Book review: Hippocrasy: how doctors are betraying their oath

Always hard reviewing your own book, so I have pasted comments from others below. The book expands on previous themes in my first book: Surgery, the Ultimate Placebo but applies them to medicine in general. It explains the problems with modern medicine but instead of blaming everyone else (industry, Big Pharma, insurers etc.) we focus on doctors and their role in creating a society that is over-dependent on an expensive medical system that often either doesn't help or harms those it touches.

Stimulating spines - the placebo trials

Addit: Two placebo studies using spinal cord stimulation (SCS) were brought to my attention by an attendee at a neuromodulation conference I was speaking at a few days ago. None of the proponents of SCS included these papers in their talks and the spine study was not included in the systematic review I refer to in my previous blog. And read on, I found a third placebo study.

Stimulating spines

Spinal cord stimulators are small battery-powered devices that are implanted in the back and electrically stimulate the spinal cord to relieve chronic pain, often from failed spine surgery. These days they can be controlled remotely and can even do your step count. They are widely used and are very expensive. But we don’t know if they work or not – good evidence hasn’t been produced, and this problem doesn’t look like being corrected anytime soon. Why should it, when everybody is paying for the treatment now?

Prius non tempore: first, do no time

The golden rule of surgery is: Primum non nocere - ‘First, do no harm’. There is another, competing rule that comes from practicing defensive medicine: Prius non tempore - 'first, do no time'.

Surgical consent: permission or a decision?

So much emphasis is placed on the consent form; we are lectured about it’s importance from our first days as an intern. Like no other form, it is constantly being modified in order to make the form better reflect the role it is meant to play. But what is that role? Is the consent form simply a permission slip, designed to minimise the risk of surgeons being sued if complications occur? Or is it a statement by the patient that they have considered all the options and have come to a decision to have this treatment over all other options, despite the risks? Looking at the form, it is a bit of both, and it probably performs the latter function very poorly.

SLAP in the face for shoulder surgery

I have always been sceptical of some shoulder procedures, and the increasing rate of shoulder surgery and the lack of high quality evidence worries me. I started a simple blog post about one particular operation (for “SLAP” lesions) and found a tale of research waste, bad science, overdiagnosis and overtreatment.

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?

Yes, you DO have to ‘live with it’, and that can be a good thing

A common ending to a consultation where I have explained to a patient that there is nothing that surgery/medicine can reliably or safely offer them for their symptoms (back pain, joint pain, limited joint movement etc.) is “So I just have to live with it do I?” A difficult question to answer but also a question that tells us a lot about the person asking it.

The wisdom of wisdom tooth extraction

I have 4 kids, 3 of whom had their wisdom teeth removed on reaching adulthood on the advice of specialists. I had mine removed in my 30s for some reason and so did my wife. In the US and much of the world this is a billion dollar per year business, with millions of molars extracted every year in the US alone. With those numbers, even a small complication rate can add up to a lot of complications, and as a surgical procedure there are also significant costs. Yet it has been argued that the reasoning behind most of the extractions are flawed and that the procedure is often unnecessary.

Book review, of my book: Surgery, the ultimate placebo.

This will be a test of how unbiased I am. Writing a review of my own book (regardless of any bias) seems like shameless self-promotion, but what the hell, it's better than just saying "Hey, I wrote a book".

Knee arthroscopy for "mechanical symptoms"

I have previously written about the (non) role of arthroscopy for osteoarthritis or degenerative meniscus tears in the knee (here, here and here). Surgeons have continued to operate, based on a belief that (now) centres on the presence of mechanical symptoms. An analysis of the recent sham surgery trial of arthroscopic partial meniscectomy (APM), which showed APM to be no better than sham for patients with meniscus tears without arthritis, has shown that this procedure is no better than sham surgery for patients with mechanical symptoms.

Laparoscopy for bowel adhesions

Laparoscopy is keyhole surgery of the abdomen in which a camera and instruments are inserted through holes in the skin, into the abdomen to see the structures within (diagnostic laparoscopy) and to correct pathology where possible (therapeutic laparoscopy). In patients that have had previous pathology or surgery to the abdomen, adhesions can develop whereby loops of bowel can get caught up in scar tissue. If this causes an obstruction of the bowel, it can be very serious, but often people just have abdominal pain that coexists with adhesions.

Sham physical therapy

Paradoxically, it is easier to perform a sham trial in surgery, the most invasive physical act, than in physiotherapy because the patient is asleep when it is delivered. Physical therapy involves physical acts that are hard to imitate as placebo treatment, but the influence of the patient-therapist interaction makes it important to tease out any placebo effect. Researchers have, however, performed sham trials in physiotherapy.

Placebo trials of surgery

In a recent systematic review of placebo trials of surgery (here) it was found that in half of the 53 trials found, surgery was not better than placebo treatment. And in the ones where it was better, the difference wasn’t great. This may not be big news to my readers, but this review was important because it highlighted many of the problems with surgery, namely that:
1) placebo studies are needed to determine the true effectiveness of surgical procedures, but …
2) surgery and associated devices are regulated less strictly than drugs, consequently …
3) surgery is often not subjected to placebo / sham studies, even though …
4) such studies are ethical and practical.

Do shoulder fractures need surgery?

Fractures that occur at the upper end of the humerus near the shoulder (called humeral neck fractures) are common. They are often treated with surgery despite a lack of supporting evidence for this, particularly in older, osteoporotic patients. Now, thanks to a recent study from the UK, it is possible that most of these fractures don’t need surgery, even in young patients. This is big news, but will this research jump the gap from research into practice and influence the decision making of the end users – the patient and their surgeon?

Surgery for high blood pressure

The most recent casualty of the sham surgery trial, adding to the list of operations that looked good and had good results until put to the leased biased test, is a procedure called renal denervation (cutting the nerves to the kidney). Years of good results showing that this procedure lowered blood pressure are now met with a blinded sham-controlled trial that showed no significant benefit over placebo.

Lessons from history #12: Lobotomy

In the 1940s and 50s (tapering into the 70s and 80s) tens of thousands of prefrontal lobotomies (severing the front part of the brain) were performed in Europe and North America for many types of mental conditions. It was done because doctors at that time believed that it worked, and they didn’t have many effective alternatives. However, it didn’t work, it made people worse and it even killed a few, despite a Nobel prize being awarded to one of the developers of the procedure.

Lessons from history #11: Extra- to Intra-cranial Bypass Surgery

This story is about a procedure that made sense and had supporting evidence, became common practice, but was later discontinued because a high quality study showed it to be ineffective. The story of extra-cranial intra-cranial bypass surgery ticks all the boxes: overestimation of benefit, seduction by the theory, unrecognised bias in studies, and just plain ineffectiveness despite our best effort and beliefs.

Surgery for shoulder impingement

When you raise your arm, the top of your humerus, where the rotator cuff tendons attach, “impinge” against your acromion. When this hurts, it is called impingement syndrome. “Decompressing” the joint by taking some bone off the acromion (an "acromioplasty”) makes sense, and seems to work well. The operation has been around for a long time, and there have been many studies looking at different ways of doing this operation, but very few studies looking at whether or not it works better than not operating. Interestingly, all of the studies that have been done conclude that this operation adds nothing.

The Hope Peddlers

When treatment choices are limited or when true effectiveness is not clear, patients want hope: they want to have a chance to get better. Doctors hold this valuable commodity, and dispense it on demand, for a fee, after which they claim any perceived improvement as being due to their efforts. Even when a treatment is not proven to be effective, or when it is proven to be no better than placebo, doctors too easily fall into the role of hope-peddler, without considering the hidden costs or unintended consequences.