The 'otherness' of research in clinical practice

“Researchers don’t know what it’s like to deal with patients”. Research is meaningless to me – I know what works”. “Most research is rubbish.” I am concerned by comments about research that suggest it is something that can be separated from clinical practice – something that can be ignored when providing good clinical practice. I know several colleagues who just ‘don’t bother’ with research. This ‘otherness’ of research is a fallacy. It would not be so easy to distance oneself from research if we simply called it what it is: science.

Saying "no" to medical cannabis

A state politician just defected to another party because that party agreed to support his stance on medical marijuana (cannabis). The politician stated that it was a moral decision because he wanted to save kids’ lives. Even if he was supporting it for other reasons, medical cannabis falls way short on effectiveness of just about anything, and it certainly doesn’t save kids’ lives. There is a real need for politicians to be more scientific in their information gathering and appraisal. This will make it less likely for them to make untrue statements, and bad decisions based on those statements. Let’s look at the evidence for the true effectiveness of medical cannabis.

Vitamin supplements: too much of a good thing?

Vitamins are vital amines, needed for everyday chemical reactions in our bodies. Deficiencies can be harmful, but that doesn’t mean that taking more than you need is beneficial. In fact, it can be very harmful yet the message that more is better prevails. Does vitamin supplementation help those who are not deficient?

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.

2 ½ litres of water per day - really?

Many people I know drink water constantly – they are always taking a swig out of a water bottle that never leaves their side. After having renal stones recently, I tend to try to drink more, but just don’t like drinking water, and I find that I am not thirsty most of the time anyway. Who’s right – those who tell me to drink water constantly, or my body, which rarely makes me feel thirsty?

Treatment for pre-term rupture of membranes in pregnancy

Another large international trial is published, and another standard practice based on little more than our bias towards doing something rather than doing nothing is reversed.

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.

Prophylactic mastectomy

Prophylactic mastectomy reduces the risk of getting breast cancer (here), but does it reduce your overall risk of dying? And what are the other risks?

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.

Fixing a hole

Migraine is common, affecting millions of people worldwide. A patent foramen ovale (PFO – a ‘hole in the heart’ that lets blood cross from the right heart to the left) is common as well, present in about 30% of people. When cardiologists started surgically closing PFOs, they noticed that many patients with migraine got better. As with the discovery of any association in medicine, theories of a causal link soon followed, and doctors started treating migraine by closing the hole in the heart; before properly testing it, of course.

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.

My right foot: predicament versus illness

My right foot hurts. It hurts in the middle, underneath, but not all the time, and only when I walk or take any weight on it, especially when I get up in the morning, when it becomes difficult to walk. It has been hurting on and off since I did an 80km trek three months ago. It could be a stress fracture, or some kind of fasciitis, soft tissue tear, fatigue, injury or degeneration, but I don't really care, because I am not going to have any tests or see any health care practitioners to get their version of a diagnosis. I'm just going to leave it alone. I am going to be a person with a predicament that I can cope with, and not a patient with an illness.

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?

Predatory publishing: when scientific quality gets in the way of a good business model

Science progresses because it is open to scrutiny. For findings to be accepted, they must pass peer-review and must be presented to other scientists for them to question, refute, or confirm. Publication in a scientific journal (and presentation at conferences) is key to this process. However, the number of journals and conferences have increased massively over the last 10 -20 years, and many of them are not the real thing – so called ‘predatory’ publishing and predatory conferences have sprung up everywhere. The problem with this is that there is no clear line between what is real and what is fake.

Lessons from history #13: Hormone replacement therapy

Hormone replacement therapy (HRT) for post-menopausal women was thought to decrease the chance of cardiovascular problems like heart attack and stroke. This ‘made sense’ because the risk of cardiovascular disease in women rose sharply after menopause, indicating that female hormones had a protective effect. Many large observational studies supported this belief, and HRT was widely prescribed in the 1980s and 1990s. Later evidence from large, placebo controlled, randomised trials failed to show any cardiovascular benefit. Again, observational evidence was shown to overestimate the effectiveness of a common medical treatment and again, practice became established before the definitive trials were done.

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.