Saturday, 14 January 2017

Don’t treat me, I’m a doctor

“Tennis elbow”, also known as lateral epicondylitis, is a common condition causing pain over the outside of the elbow, where the muscles to the wrist and fingers attach. I’ve got it, and I am doing absolutely nothing about it. Doctors often do not seek treatment, even treatments that they themselves recommend to others. What do these doctors know that makes them avoid treatment?
There are many enlightening articles written about why doctors don’t get treated themselves. Often, it is because they are aware of the true effectiveness (less than commonly believed) and the true risks and harms (greater than commonly believed). Possibly also because they have seen the treatments and know the data – and are therefore in a good position to weigh up the effect of the risks and benefits on their quality of life. For end of life care, they also realise that everybody has to die, and sometimes how you die (quality of life) is more important than how many extra days you can sneak in before you go (length of life). Funnily enough, we know from research (mentioned elsewhere in this blog) that doctors tend to overestimate the effectiveness and underestimate the harms of medicine – yet they still often refuse treatments. What does that say about the true effectiveness of some of these treatments?


For me, my tennis elbow is painful. I frequently have trouble lifting things or doing heavy work and it wakes me occasionally at night. However, I am not ‘bothered’ by it. I know that it is a condition of uncertain origin, that the myriad of treatments (including injections, ultrasound, surgery, medications and splints) are largely ineffective, and that the condition is self-limiting – it gets better by itself, eventually.

Tennis elbow is a classic example of medicalisation, overdiagnosis and overtreatment. The lack of a clear cause does not stop people from making up causes and therefore diagnoses on which they base treatments that have little or no effect beyond placebo.

The apparent effectiveness of treatments for conditions that are self-limiting is what drives sales and continued treatment. Fear is another driver, promoted by doctors that use the knowledge difference between them and their patients. Unexplained, spontaneous moderate elbow pain can be distressing, and that can easily drive full blown medicalisation with all its tests, labels and treatments. And for many doctors, treating people is just a case of going through the motions. We think that patients expect treatment, so why not just give them everything?

It doesn’t have to be that way. I am telling myself exactly what I tell my patients: you have a common condition that causes elbow pain and some functional limitation but gradually gets better over time and for which, treatments are largely a waste of time. With that advice, the condition becomes a minor annoyance and doesn’t ‘bother’ me.

The bottom line

How much something bothers you, and how much you seek treatment, are subjective and depend on your beliefs and fears; we need to manage them as doctors and provide accurate information and reassurance, not just reflexively order tests and treatments for every complaint.

10 comments:

  1. Ha, physician heal thyself. I woke one morning with a stiff shoulder and because I had just had gallbladder surgery four months prior I thought it was related. Turns out it was. It was stress and anxiety related. However, my own doctor and others didn't take into account my recent history or ask me how I felt about my shoulder --i.e., did it scare me-- and I ended up tested for everything from Diabetes to MS, with brain scans and MRI of my spine and on on and on. Various doctors told me that I would have to live with the pain forever, so sorry. I had an idea that the shoulder pain was stress related -- the upper trap and Lavater Scapule-- but by the time I got the Doctor-Go-Round I was convinced by them I had a horrible spine condition and pain was my sentence for waking up one morning with an unexplained stiff --not even sore-- shoulder. My health spiraled downward. I began to guard and brace my "wounded" area which consisted of now not only my shoulder but my entire back. My pain grew as the muscles deconditioned and as other muscles compensated. More anxiety and more panic followed. Finally, I gave up on doctors and doctored myself. None knew why I was in pain, and those in the psychiatric community were of no help either, because they had no cognitive instructions as to help me change my thinking; they only had pills.

    It was a long, long path back to health. I was so messed up mentally and physically and in chronic pain all day and most night that I wanted to take my life. Finally, I had to get myself mentally back together, which meant improving sleep. Then physically I had to re-condition, and that was exceedingly painful during the process, and I was not sure what muscles had weakened and which had overcompensated.

    So...do not see a doctor about your elbow. And you might STRONGLY advise against almost all your patients doing so too for a non-accident type of injury such as yours.

    Doctors are not known anymore for their follow-up on problems like yours, so if you had the wrong type of personality or had just had a surgery sending the person into the Medical Mill will ramp up their anxiety and, in the worst case, cause them to take their lives. People like answers, even if the answer is, "We don't know what causes it, but it goes away."

    Had one doctor layed his hands on my super tight traps he would have automatically, based on my history of no accidents, concluded or at least suggested that it might be stress.

    I can't put my name down, though I would like to, but I had to soldier on through work and life in a near panic state, depressed and in pain for years, and had to keep it a secret, otherwise I would have lost everything.

    It is good to be skeptical.

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  2. That's all very well - but what about hip replacements, I've avoid the operation because orthopaedic surgeons have about as much empathy as asphalt, so I hobble around in pain it's not great to have a fear of the medical profession.

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    1. Thanks. For the right patients, usually those with severe hip disease (like osteoarthritis) total hip replacement is a very effective operation. Like some of the treatments mentioned above, I think that doctors probably hold our longer before they have a hip or knee replacement than they recommend for their patients, but they still have them.
      Don't fear doctors, just go in their armed with a little skepticism and ask the right questions. Don't miss out on an effective treatment.

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  3. Wow, Anonymous, well done for finding your way through the maze. I've been managing a "sensitive" back for more than 30 years. Successfully! I am 66, and ride my horse every day.
    There is certainly a lot of nonsense out there... And some good, evidence-based stuff too.
    Pythinia, partly because of my scepticism, i held out against having a hip replacement. Possibly created some very unhelpful neuromuscular patterns while i was compensating. Almost exactly 4 years ago i had the op. It's been a wonderful success. Given me an amazing, joyful new lease of life!

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  4. And, ha, Doctor Skeptic, i had tennis elbow, too, a year or so ago. I was vaguely aware it might have been a self-limiting problem, and i was too busy riding my horse to seek advice about it. It went away in a couple of months!

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  5. "We think that patients expect treatment, so why not just give them everything?"

    Indeed. Including things they never asked for and know nothing about like surreptitious PSA screening (just take the blood sample when one is already being taken for cholesterol testing). Pretty shameful behaviour by a lot of doctors.

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  6. I had a good GP in North Carolina give me a simple treatment for "tennis elbow". Hold your arm out straight (knuckle up). Turn your hand over(palm up), close your fist, and bring your fist up to your shoulder. Repeat several times in a row, several times a day. This really helps immediately, and within a few days, the elbow is no longer getting sore.

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  7. http://cepr.net/documents/working-paper-upward-distribution-income-rents.pdf

    Economic rents may help explain why ineffective procedures are still done.

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  8. http://www.afr.com/leadership/careers/australias-top-50-highest-paying-jobs-20161204-gt3uzx

    Neurosurgery and orthopedic reimbursement is so high it is like heroin- surgeons simply can't help themselves

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  9. Doctors are full of crap. Plain and simple.

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