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Why do ineffective treatments seem helpful?

Discussion in 'General Issues and Discussion Forum' started by admin, Oct 14, 2009.

  1. admin

    admin Administrator Staff Member

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    Why do ineffective treatments seem helpful? A brief review
    Steve E Hartman
    Chiropractic & Osteopathy 2009, 17:10doi:10.1186/1746-1340-17-10Published: 12 October 2009
    Full text
  2. Craig Payne

    Craig Payne Moderator

    Obviously I posted the above wearing the Admin hat, but I am posting it again as I think this has to be compulsory reading for everyone in the professions. I will break it up to make the point:
  3. Not a popular view you eliteist academic ivory tower dweller you;). Sounds like Paynes law to me (I forget which).

    But I would fully agree. EBM is very much the "road less traveled", perhaps because nobody, neither clinicians nor patients likes to be faced with inconvenient truths.

    For a fantastic read on what EBM is, and what it is not, I can wholeheartedly recommend Bad Science by Dr Ben Goldacre, which is both educational and easy and entertaining reading.

    And if you are interested in the cognitive psychology side of WHY we do this, tryInevitable Illusions, a slightly heavier but still fascinating read.

    And whoever I leant my copy of the above to, could I have it back please!

  4. "Science is the great antidote to the poison of enthusiasm and superstition."
    Adam Smith
  5. Craig Payne

    Craig Payne Moderator

    I did not say I agreed with it!

    I think it is such an important read as it raises issues that everyone needs to factor into THEIR world view of where knowledge for clinical practice comes from. Needless to say, my own views have 'evolved' a lot in the last few months due to a number of things that came my way and this paper further informed those views .... who says I do not change my view? :santa:
  6. Peter1234

    Peter1234 Active Member

    Hi Craig,

    we may as well not do any research judging by this article!! Can it get any more

  7. I think we're reading different articles! I found it to be immensly encouraging!

    Over the past few years I have developed great respect for the modes of efficacy described in the article. I suspect they contribute far more to our treatments than we care to admit. But whilst we should not deny them, they should not detract from the other half of what we do, the actual objective scientific and physical side.

    There are, I beleive, two equal and opposite errors one can fall into with regard to the "non clinical" side of medicine.

    One is the error into which many CAM practitioners fall, which is to deny that factors like regression to mean, placebo etc exist and jealously claim all benefit as a direct result of their treatment. This empowers them to use "placebo power" to amazing effect, getting results where mainstream medicine fails. One place this can be seen is in pain clinics, many of which embrace CAM techniques because they offer something other than mainstream. The problem with this is that it retards investigation into any actual clinical or pharmaceutical benefit because the proponents tend to fear stripping the non clinical benefits away lest there be nothing beneath! It could also be argued to be modestly unethical because whilst the non clinical benefits from CAM are real, they are often sold to the consumer as clinical benefits.

    The second error, which I beleive many in mainstream medicine fall into, is superficially similar but subtley different. There are many who hold themselves so rigidly to the provable and reducible scientific side of medicine that they deny the value of the non clinical. Placebo is sometimes used as a dismissive, but how many other treatments are there which can produce such measureable benifits for so many conditions? This withdrawal from the more esoteric side of medicine produced the vacuum which the CAM part burgeoned into. It is now the fashion to be in "holistic medicine", my GP is irritatingly persistant in telling me to eat 5 a day and lose weight when I go to him to have my blood pressure medication review, but the psychological side of the treatments we give is considered by many to be somewhat taboo!

    I suppose the ideal is a sort of hybrid clinician, one who is fully aware of the modes of action for the non clinical side of medicine is not afraid to take advantage of them for the benifit of the patient, but also knows when and where the pure clinical evidence based approach is needed. One who knows how to design or critically analyse a clinical trial but also knows that sometimes pragmatism can have value as well. Such a clinician would need to be a mental gymnast to master the cognitive dissonance of administering treatment knowing it had no clinical efficacy whatsoever (like water, as in homeopathy) knowing that it might nonetheless have real benefit to the patient. He would also need to be able to walk the razor sharp ethical line of deceiving the patient (claiming clinical efficacy) knowing that the deception would become a truth (that it WOULD GAIN clinical efficacy from his claim).

    Such a clinician would need be a far cleverer and more open minded one than I, I can think of only one podiatrist who is close to this condition. But articles like this one move us closer to a truly holistic understanding of what we do if we are but brave enough to read them with an open mind.

    So I found it immensely encouraging!

    Robert Isaacs

    *As an aside it was not always thus. There was a case reported in a medical editorial in 1890 which tells of a patient who was injected with saline instead of morphine post surgery. The patient, we are told, recovered well but discovered the deception and took the doctor to court, successfully, for the accuracy of the bill. The editorial wrote

    "Shall {the plaebo} never again have the oppertunity of exerting its wonderful pyshological effect as faithfully as one of its more toxic conveners. "
  8. Peter1234

    Peter1234 Active Member

    Hi Robert,

    the article really makes sense in terms of understanding treatment from a holistic approach. There is so much we do not know - one of my lecturers at Uni stated that only seven per cent of western medicine is thoroughly researched and we 'know' work.

    However when stating 'know' we are also going into somewhat unchartered territory- for the reasons stated in the article. It is very uplifting to acknowledge that science as we understand it today has its limits. But we can also celebrate how much we also do know - that some treatments do work.

    As a budding clinician I will have to practice my bed side manner more, me thinks!!!! (and what about the white coat, why don't we get to wear one??)
  9. I think the tittle of the book is brillant.

    maybe a better one would have been Why do ineffective treatments seem so effective ? but maybe that would confuse too many.
  10. Who says you don't;).

    When I started working for the NHS you could wear what you damn well wanted and I DID wear a white coat. Eminently practical. Now I see Students in rather smart smock type things which I would not be seen dead in. My trust has a uniform policy of scrubs which also look quite spiffy and which I completely ignore (its the paeds you see, would hate to scare the lil'uns).

    Whatever works for you and is right for the context. White coat syndrome is about far more than a white coat. Go around a hospital and you'll see surgeons in suits and junior doctors in white coats, what does that tell you? Gillian Mckeith, or to give her her full medical title, Gillian Mckeith wears a white coat for crying out loud and I doubt she can even spell "medical school" much less graduate from one.

    Ah but why ;). Sorry, just teasing.

    I think much depends on how one defines evidence. I doubt there is a controlled trial for removing corns or cutting nails, but there is plenty of deductive evidence that these interventions "work". So would that be part of the 93% which is "unproven"?

    Good fun.
  11. Griff

    Griff Moderator

    Just found this pretty cool video on youtube re: the placebo effect

    Last edited by a moderator: Sep 22, 2016
  12. Craig Payne

    Craig Payne Moderator

    ...and this one of the Arena'ettes:
    Last edited by a moderator: Sep 22, 2016

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