Reasons to operate: the ‘wobbly tripod’ of evidence

"When good evidence is lacking, the best and most dedicated of us do wrong in the utter conviction of being right"

(L. Eisenberg 1977, NEJM, 297, 1230-2)

When surgical practice varies between doctors, hospitals, regions and countries (and it does), there are many possible reasons, apart from variations in the disease or the population. Some reasons that have been given for practice variation in surgery are:

Is back fusion surgery just a placebo?

It is possible that spine fusion surgery for back pain achieves its effectiveness through the placebo effect. I would like to make the case that it is not only possible, but also probable.

Achilles tendon ruptures: let the patient decide

As we age, our collagen loses its elasticity and our tendons weaken. A ruptured Achilles tendon (TA) is often the result. This is a common injury; patients are usually aged 30 – 50 and it normally occurs with a sudden push-off during sport. Now, the initial reaction when anything is torn is to repair it, and while this holds true for inanimate objects, living things are different – 4 billion years of evolution has made some headway in that regard. Many people do not appreciate that as surgeons, when something is broken, cut or torn, all we do is put the ends roughly together and it is nature that does all the healing; we just take the credit. Placing the torn ends of a ruptured TA together is easy: you just flex the ankle. And it turns out that if you do this, and gradually bring the ankle back to normal position over a few weeks, it heals fine – without surgery, and without the complications associated with surgery.

Placebo surgery #4: Knee arthroscopy in arthritis

An arthroscopy (key hole surgery to wash out, trim or clean up) in the knee joint is one of the most common procedures in orthopaedics, and one of the most common surgical procedures overall, with over one million performed in the USA each year. An overview of arthroscopy for knee osteoarthritis can be found in a previous blog; this post covers the sham surgery trial as part of a series on that topic.

Lessons from history #3: From railway spine to whiplash

‘Railway spine’ was the name given to the widespread finding of chronic back pain and disability associated with railway injuries, and reaching near epidemic proportions in mid and late nineteenth century England. It has many similarities with other post-traumatic conditions and provides lessons about chasing physical diagnoses, and the role of psychosocial factors (in particular, the role of compensation). Lessons that we never seem to learn.

Financial incentives and surgery rates

Recently, a reader asked me if financial incentives could be responsible for the findings referred to in previous posts, like practice variations and the persistence of some surgical procedures despite evidence of their ineffectiveness. We know that you can change physician behaviour by altering financial incentives (Cochrane review), but anyone who believes in Homo Economicus will tell you that. And there is also evidence that financial incentives lead to increased health care usage amongst primary care doctors (here), but what about the evidence for financial incentives influencing surgery rates?

I'm not sick but I'm not well

This phrase got me thinking: what happens to people who do not have an identifiable disease, but still feel unwell; when the tests do not reveal any pathology, but they still have symptoms? They get a label, that’s what, because doctors cannot say: “Your tests are normal and you do not have any evidence of an underlying disease process. Further opinions and investigations are unlikely to help, and may lead to unnecessary and potentially harmful treatments”.

I don’t have time for a discourse on medicalisation, but I wanted to ask: What label do these people get? It turns out that it depends on the specialty training of the doctor that sees them.

Placebo surgery #3: Meniere's disease

Meniere’s disease is a disorder of balance (dizziness) and hearing (ringing or hearing loss). The underlying cause is not understood (idiopathic), the symptoms often fluctuate, there is crossover with other symptoms (vertigo, migraine), and there are many other conditions that cause “Meniere’s-like” symptoms. This makes the condition ripe for any treatment to look good if we think it works, due to the subjective nature of the symptoms, symptomatology that is open to misinterpretation, and the lack of any objective pathological test. Therefore, for such conditions, reporting good results from a series of patients is not enough; a more scientific (unbiased) assessment is necessary. Fortunately, somebody did just that. Unfortunately, despite the results of that study, surgery (now in many different forms) is still being used for this condition.