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Letting Go is Never Easy
August 25, 2015 by Dr Matthew D. Long
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Letting Go is Never Easy
August 25, 2015 by Dr Matthew D. Long
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Letting Go is Never Easy
August 25, 2015 by Dr Matthew D. Long
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I think that it would be safe to say that the world of health care could always do with a bit more critical thinking. No matter the profession or educational background, it seems that many treatments are accepted without question - often in spite of evidence to the contrary. Given that most clinicians would like to view themselves as 'scientists', such behaviour seems odd.
This has been highlighted recently by an interesting paper that looked at the ongoing use of arthroscopic surgery for the degenerative knee. Thorlund and colleagues (1) performed meta-analysis on current literature regarding this common orthopaedic procedure, in an effort to determine what benefits we might reasonably expect to see in middle-aged or older patients. Their curiosity had been piqued by other research that demonstrated common features of osteoarthritis present in the asymptomatic population. The question then arises, are these changes actually relevant, and does arthroscopic surgery offer any advantage that outweighs the possible risks of the procedure? The answer seems to be 'no'.
Thorlund concluded,
This has been highlighted recently by an interesting paper that looked at the ongoing use of arthroscopic surgery for the degenerative knee. Thorlund and colleagues (1) performed meta-analysis on current literature regarding this common orthopaedic procedure, in an effort to determine what benefits we might reasonably expect to see in middle-aged or older patients. Their curiosity had been piqued by other research that demonstrated common features of osteoarthritis present in the asymptomatic population. The question then arises, are these changes actually relevant, and does arthroscopic surgery offer any advantage that outweighs the possible risks of the procedure? The answer seems to be 'no'.
Thorlund concluded,
"The overall additional benefit on pain from arthroscopic surgery, using the primary endpoint of each trial, was small (effect size 0.14) and limited in time. This benefit is comparable to the small pain relieving effect on knee pain seen from paracetamol (effect size 0.14), less than that of non-steroidal anti-inflammatory drugs (0.29), and markedly smaller than the moderate to large pain relieving effect seen from exercise therapy as treatment for knee osteoarthritis (overall standardised mean difference 0.50 regardless of type or dose, or 0.68 for exercise performed three times a week)."
Even more telling, the authors concluded that,
"Available evidence supports the reversal of a common medical practice. However, disinvestment of commonly used procedures remains a challenge, and use of arthroscopy seems to be undiminished, in analogy with use of vertebroplasty following the publication of trials showing absence of benefit of this procedure. Surgeon confirmation bias in combination with financial aspects and administrative policies may be factors more powerful than evidence in driving practice patterns."
Ouch! An accompanying editorial by Professor Andy Carr (2) asked the question, why is arthroscopy still so common then? He wrote,
"Another possibility is that surgeons are falling prey to confirmation or myside bias, whereby robust and high quality evidence is contested and ignored in favour of deeply held convictions or entrenched attitudes. Such bias is not new and was well described by Leo Tolstoy in 1899: “I know that most men not only those considered clever, but even those who are very clever, and capable of understanding most difficult scientific, mathematical, or philosophic problems can very seldom discern even the simplest and most obvious truth if it be such as to oblige them to admit the falsity of conclusions they have formed, perhaps with much difficulty conclusions of which they are proud, which they have taught to others, and on which they have built their lives.”
We could take a cynical viewpoint and simply place the blame upon economics. As Upton Sinclair so succinctly put it (3), "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" However, there appears to be more at play than money.
'It is difficult to get a man to understand something, when his salary depends upon his not understanding it!'
Abandoning closely held beliefs or ideas is extremely difficult - and costly in terms of our identity. We define ourselves by what we do, so letting go of a long-term conviction is emotionally challenging and earnestly resisted. We become invested in our methodologies and theories and find change both challenging and threatening. Furthermore, if we choose to cease using a treatment because it is ineffective, we face the challenge of finding something to replace it with. This requires thought, and possibly additional study or training, all of which creates great friction and hinders change. Science often throws up results that we might not like. However, the mature clinician recognises that ultimately science is our friend and helps us to sort out what is truly valuable.
You might ask, "Why do I need help in determining whether my treatment is effective? I see it work every day!"
Unfortunately, this argument has been used since time began to justify all manner of treatments that ultimately did prove to be worthless. It is quite apparent that humans are hard-wired to see patterns and associations, even when none exist. In an effort to make sense of our complex and noisy world, we attribute causal relationships to actions and events that are truly unrelated. Furthermore, patient expectation is a powerful force that constantly muddies the waters of investigation. This idea was examined in depth by Hartman (4) in a paper entitled, "Why do ineffective treatments seem helpful? A brief review." He wrote,
You might ask, "Why do I need help in determining whether my treatment is effective? I see it work every day!"
Unfortunately, this argument has been used since time began to justify all manner of treatments that ultimately did prove to be worthless. It is quite apparent that humans are hard-wired to see patterns and associations, even when none exist. In an effort to make sense of our complex and noisy world, we attribute causal relationships to actions and events that are truly unrelated. Furthermore, patient expectation is a powerful force that constantly muddies the waters of investigation. This idea was examined in depth by Hartman (4) in a paper entitled, "Why do ineffective treatments seem helpful? A brief review." He wrote,
"For thousands of years, practitioners administered therapies, monitored symptoms, and then proclaimed their efforts beneficial. Patients considered their post-treatment perceptions, and agreed. Now we know, both practitioners and patients often were wrong. Whatever treatment was engaged, direct, positive effects on patient health probably were rare. This lengthy record of misplaced medical confidence has done little to halt similar, 21st century errors in judgment...
Why does faith in personal clinical experience persist, given its clear and protracted reputation for unreliability? I consider three related components to this deductive malfunction:
I. due to natural history of disease, regression to the mean, and the placebo effect, real signs and symptoms often improve -- with or without treatment;
II. patients and practitioners often convince themselves that treatment was effective -- when it was not (due to confirmation bias and other human cognitive imperfections); and
III. personal evaluation of efficacy is quick and convincing, but properly controlled, scientific determinations can be slow, complex, and costly."
Why does faith in personal clinical experience persist, given its clear and protracted reputation for unreliability? I consider three related components to this deductive malfunction:
I. due to natural history of disease, regression to the mean, and the placebo effect, real signs and symptoms often improve -- with or without treatment;
II. patients and practitioners often convince themselves that treatment was effective -- when it was not (due to confirmation bias and other human cognitive imperfections); and
III. personal evaluation of efficacy is quick and convincing, but properly controlled, scientific determinations can be slow, complex, and costly."
We might question whether all of this actually matters, given that patients feel better, and often do recover, in spite of the lack of validity of the treatment. Does it matter, as long as no-one is getting hurt? As Hartman concluded,
"Independent of direct, effective, therapeutic support, patients often come to feel better. This is not trivial, but ethics of all healing professions demand that such effects not be falsely credited to specific treatments."
I agree. Our patients rely on us to solve their problems, using the best available options for them, and to do this we need to keep abreast of contemporary evidence - even if we don't like it. Of course, as I have previously written, such mental manoeuvring requires us to keep an open mind. In another blog post of the same name (here) I argued that we need to respect empirical observation, and appreciate that many treatments do work - just not for the reasons put forth by their originators. A balanced clinician can look past outdated theory and look for updated explanations in the contemporary literature. But we also need to know when science has truly come to grips with an issue, and has shown that it is time to put it to bed.
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Thorlund, J. B., Juhl, C. B., Roos, E. M., & Lohmander, L. S. (2015). Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ (Clinical Research Ed), 350, h2747. http://doi.org/10.1136/bmj.h2747)
2. Carr, A. (2015). Arthroscopic surgery for degenerative knee. BMJ (Clinical Research Ed), 350, h2983. http://doi.org/10.1136/bmj.h2983
3. Sinclair, U. I, Candidate for Governor: And How I Got Licked (1935), ISBN 0-520-08198-6; repr. University of California Press, 1994, p. 109.
4. Hartman, S. E. (2009). Why do ineffective treatments seem helpful? A brief review. Chiropractic & Manual Therapies, 17(1), 10. doi:10.1186/1746-1340-17-10
1. Thorlund, J. B., Juhl, C. B., Roos, E. M., & Lohmander, L. S. (2015). Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ (Clinical Research Ed), 350, h2747. http://doi.org/10.1136/bmj.h2747)
2. Carr, A. (2015). Arthroscopic surgery for degenerative knee. BMJ (Clinical Research Ed), 350, h2983. http://doi.org/10.1136/bmj.h2983
3. Sinclair, U. I, Candidate for Governor: And How I Got Licked (1935), ISBN 0-520-08198-6; repr. University of California Press, 1994, p. 109.
4. Hartman, S. E. (2009). Why do ineffective treatments seem helpful? A brief review. Chiropractic & Manual Therapies, 17(1), 10. doi:10.1186/1746-1340-17-10