Personally, I prefer to take my placebos in sugar pill form.
Can you imagine being the surgeon? "Ok, we gotta make this scar look nice and realistic. Really get that cut going."
I know people who've done it. It's not uncommon.
So sham surgeries are a common practice in medical experiments?
Yes. Medical experiments and, I suppose, insurance fraud.
Crazy. So patients sign disclosures that they may be put under anaesthesia and scarred for nothing? Is this the biggest thing we ever ask of a control group, or are there even bigger traumas?
The control group in the parachute RCT was very put upon.
You have to figure that not having to do the surgery for real improves the odds of coming out of it with minimal scarring -- like, a fake incision doesn't have to do more than break the skin to be convincing. Although I guess I don't really know.
Well, depending on how common the first situation is, the problem could be that stents work to solve the primary issue but there are negative side effects such as a requirement for anticoagulants so that the overall survival effect is negative. In that case doctors are being shortsighted but not completely wrong when they say a stent solves the problems they see, they just aren't thinking about long term survival which of course isn't the surgeon's problem once his part is done. There are efforts to mitigate the side effects, e.g. more rapidly reversible anticoagulants, which might then make the pro-stent numbers more favorable again. It's all so complicated, how can you expect such minimally educated people to understand all the information! Which brings me back to my main point whenever discussing how doctors aren't superhuman, remember that just about every doctor was once a pre-med student.
Go to the doctors with fraudulent credentials?
Ugh. Last fall they had to wait a couple months to biopsy my dad's bile duct for this very reason--he'd had a cardiac stent implanted a few months before the bile duct blockage was discovered, had to finish the course of blood thinners and then wait a couple more weeks beyond that. In his case, though, there's no reason to think that the delay mattered, treatment likely wouldn't have made sense anyway. In fact we discussed the comparative risks of suspending the blood thinners to do the biopsy sooner, and there was no real upside. If anything, it spared him a couple months of staring death in the face I guess.
I think the stents started my dad's current decline. But then the ones five years ago seem to have given him five years extra good times.
Find a doctor who cared about learning chemistry or statistics or whatever as an undergrad and didn't just see those classes as hurdles where they needed good grades.
Doctors who know statistics are a threat to my business model.
Probably there aren't enough of them to have a noticeable effect on your business.
The level of unnecessary medical interventions and prescriptions is kind of insane. As of the last time I checked, the benefit of surgical intervention for back pain (for things like slipped discs) is essentially indistinguishable from placebo. But there's a whole lot of fusions happening out there.
Speculating ex recto, but I know that you can align physician specialties with particular psych profiles fairly easily--the stereotype in the world of folks who market to physicians is that surgeons just like to cut--they feel they can just get in there and solve the problem. The sorting hat of med school seems to lead people with particular problem-solving approaches into certain specialties.
So on top of slow dissemination of new information (continuing education is required, but can't cover the pace of change in best practices/scientific evidence), you have folks who are by personality inclined to intervene rather than engage in "watchful waiting" and incented by current malpractice law to intervene even when best practice doesn't dictate said intervention...well, you get a mess.
20- that's not exactly right, at least if we're talking about the same thing. My understanding (pre-surgery, for a slipped disc) was that the 5-year-out rate of needing intervention would be the same, whether or not I had the surgery. The amount of pain I'd be in during the intervening 5 years was going to be different, though.
(Which is what happened. I was completely pain free for about a year and a half, then fell again and re-injured myself, and am now back on a decline but nowhere (yet) near the amount of pain pre-surgery. I'll do it again in a heartbeat when it gets bad enough. 2 months of recovery is absolutely worth 2-3 years of walking.)
I didn't have a fusion, though. Discectomy.
I agree with 20.2 and 20.3 though.
It's really easy to get an article published that says a certain type of surgery is probably less effective than doing nothing. The trick is to send it to a journal that no surgeon reads.
21--it was a hazy recollection, but I do think it was specifically fusions. I don't have access to any of the good medical databases right now or I'd do some research. Obviously, some things help a lot--new joints are a godsend for one. I'm glad your procedure helped and hope you find relief from your current pain soon.
The sham surgery is not hard to do. The real trick is the placebo fall to prove falling over is bad for you.
I think nobody is using it now, but there's a machine for knocking people over near my office. They used to do studies where they would see how hard it was to knock over the elderly.
I assume they were training to be purse snatchers.
I've heard bad things about fusion, too, but not anything sciency. Just angry anecdotes.
You can also trip old people with just a rope tried to a fence post outside Golden Corral.
Is everybody else drinking and ordering camping equipment from the internet?
Glacier National Park? Are there direct flights?
Looks like this thread is wandering around in the weeds but regarding the OP: remember when we were informed that flossing did not improve oral health? Or when coffee was bad for you but then it was good. Same with wine. How about butter vs margarine? Sugar vs fat? I think I've read about studies that show that exercise is bad for you. This is one study. The reporting looks suspect to me because it compares stable angina patients with people who received stents. What about the not stable patients who did not receive stents? They probably got heart attacks. How do you determine if someone is stable? Would the criterion be that they didn't get a heart attack? And how about quality of life? Who wants to have angina every time they ascend the stairs or have sex?
33: La Ronge, Saskatchewan seems to be the closest airport to the midpoint on a great circle route. There are not direct flights.
Chopper@20:
I've had 3 spinal surgeries for injuries I received when I was younger. I guarantee you that I would not be alive now without each and every one of them. I don't think that I could have lived with the level of pain that I suffered from 3 pinched nerves. Unless you've been there, you really have no idea what it's like to live with spinal nerve pain. I highly recommend spinal surgery for everyone who is in the situation I was in. 8 years out from the last one I am as pain free as anyone my age could expect and am able to live a completely normal life.
drinking and ordering camping equipment from the internet?
Earlier today, I read an article about ice-fishing in Adirondack Life magazine. Does that count? (haven't yet ordered any equipment, I must admit).
On the subject of maybe-not-so-evidence-based medicine, am I being too sceptical here? too "neoliberal" in my deference to conventional medicine and its authorities?
We recently finished a home remodeling project (gut reno of our kitchen; along with addition of new family room, mudroom, half-bathroom, and basement rec room), for which we used a design-build firm. Completely happy with the results; and I also appreciate some of the quirky characters who work for this design-build company. E.g., Ken, the hippie carpenter, who recommended Bach's flower remedies for my dog, and who lent me a book on First Nations rights in Canada.
Long story short: the guy who designed our remodel is currently (and has been for the past two years) battling an aggressive form of bladder cancer. About three weeks ago, he and his wife put out a plea for funds through a "compassionate crowdfunding" site. Outstanding medical bills, and the possibilities of new treatments, and so on and so forth. I made a small contribution, which is why I now get almost-daily updates.
And now he and his wife and son are in Mexico, where he is receiving "alternative" treatments, which will apparently allow him to beat this thing, when conventional, USian medicine says treatment options are limited, and there's basically not much hope.
So Ken the hippie carpenter dropped by yesterday to install a fixture, and he assured me that this clinic in Mexico has a "70 percent success rate." And I'm thinking: a clinic in Mexico, very near the US border, has a cure for cancer that nobody else knows about?! about which the experts at the Mayo Clinic remain ignorant?! It all sounds a bit scammy to me, a bit 'let's take advantage of desperate Americans with some money,' or something like that.
Anyway, maybe I'm wrong, and too sceptical and too "neoliberal." But it's making me feel sad.
34: Did you read the link? It uses stents as an example, but it's talking about a more general issue that would still be there even if the stent conclusions (which are not just based on the one study mentioned in the OP excerpt but on a meta-analysis of all studies comparing stents to less invasive treatments) turn out to be wrong.
Anyway, I've been reading The Lives of a Cell by Lewis Thomas lately, and in one of the essays in it he sets up a classification of medical technologies that's very relevant to the present discussion:
1. "Nontechnology," which is essentially palliative care for diseases for which we don't have enough of an understanding to have any effective treatments. This consists primarily of the time spent by medical professionals in looking after patients, and it is therefore very expensive. Care for terminal cancer and other end-of-life problems falls in this category.
2. "Halfway technology," which includes treatments with varying degrees of effectiveness for the symptoms of diseases for which we have limited but incomplete knowledge. This means highly elaborate hospital equipment, specialized medications, etc., and many of the other things we typically think of as "medical technology." It is extremely expensive. Much care for cancer and heart disease falls in this category.
3. Technology to address diseases which we can prevent or decisively cure immediately because we have a full understanding of their causes. This is generally inexpensive, simple, and easy to deliver. Vaccines and antibiotics are the classic examples.
The types of diseases and treatments discussed in the OP and link seem to fall in the second category, which is why they are subject to debates and arguments over relative effectiveness, and also why they play such a prominent role in discussions of the cost of health care.
Maybe this categorization is old hat to people better-informed about medicine than me, and either widely accepted or debunked. (The book was published in 1974.) But I found it helpful in making sense of the strengths and weaknesses of medical practice and research, and reading it reminded me of the OP link, which I read when it was first published a couple weeks ago.
38: What about quality of life? Have you ever had angina?
Guess I can't justify my other points any further without reading the studies and addressing them point by point but I can share my own experience, which is that I would certainly have had a heart attack and either be dead or had bypass surgery without a stent. Maybe I'm the only guy in history who had an obviously beneficial outcome from a stent but I doubt it.
40: Have you ever read the link in the OP? It's not the usual "turns out X isn't good for you after all!" kind of science journalism, and yes, it does acknowledge that stents can be beneficial for relieving angina in some patients. That's not the point.
The knee surgery example is a better illustration of the point than the stent one, anyway.
I read the article before it was linked here and may be getting things confused, but I was surprised there was no differentiation between drug-eluting and bare-metal stents, when the relative benefits used to be huge marketing drivers and explanations for the R&D being done. They definitely don't seem trendy for pharma companies the way they were 10-15 years ago, but I only notice superficial stuff like that.
I don't think that stents before a heart attack are a thing in KnifeCrimea, but certainly got stented after (or during, I suppose) my little heart attack, and it made a lot of sense then.
A "cardiac stint" is another name for your pulse.
This is something I wrestle with about the Kaiser model. Friends complain about how bureaucratic it feels there, like it's treating them like a cog in the machine. I get that, and at the same time I suspect that could checklist-based treatment could actually work out more beneficial overall than warm, personal doctor's care.
So Ken the hippie carpenter dropped by yesterday to install a fixture, and he assured me that this clinic in Mexico has a "70 percent success rate." And I'm thinking: a clinic in Mexico, very near the US border, has a cure for cancer that nobody else knows about?! about which the experts at the Mayo Clinic remain ignorant?! It all sounds a bit scammy to me, a bit 'let's take advantage of desperate Americans with some money,' or something like that.
This is sort of the opposite - my xfit trainer was telling me that his super-fancy Austin clients fly down to South America to get stem cell treatments to heal their slipped discs and such. I had no idea that sort of thing existed and had established wealthy clientele. He claimed the stem cell treatment cured these back problems.
Or maybe it's the same. Except it sounded plausible to me.
36: I've live with chronic lower back pain from a pinched nerve for a decade now (don't ignore your back when landscaping and just push through, kids!). So I do have some idea of what spinal nerve pain is like. It's most definitely not as bad as many chronic pain sufferers deal with, but it's a real quality of life issue for me.
I've tried most non-surgical interventions (off the top of my head: massage, heat/cold, anti-inflammatories, muscle relaxants, opioids, chiropracty, traction, probably others). The only thing that consistently provides results are core-strengthening exercises. Of those, powerlifting (deadlift, squat, etc.) have been the best for pain relief.
Anyway, I'm not a doctor and if your surgeries have worked for you, I am very glad to hear it. I am in no way saying that surgeries don't work some of the time, and each individual technique needs to be evaluated on its own merits. I don't claim any particular medical expertise beyond what 15 years in medical device marketing (nothing whatsoever like medical school provides, but I can read medical papers and generally follow what's going on at the macro level).
The study I'm recalling was fairly large. I wish I had perfect recall and could give you a cite. I dislike making claims without being able to point to evidence. This looks like a likely candidate for what I'm recalling--a relatively large scale meta-analysis that indicates a slight benefit for surgical intervention (fusion) outweighed by the increased risk to patients from surgical complications. This study may also have been superseded by additional research/new procedures in the intervening years. Things are a moving target.
Continuing 50, I'll again handwavily note that from conversations with docs, we can't evenly consistently identify what causes spinal pain in some patients and not in others. I've heard (again, sorry, no cites for this) multiple stories of patients going through MRIs for non-back-pain reasons and having what appear to be horrific spinal issues--slipped discs, crushed and rehealed vertebrae--with absolutely no associated pain. So teasing out what interventions work for which condition is made even more challenging because we're not even working with the entire population of people with spinal injuries--only those who experience pain.
51 is basically my professional life, but in the wrong body part.
The Lives of a Cell by Lewis Thomas
Teofilo, I'd be interested to know if you recommend this. It's been on my to-read list for a long time now, but every time I flip through it, it doesn't quite move up in the queue. It was originally recommended to me by someone with similar scientific interests to mine, but highly suspect taste in fiction (which I realise this isn't) and most other matters of style. So I've always wondered.
Last, I want to make sure my larger point from 20 isn't lost. Some interventions do work, but between the constantly moving definition of best practices/insufficiency of CME for dissemination of same, a psychological bias for action (sorted for by med schools), and a malpractice system that incents intervention over inaction, we're going to have a lot of unnecessary procedures and procedures performed without evidence of efficacy--at a real cost to the healthcare system, the economy, and patients.
I have no solutions that don't involve massive societal change.
I don't think there are any solutions to lots of these problems. It's not just a question of a bias for action. Even if you could control that without making everybody scream "Death Panels", you've only solved a small bit of the problem. People are, methodologically speaking, fucking messes. You can know the best practice for stents in stable patients in the aggregate, but by making a study that isolates just the issue of stents in a given population and defining efficacy in a way that you can actually study it (e.g. end points of death or heart attack), you've limited the scope of generalization quite a bit. Neither you nor your doctor know enough if they know that in 67 out of 100 cases it would be better not to do the stent. You've got your own medical history full of other conditions that probably weight for or against a stent, but there's no way for sure to know. And you've got your own values as to different types of live/die trade offs.
Overall don't other countries have way fewer diagnostic tests and surgeries than the US? And yet their health outcomes aren't worse, and are often better, than the US?
There is definitely a cultural difference in the US medical system. I remember being offered a ultrasound at my yearly gyn appointment when I was in my late 20s. Like it was dessert or something - 'if you want, it's an option!'. And of course, back then I didn't realized these offers weren't free.
Overall don't other countries have way fewer diagnostic tests and surgeries than the US? And yet their health outcomes aren't worse, and are often better, than the US?
Yes, and yes. US doctors overtest, overprescribe and overtreat. (If your income is in part a fixed percentage of how much your patients spend on medicine... guess what happens to your prescription habits.)
See Atul Gawande. Or rather ATUL GAWANDE! (I feel that he deserves to have his name rendered in BRIAN BLESSED! font.)
http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
Seconding Gawande. The Checklist Manifesto is an essential read.
And since it's the first counter many centrists put up: overtreatment does not decrease with malpractice "reform".
(Physician salaries are also a problem independently.)
Thank ATUL!
(to be said with a sign of relief)
46: The world is going to machines. I think checklist psychiatry stinks, because the relationship can be part of the healing.
And I don't like it when a doctor just gives me a handout. I can find what's on the handout myself. What I want from the doctor is a conversation.
Also, if you are being cared for in the hospital, you want your generalist- the hospitalist to be a woman. Fewer read missions and post discharge deaths.
The only thing that consistently provides results are core-strengthening exercises. Of those, powerlifting (deadlift, squat, etc.) have been the best for pain relief.
I love this. Your back hurts? HEAVY SQUATS. Your back is stiff? ROMANIAN DEADLIFT. You hate the world and want to die? POWER SNATCH. The best of it is that it's the stinking truth, too.
I think checklist psychiatry stinks, because the relationship can be part of the healing.
I really liked The Checklist Manifesto, and he doesn't say that Checklists should be the entire framework for care, but that they're an important tool to make sure that questions or treatment options don't get skipped.
They're a way to compensate for the fact that human beings are really good at following stories but really bad at consistently doing the same things every time.
53: I'm liking it so far. It seems to be mostly about symbiosis and commensalism, especially at the microbial level, and whether and how this better understanding of this may have implications for ecosystems and communities at larger scales. But there's lots of other stuff too, like the medical technology chapter I mentioned. Each chapter is a short, stand-alone essay, so it's an easy book to dip into and out of.
65: I like Atul Gawande quite a bit. I'm not worried about him. He's also really good about things like end-of-life conversations. What worries me is the relentless push to have doctors see more patients. And as ACOs come on board, there will be more pressure for patients to see a nurse practitioner or an RN or even to get coaching from a medical assistant, which is ok, but it replaces the relationship with a doctor in favor of a team.
My PCP is fairly conservative and doesn't overtest. She talks a lot about how we overtest compared to the rest of the world. She got a baseline cholesterol and then repeated it a few years ago. Usually she orders no bloodwork. Mostly we talk when I see her. My physicals with her are 40 minutes.
A lot of places they are 15 minutes for a reasonably healthy person. There are efforts to curb doctors' use of high-cost imaging and efforts to reduce administrative burden so that doctors can be more efficient. But the thing that I want most is time from my doctor.
I want time and not too many questions to my transparent lies about drinking. It's like marriage.
He claimed the stem cell treatment cured these back problems.
Interesting. And again, I'm open to the possibility that I'm (ignorantly and unreasonably) exaggerating the excellence of USian health care, while (cluelessly and arrogantly) dismissing the care provided by other countries.
My sense of American health care:
For those at the very top of the food chain, it offers the very best care in the world. But for those less fortunate than the one percent, access and efficacy range from middling to abysmal. And as a "system" (it's not really a system, more a confused hodge-podge of rules, regulations, and insufficient subsidies) of health care delivery to its citizenry, it's pretty much a model of how not to do it. As my (Canadian) dad used to say, "The US is a great place to live. Just don't get old, and don't get sick."
Anyway, if the GOP has its way, the lesser than the one percent will soon be communicating the old-fashioned way (perhaps by carrier pigeon?): no iphones for the unwashed and the unworthy, unless they're willing to forgo life-saving medical treatments. Maybe they can swap receipts for homemade herbal tonics and mustard poultices and such; they certainly won't be able to afford modern, conventional medical care and treatment.
She talks a lot about how we overtest compared to the rest of the world
Bloody amateurs! In the last ten days I've had two MRIs and an Ultrasound, plus a set of bloods that would be tedious to enumerate.
Hope they find nothing! Or just turtles, anyway.
And again, I'm open to the possibility that I'm (ignorantly and unreasonably) exaggerating the excellence of USian health care, while (cluelessly and arrogantly) dismissing the care provided by other countries. My sense of American health care: For those at the very top of the food chain, it offers the very best care in the world. But for those less fortunate than the one percent, access and efficacy range from middling to abysmal.
Well, I don't think this is contradictory to the stem-cell treatment claim, because stem-cell treatments are such a unique little thing which have been singled out for illegality. I don't think South America has necessarily better health care, but I'm fully prepared to believe that they'd offer exotic treatments to very wealthy people, especially treatments that capitalize on the dumbness/inefficiency created by pretending that stem cells are children.
70: not clear it's the best for the top 1%. Maybe the best for the top .1 or .05 percent but even then it's really more like .01 percent, and that's only because they have more eyes on them and more care coordination from the PCP.
Your back hurts? HEAVY SQUATS. Your back is stiff? ROMANIAN DEADLIFT. You hate the world and want to die? POWER SNATCH.
Power running! Power lifting! Power sleeping! Power dating! Power eating! Power laughing! Power spawning babies! You'll have so many babies! 400 BABIES!
Omg, flashback. That was an old video we loved here, wasn't it? I GET THE JOKE! But what was the joke again?
"The US is a great place to live. Just don't get old, and don't get sick."
The US seems to be a pretty decent place to get old, all things considered. Single payer, taxpayer funded healthcare mitigates the one obvious downside. Social Security, for all the doom-mongering, is a lot more robust and generous than the state pension elsewhere in the Anglosphere. Seniors seem to have an awful lot of political power and social capital compared to the UK, where pensions (public and private) and social care are a rolling clusterfuck and the old are generally ignored or marginalised. Housing is cheap in places with a livable climate. Care homes can be hit and miss, of course, but I've never heard any horror stories from my US family.
77: long term care is the issue. Medicare doesn't cover nursing homes. You must become destitute before Medicaid will pay at all. Then you're left with a couple hundred a month for personal items.