kidney malfunction. It was great to be on diuretics from 19-69 years old. !?

I want to let you know that as a 30 yr healthcare professional, you are DEAD right about this. I have seen it first hand with my own dad, and recently had a close brush with a friend who was misprescribed a drug that gave her what looked like aplastic anemia, until I requested that we stop that drug until we could see an oncologist. We did. Six months later, no sign of blood abnormalities, but neither doctor would confirm it. Keep up the good work; I have TONS of stories about this issue. Thx.

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