tag:blogger.com,1999:blog-61930436953567128432024-03-16T18:08:41.564+11:00Doctor SkepticDr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.comBlogger142125tag:blogger.com,1999:blog-6193043695356712843.post-41910821776179854702022-02-22T10:59:00.000+11:002022-02-22T10:59:11.325+11:00 Book review: Hippocrasy: how doctors are betraying their oath<p>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.<span></span></p><a href="https://doctorskeptic.blogspot.com/2022/02/book-review-hippocrasy-how-doctors-are.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com0tag:blogger.com,1999:blog-6193043695356712843.post-63766544510760605972018-06-26T16:01:00.001+10:002018-06-26T16:01:12.795+10:00Placebo pacemakers<div dir="ltr" style="text-align: left;" trbidi="on">
<br>
<div style="margin: 0px 0px 10.66px;">
<span style="font-family: Calibri;">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.</span></div>
</div><a href="https://doctorskeptic.blogspot.com/2018/06/placebo-pacemakers.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com0tag:blogger.com,1999:blog-6193043695356712843.post-83726286256219918282018-04-15T00:13:00.003+10:002018-04-15T00:13:59.579+10:00Stimulating spines - the placebo trials<div dir="ltr" style="text-align: left;" trbidi="on">
<br>
<div style="margin: 0px 0px 10.66px;">
<span style="font-family: calibri;">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 <a href="https://doctorskeptic.blogspot.jp/2018/04/stimulating-spines.html"><span style="color: #0563c1;">previous
blog</span></a>. And read on, I found a third placebo study.</span></div>
</div><a href="https://doctorskeptic.blogspot.com/2018/04/stimulating-spines-placebo-trials.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com1tag:blogger.com,1999:blog-6193043695356712843.post-75011628646172502572018-04-13T11:21:00.002+10:002018-04-15T00:14:50.254+10:00Stimulating spines<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: left;">
</div>
<div style="margin: 0px 0px 10.66px; text-align: left;">
<span style="font-family: "calibri";">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?</span></div>
</div><a href="https://doctorskeptic.blogspot.com/2018/04/stimulating-spines.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com0tag:blogger.com,1999:blog-6193043695356712843.post-65057565766194775532017-08-20T07:07:00.000+10:002017-08-20T07:08:19.715+10:00Prius non tempore: first, do no time<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="margin: 0px 0px 11px;">
<span style="font-family: "calibri";">The golden rule of surgery is: <i>Primum non nocere -</i> ‘First, do no harm’. There is another, competing rule that comes from practicing defensive medicine: <i>Prius non tempore - </i>'first, do no time'. </span><br>
</div></div><a href="https://doctorskeptic.blogspot.com/2017/08/prius-non-tempore-first-do-no-time.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com0tag:blogger.com,1999:blog-6193043695356712843.post-20409165731420223252017-08-19T22:14:00.002+10:002017-08-19T22:14:28.687+10:00Surgical consent: permission or a decision?<div dir="ltr" style="text-align: left;" trbidi="on">
<br>
<div style="margin: 0px 0px 11px;">
<span style="font-family: Calibri;">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.</span></div>
</div><a href="https://doctorskeptic.blogspot.com/2017/08/surgical-consent-permission-or-decision.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com7tag:blogger.com,1999:blog-6193043695356712843.post-44874510138568169422017-05-21T15:05:00.003+10:002017-05-25T21:10:45.979+10:00SLAP in the face for shoulder surgery<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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.</div>
</div><a href="https://doctorskeptic.blogspot.com/2017/05/slap-in-face-for-shoulder-surgery.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com11tag:blogger.com,1999:blog-6193043695356712843.post-23910842241072988652017-05-17T20:08:00.003+10:002017-05-17T20:08:59.777+10:00Steroid injections in the knee<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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.</div>
</div><a href="https://doctorskeptic.blogspot.com/2017/05/steroid-injections-in-knee.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com3tag:blogger.com,1999:blog-6193043695356712843.post-75010095220127261802017-05-08T12:27:00.002+10:002017-05-08T12:27:33.274+10:00Overcoming cognitive biases<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
A recent paper in the Medical
Journal of Australia (<a href="https://www.mja.com.au/journal/2017/206/9/countering-cognitive-biases-minimising-low-value-care">here</a>) 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.</div>
</div><a href="https://doctorskeptic.blogspot.com/2017/05/overcoming-cognitive-biases.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com0tag:blogger.com,1999:blog-6193043695356712843.post-29218209452757097532017-04-15T19:52:00.002+10:002017-04-15T19:52:55.320+10:00Treating the numbers, not the patient<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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:
<a href="http://doctorskeptic.blogspot.com.au/2013/11/the-map-is-not-territory.html">The map is not the territory</a>). 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 <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1603825#t=article">this randomised trial</a>, 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.<br /><o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.</div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
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 <i>before</i>
the treatment was introduced.<o:p></o:p></div>
</div>
Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com0tag:blogger.com,1999:blog-6193043695356712843.post-77169555033894504402017-03-22T21:51:00.004+11:002017-03-22T21:51:32.304+11:00The 'otherness' of research in clinical practice<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
“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.</div>
</div><a href="https://doctorskeptic.blogspot.com/2017/03/the-otherness-of-research-in-clinical.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com2tag:blogger.com,1999:blog-6193043695356712843.post-76012998724481566662017-03-02T21:40:00.001+11:002017-03-02T21:40:11.217+11:00Saying "no" to medical cannabis<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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.</div>
</div><a href="https://doctorskeptic.blogspot.com/2017/03/saying-no-to-medical-cannabis.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com5tag:blogger.com,1999:blog-6193043695356712843.post-91809633630970986552017-01-23T21:37:00.002+11:002017-01-23T21:37:38.668+11:00Vitamin supplements: too much of a good thing?<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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?</div>
</div><a href="https://doctorskeptic.blogspot.com/2017/01/vitamin-supplements-too-much-of-good.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com1tag:blogger.com,1999:blog-6193043695356712843.post-47158412827030411742017-01-14T19:56:00.003+11:002017-01-14T19:57:30.051+11:00Don’t treat me, I’m a doctor<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
“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?<br>
</div></div><a href="https://doctorskeptic.blogspot.com/2017/01/dont-treat-me-im-doctor.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com10tag:blogger.com,1999:blog-6193043695356712843.post-67715195611960496322016-10-02T16:31:00.002+11:002016-10-02T16:31:33.420+11:00Yes, you DO have to ‘live with it’, and that can be a good thing<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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.</div>
</div><a href="https://doctorskeptic.blogspot.com/2016/10/yes-you-do-have-to-live-with-it-and.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com7tag:blogger.com,1999:blog-6193043695356712843.post-79432341679443422042016-09-10T14:13:00.002+10:002016-09-10T14:13:47.050+10:00The wisdom of wisdom tooth extraction<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
I have<span lang="EN-US"> 4 </span>kids<span lang="EN-US">, 3 </span>of whom
had their wisdom teeth removed on reaching<span lang="EN-US"> adulthood </span>on the advice
of specialists<span lang="EN-US">. </span>I had mine removed in my<span lang="EN-US"> 30s </span>for some reason and so did
my wife<span lang="EN-US">. </span>In the US and
much of the world this is a billion
dollar per year business<span lang="EN-US">, 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.</span></div>
</div><a href="https://doctorskeptic.blogspot.com/2016/09/the-wisdom-of-wisdom-tooth-extraction.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com2tag:blogger.com,1999:blog-6193043695356712843.post-88248719746815907332016-07-09T10:15:00.001+10:002016-07-09T10:17:38.038+10:002 ½ litres of water per day - really?<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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?</div>
<div class="MsoNormal">
</div>
</div><a href="https://doctorskeptic.blogspot.com/2016/07/2-litres-of-water-per-day-really.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com5tag:blogger.com,1999:blog-6193043695356712843.post-60395243039886058362016-06-18T22:18:00.003+10:002016-06-18T22:18:25.540+10:00Treatment for pre-term rupture of membranes in pregnancy<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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.</div>
</div><a href="https://doctorskeptic.blogspot.com/2016/06/treatment-for-pre-term-rupture-of.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com0tag:blogger.com,1999:blog-6193043695356712843.post-14062325314067103202016-03-12T21:18:00.001+11:002016-03-12T21:18:34.062+11:00Book review, of my book: Surgery, the ultimate placebo.<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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".<o:p></o:p></div>
<div class="MsoNormal">
</div>
</div><a href="https://doctorskeptic.blogspot.com/2016/03/book-review-of-my-book-surgery-ultimate.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com10tag:blogger.com,1999:blog-6193043695356712843.post-48259239321624643042016-02-13T20:45:00.001+11:002016-02-13T20:45:17.131+11:00Knee arthroscopy for "mechanical symptoms"<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
<span lang="EN-US">I have previously written about the (non)
role of arthroscopy for osteoarthritis or degenerative meniscus tears in the
knee (<a href="http://doctorskeptic.blogspot.com.au/2012/06/knee-arthroscopy-in-arthritis-evidence.html">here</a>,
<a href="http://doctorskeptic.blogspot.com.au/2014/01/knee-arthroscopy-for-torn-meniscus.html">here</a>
and <a href="http://doctorskeptic.blogspot.com.au/2012/08/placebo-surgery-4-knee-arthroscopy-in.html">here</a>).
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.</span></div>
</div><a href="https://doctorskeptic.blogspot.com/2016/02/knee-arthroscopy-for-mechanical-symptoms.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com7tag:blogger.com,1999:blog-6193043695356712843.post-24390301248364113132015-11-02T22:49:00.000+11:002015-11-02T22:49:34.450+11:00Laparoscopy for bowel adhesions<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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 (<i>diagnostic</i>
laparoscopy) and to correct pathology where possible (<i>therapeutic</i> 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.</div>
</div><a href="https://doctorskeptic.blogspot.com/2015/11/laparoscopy-for-bowel-adhesions.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com3tag:blogger.com,1999:blog-6193043695356712843.post-46111399083074243782015-10-04T12:48:00.002+11:002015-10-04T12:48:15.124+11:00Prophylactic mastectomy<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
Prophylactic mastectomy reduces the risk of getting breast
cancer (<a href="http://academicdepartments.musc.edu/surgery/education/resident_info/journal_club/08-09/january09.3.pdf">here</a>),
but does it reduce your overall risk of dying? And what are the other risks?</div>
</div><a href="https://doctorskeptic.blogspot.com/2015/10/prophylactic-mastectomy.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com0tag:blogger.com,1999:blog-6193043695356712843.post-65492264661227821992015-08-23T09:47:00.000+10:002015-08-23T09:47:15.422+10:00Sham physical therapy<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">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.</span></div>
</div><a href="https://doctorskeptic.blogspot.com/2015/08/sham-physical-therapy.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com5tag:blogger.com,1999:blog-6193043695356712843.post-68650383117671776132015-08-15T11:12:00.002+10:002015-08-15T11:12:32.570+10:00Fixing a hole<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
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.</div>
</div><a href="https://doctorskeptic.blogspot.com/2015/08/fixing-hole.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com2tag:blogger.com,1999:blog-6193043695356712843.post-67307452444742228712015-05-19T22:58:00.004+10:002015-05-19T22:58:47.559+10:00Placebo trials of surgery<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
<span style="font-family: inherit;">In a recent systematic review of placebo trials of surgery (<a href="http://www.bmj.com/content/348/bmj.g3253">here</a>) 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: <br>
1) placebo studies are needed to determine the true effectiveness of surgical
procedures, but … <br>
2) surgery and associated devices are regulated less strictly than drugs, consequently
…<br>
3) surgery is often not subjected to placebo / sham studies, even though …<br>
4) such studies are ethical and practical.</span></div>
</div><a href="https://doctorskeptic.blogspot.com/2015/05/placebo-trials-of-surgery.html#more">Click to read more »</a>Dr Skeptichttp://www.blogger.com/profile/09376469049519802493noreply@blogger.com6