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.
Doctor Skeptic
Tuesday, 22 February 2022
Tuesday, 26 June 2018
Placebo pacemakers
Once inserted, heart pacemakers can be turned off and on
remotely. This makes them well suited for a placebo study, and that’s what
these researchers did in the late 1990’s, with surprising results. It is a
shame that no one else has done it since.
Sunday, 15 April 2018
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.
Friday, 13 April 2018
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?
Sunday, 20 August 2017
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'.
Saturday, 19 August 2017
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.
Sunday, 21 May 2017
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.
Wednesday, 17 May 2017
Steroid injections in the knee
Corticosteroid injections
in the knee are VERY commonly performed for any knee pain, but particularly for
osteoarthritis. They don’t provide significant benefit to people, and they
cause harm.
Monday, 8 May 2017
Overcoming cognitive biases
A recent paper in the Medical
Journal of Australia (here) provides a nice overview of the biases that lead doctors to
overtreat and overinvestigate, but also offers useful solutions that we need to
act on.
Saturday, 15 April 2017
Treating the numbers, not the patient
This story is a good
example that goes along with a previous post about treating (and correcting) surrogate
factors (like X-rays and blood tests) instead of treating patient health (see:
The map is not the territory). In this case, hypothyroidism (low thyroid
hormone levels) in older people comes under the spotlight. If patient don’t
have any symptoms, it is still often treated in order to correct the ‘disease’
state. But as researchers found in this randomised trial, replacing their thyroid hormone
(compared to placebo) definitely improved the thyroid hormone levels in the
blood, but it did nothing to any other outcome measured. It didn’t help the people
being treated.
This is a classic
example of overdiagnosis – discovering an abnormality in some people (a low thyroid
hormone level is common in older people) and labeling it a disease. Doing so
then leads to overtreatment aimed at addressing the ‘abnormality’ rather than
aimed at improving the health of the patient. This last part is the trick of
overtreatment – correcting things in our body is surely good for us, right? No, not always. It needs to be shown that it is
– not assumed. And any benefit shown needs to outweigh any unintended
consequences and direct harms from the treatment.
The other problem I
have with the problem of overdiagnosis and overtreatment is that the research
that shows them wrong comes so many years after the practice has become
entrenched (like in this case), making it much harder to undo common practice
than if the research was done before
the treatment was introduced.
Wednesday, 22 March 2017
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.
Thursday, 2 March 2017
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.
Monday, 23 January 2017
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?
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?
Sunday, 2 October 2016
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.
Saturday, 10 September 2016
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.
Saturday, 9 July 2016
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?
Saturday, 18 June 2016
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.
Saturday, 12 March 2016
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".
Saturday, 13 February 2016
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.
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