Science, sometimes - stroke and chiropractic

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The Connecticut Board of Chiropractic Examiners ruled on the issue of informed consent.  There was a hearing on a declaratory ruling regarding informed consent and stroke.  The board heard four days of testimony (which are available as videos at CT-N).  Although the board's ruling hasn't yet hit the internet where I can find the exact text, it appears from newspaper reports that they ruled affirming that informed consent is the law in Connecticut but refused to require specific consent about a risk of stroke.  Both the New Haven Register and the Hartford Courant have weighed in on this issue and it appears that science isn't the strong suit for either newspaper.

Both papers believe that there is a risk of stroke from cervical manipulation.  Of course the two groups that advocated before the board for the ruling to require telling prospective chiropractic patients of the risk also believed there is a risk. To me what I have learned being part of this process is that science matters to many people only when it serves their interests. 

Nature of science

Science is an epistemological theory.  Epistemology is the study of how we acquire knowledge.  Science, as we know it, is just one method to acquire knowledge through what's called the scientific method.  Wikipedia's explanation of the scientific method is well done (at least today).  Simply, the method is to observe some phenomenon, create a hypothesis (i.e. a prediction) about that phenomenon, then test that hypothesis by controlled observation, an experiment. 

There are other epistemologies besides science.  For example divine revelation where knowledge comes from a deity. Some have called my profession, chiropractic a cult because there are some in the profession whose epistemology is based upon the work of a guru, typically BJ Palmer.  At one time most of medicine was based upon some guru's dogma.  For example anatomy was controlled by the works of Galen (1st - 2nd century of the common era) who really didn't have a clue what was in the human body - he'd looked at monkeys as human dissection wasn't allowed in his time. It wasn't until a skeptic Andreas Vesalius (16th century) applied the empirical method - noting that the bodies he dissected didn't look the way Galen said that anatomy progressed beyond the dogma of Galen.

One common epistemology is the use of anecdotes.  You know, "I once knew a guy who smoked a carton of cigarettes a day for 70 years and never got lung cancer.  So cigarettes are safe."  OK that's extreme but anecdotes have a tremendous hold upon our thinking and often it is very difficult to let science triumph when anecdote sits in contradiction of the science. Anecdotes which in health care publications are called case reports are very good at hypothesis generation, remember the scientific method is based upon an observation generating a hypothesis.  Case reports can help generate a hypothesis but never can validate the hypothesis.  I've heard it said often amongst skeptics of chiropractic that the pleural of anecdote is anecdotes not evidence.  I'll come back to this quote again!

Autism and Vaccinations

I know it looks like I'm completely switching gears but there is a logic to my digression.  As I have thought a lot about stroke and manipulation and autism and vaccinations I've come to see that they are analogous situations.  Think about this, a family has what appears to be a healthy normal baby.  They are in this blissful state of early parenthood enthralled with the baby who is developing a similar love for them.  Then suddenly the developing relationship on the babies side changes and the child becomes distant.  The parents seek advice and find that their now more withdrawn child appears to have autistic spectrum disorder.  To the parent this can be a devastating event. They want desperately to find a cure and if there isn't a cure (which there doesn't seem to be) they want to blame someone, something. This is only natural.  The parents feel as if someone, something has taken their child away from them.  Then they hear about a supposed link between autism and vaccinations.  Now they have people to blame.  They can blame the vaccine manufactures.  They can blame the government for trying to tell us that vaccines are safe. They can blame their doctors for giving their baby this poison which caused the problem.  To hear the anti-vaccination folks go on about autism and vaccines is to hear the voice of anger and vindictiveness.  They are not malicious people just untrained in the ways of science and prone to letting their emotions have greater sway over how they look at the evidence.

What about the evidence?  Those parents when confronted with the scientific evidence that does not support their belief that autism is caused by the vaccine, reject the evidence.  What is the basis for the rejection, valid critique of the science?  No, usually it is what comedian Stephen Colbert called truthiness.  Truthiness, which was the Merriam-Webster word of the year in 2006, is defined as: "Truth that comes from the gut, not books," and "The quality of preferring concepts or facts one wishes to be true, rather than concepts or facts known to be true."

Then a whole support industry develops around this belief.  There are organizations whose purpose is to advocate on behalf of the parents and spread the word that autism is definitively caused by vaccines.  This theory is advanced in such a way that reading the web one might believe it was the only one.

I was a participant in a webcast on vaccines for the California Department of Public Health titled "Wading through the Confusion".  As one of my colleagues on the webcast, David G. Amaral, PhD, an autism researcher from the UC Davis M.I.N.D. Institute lamented is that there is inadequate research money available to find the cause of autism because the theory advocated by these groups has so dominated the discussion.

[Any one wishing to know more about this battle should read Paul Offit's book Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure. The NYTimes article on Offit is enlightening about the lack of civility of public discourse on this issue.] 

Back to Stroke

Now think about ischemic strokes.  Isn't this what happens after a stroke in a younger person.  I mean we sort of think of stroke as a disorder that affects the elderly and it is.  The CDC lists death from stroke as the third most common cause of death behind heart attacks and cancer.  The rate of stroke increases dramatically as one ages. Stroke is a life changing event that affects not only the person who may be disabled, but the entire family and other caregivers as well. Utility analyses show that a major stroke is viewed by more than half of those at risk as being worse than death. (1)

So a younger person, say in their 40s - 50s has a ischemic stroke.  That person and their family are going have the same desire as the family who finds their child has developed autism, find someone to blame.  Well instead of a radicalized group of parents spreading the word that vaccines are the cause for autism there is a radicalized group of patients spreading the words that it must be a visit to a chiropractor. This theory that chiropractic cervical manipulation is the cause of strokes in the young has become so common that many MDs speak as if this is an established fact.  They don't really know what the research says about stroke but couple their distrust of chiropractic (2) which I think is a result of the AMA's illegal boycott(3) and it's easy to see how they would assume the connection between chiropractic care and stroke is valid.  Plus why search the literature to find this out, most people they know will tell them it is true.  It seems scientific evidence doesn't always matter.(4)

What is the epidemiology of these strokes?  They are rare representing 2% of all ischemic strokes but 10 to 25 percent of strokes in the young and middle aged.(5)  These facts are not well known so when someone in who is young or middle aged presents to a hospital with a stroke everyone wants to know why.   Given the bias and bad information then the question comes, "did you see a chiropractor within the past month?"  This only serves to expand the perceived value of this belief.  It is not uncommon to hear someone say that the risk is proven.  Proof is a word I tell my students that they can never use when referring to biomedical research.  There is either evidence that supports or refutes a particular hypothesis.  IF they want PROOF then their career choice should become mathematics not health care. 

Or that there is 80 years of science backing this up.  Well time to go back to that earlier quote: "the pleural of anecdote is anecdotes not evidence."    There isn't an 80 year history of science with respect to the association between cervical manipulation and stroke, there is an 80 year history of anecdotes that appears in the scientific literature.  The real science behind this issue has a much shorter history.  We get a survey of neurologists in 1995 (6) with a very poor response rate and which suffers from referral bias. (7)  Plus a survey doesn't establish cause and effect.  There are many studies of cases that have tried to discover the incidence.  For example this paper by Haldeman et al which estimated that one chiropractor in 48 would during the course of their practice career would be made aware of an arterial dissection following cervical manipulation.  But none of these papers actually evaluated the risk. 

There are only three studies that have evaluated the risk of stroke after manipulation.  And all three agree there is an association.  (9- 11)  The first two found a risk (9, 10) and the third (11) finding the same association provided evidence that explains the first two.  Cassidy et al (11) used the same data sources as Rothwell et al (9) but Cassidy et al study investigated one thing neither Smith (9) nor Rothwell (10) did and that is they determined the background rate of these strokes.  The issue is if the rate of strokes after chiropractic care was greater than the background rate (those that were occurring spontaneously not caused by the manipulation) then we would know what the added risk was due to manipulation. The finding, the rate of strokes in patients under 45 seeking care from their primary care physician was identical to the rate for those who had seen a chiropractor.  Thus seeking chiropractic care produced no extra risk for stroke over and above the background rate.  It appears that patients about to have a stroke from a dissection of a vertebral artery (the kind blamed on chiropractic for 80 years) seem to go to a doctor (a medical doctor or a chiropractic doctor) and the only reason the association between chiropractic and stroke appeared to be strong and not for PCPs is that no one asks the question in the emergency room, "did you see your MD within the past month?"

Some have complained that Cassidy et al was a "statistical study" (see this opinion piece or listen to Dr. Murray Katz's testimony before the Connecticut Board of Chiropractic Examiners)  That's almost comical as a critique if not that it might ring true to people who don't understand biomedical research.  Those same critics never said that Rothwell (9) and Lee (10) were "statistical studies" which they are. 

In the publication BottomLine Health there is an article about stroke risk.  The author Dr. Steven Messe essentially dismisses cervical manipulation as a risk factor based upon Cassidy et al's work.(12) 

The nature of science is that what was known one day may change the next.  This isn't often comfortable to the average person but it is the way it is.As the late Prof. Natalia Romalis-Reytblatt (she was a math professor at UB and UB’s 2006-07 Professor of the Year) wrote:

Mathematical results are either false or true (that is, proven or false) and nothing in between. Mathematics is one of the oldest fields of study and, probably, the only field whose findings are not reversed over time, only accumulated.

Math doesn't reverse it's findings but biomedical science does.  A few years ago I wrote about the risk of stroke from cervical manipulation.  But then the evidence changed.  So in the end this is an argument about looking at the science or ignoring the science and using emotion or choosing to use old science only.  To hear the science you can listen to Dr. David Cassidy testify before the board.  You can decide. 

SMP

1. Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline. Stroke. 2006 Jun;37(6):1583-633.  (this paper is available for free here)
2. Busse JW, Jacobs C, Ngo T, Rodine R, Torrance D, Jim J, et al. Attitudes toward chiropractic: a survey of North American orthopedic surgeons. Spine (Phila Pa 1976). 2009 Dec 1;34(25):2818-25. (Pubmed link)
3. Getzendanner S. Permanent injunction order against AMA. Jama. 1988;259(1):81-2. (Pubmed link)
4. Gabbay J, le May A. Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care. Bmj. 2004 Oct 30;329(7473):1013.(this paper is available for free here)
5. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. (Pubmed link)
6. Lee KP, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology. 1995;45(6):1213-5. (Pubmed link)
7. Haldeman S, Carey P, Townsend M, Papadopoulos C. Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias. Spine J. 2002 Sep-Oct;2(5):334-42. (Pubmed link)
8. Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ. 2001 Oct 2;165(7):905-6. (this paper is available for free here)
9. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001;32(5):1054-60. (this paper is available for free here)
10. Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003 May 13;60(9):1424-8. (Pubmed link)
11. Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83. (Pubmed link)
12. Messe SR. Stroke Risk. BottomLine Health. 2010;24(3):1-2. 

Baseball and health care - evidence based care

Image by The Library of Congress via Flickr

As I hear more debate (or is it partisan rancor - I mean despite obvious lies not one Democrat disrespected the office of the President and yelled to President Bush liar) regarding health care reform I am reminded of a remarkable Op-Ed piece from the NY Times (of course) by the strangest of bed fellows: Billy Beane, Newt Gingrich And John Kerry.  For those who do not know Beane is the VP and General Manager of the Oakland A's, I might be wrong but I figure everyone else knows former Congressman Gingrich and Senator Kerry.

Just brings Garrett Morris as Chico Escuela on SNL- "Baseball be berra good to me"

Why would baseball be a benchmark for health care?  Because baseball is a game of statistics and coaching decisions and in particular staffing decisions are made by using those statistics.  The use of a newer way of looking at baseball statistics is what Beane is known for.  It is called sabermetrics. And the point of this op-ed is better health care is possible if we use the data, i.e. evidence based health care.

SMP

What does it take to put an ugly fact through the heart of a beautiful hypothesis?

NPR yesterday did a piece on treating fractured vertebra and so did the NYTimes This is hot news because two papers appeared in the New England Journal of Medicine that compared vertebroplasty to placebo and found them comparable.

The great problem is that the treatment is perceived by both doctors and patients as effective. This treatment provides opportunity for discussion about a huge problem for health care reform. When common knowledge suggests a treatment is effective but the data show, in a compelling way, that the treatment (which has risks and financial costs) is no better than placebo should insurance pay for the treatment?

The fear of some is that because a treatment does not appear to be clinically effective "big brother" will say, "we won't pay." I understand the fear that some all powerful insurance company will get to decide what is and is not effective. But is this bad, per se? I do not think so. Both doctors and patients have for years mistakenly believed that various treatments that aren't effective actually are. I've blogged on this before, see Treatments That Don't Work.

I recently read a great paper whose title I love: What does it take to put an ugly fact through the heart of a beautiful hypothesis? (1) The title is from a quote by Thomas Huxley who lamented "The great tragedy of Science - the slaying of a beautiful hypothesis by an ugly fact." The point in this article is that our modern history of health care is full of beautiful hypotheses, that some treatment is effective, slayed by a ugly fact, research showing the treatment to be ineffective. The problem is that although the hypothesis, that the treatment is effective is dead, the belief in the effectiveness of the treatment isn't dead. Both doctors and patients alike have resurrected these treatments that ugly facts have slayed like the zombies in the classic Night of the Living Dead.

Another quote from Haynes (1) paper from Max Planck, renowned physicist

‘‘A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it.’’

However, it seems that while opponents of the new scientific truth die they unfortunately are capable of infecting a new generation that because of truthiness will accept these slain hypotheses.

Truthiness, is defined by Merriam-Webster as:

Truth that comes from the gut, not books
The quality of preferring concepts or facts one wishes to be true, rather than concepts or facts known to be true.

For more on truthiness and the danger it poses for patients see my article in Dynamic Chiropractic, The Dangers of Truthiness

As Prof. Dov Cooperman of the University of Maryland wrote in a letter to the editor of Newsweek: "...our society is more than happy to accept spin and cant because we have come to believe that all expertise is bias, that all knowledge is opinion, that every judgment is relative. I see this daily in my university classroom. Many of even my best students seem to have lost the ability to think critically about the world. They do not believe in the transformative power of knowledge because they do not believe in knowledge itself"

Unfortunately I see it everyday in my classroom and hear it from many of my professional colleagues too.

My final quote from Haynes (1): Samuel Johnson, the 18th century poet and critic

‘‘The chains of habit are too weak to be felt until they are too strong to be broken.’’

The habits that are so problematic are a lack of critical thinking skills and reliance upon the "wisdom" of others (i.e. dogma), unsystematic and uncontrolled observation, and just truthiness.

For more information on critical thinking I recommend the Foundation for Critical Thinking.

SMP

1. Haynes RB, Haynes GA. What does it take to put an ugly fact through the heart of a beautiful hypothesis? Evid Based Med. 2009 Jun;14(3):68-9. Pubmed link

Malpractice

In the NYTimes (what else?) there is an interesting op-ed about malpractice, Liability = Responsibility. Knock on wood I've never been sued but I have taught risk management for a few years and have been a consultant for some malpractice cases so the issue has more than a casual interest to me. The article cites a paper from NEJM that is a study of malpractice cases which is very enlightening.

To put it simply the problem which has created the "malpractice crisis" in the US isn't those nasty litigators, it is negligent doctoring. It seems that the vast majority of malpractice cases the doctor involved actually treated the patient in a negligent way. So the cure for the malpractice crisis is better doctoring which the Times op-ed piece suggests means evidence based practice.

Then again when one looks at how low chiropractic malpractice insurance costs one understands that such events are extremely rare in chiropractic. I think most people are shocked to find out how little chiropractors pay for malpractice, I know that every MD I have spoken to about the amount has envy. Most chiropractors pay a few thousand dollars for the same malpractice coverage that MDs pay tens to hundreds of thousand dollars in premiums.

SMP

A NICE approach to treating low back pain

NICE which is the UK's National Institute for Clinical Excellence has just released guidelines for treating low back pain (LBP).

The first recommendation is to promote self-management. This means to suggest to patients with LBP to exercise and try to continuing doing ones normal activity, as possible. The next one is pain medication - first acetaminophen. The final recommendation is exercise or manual therapy (i.e. spinal manipulation) or acupuncture.

Another interesting feature is what the guidelines proscribe. All of the following are treatments/diagnostic tests that are NOT allowed (because they either don't work or aren't needed):
Medical/Surgical treatments

• SSRIs for pain management
• Facet injections
• Radiofrequency facet joint denervation
• IDET (Intradiscal Electrothermal Annuloplasty)
• PIRFT (Percutaneous Intradiscal Radiofrequency Thermocoagulation)
  

Physical therapy

• Laser therapy (AKA Cold Laser)
• Interferential electrical stimulation
• Therapeutic ultrasound
• TENS (another kind of electical stimulation)
• Lumbar supports or belts - back braces
• Traction

Diagnostic tests

• Plain film x-ray under any circumstances
• MRI to be offered only to rule out red flags or for surgical referral
• I think of an MRI for a a back pain patient, a road map for a surgeon. Keep that in mind if you are pushing your doctor to get one.
• Red Flags are signs of:

• Spinal cancer
• Cauda equina syndrome
• Infection
• Ankylosing spondylitis or another inflammatory disorder
• Fracture

Of course as I noted in previous blogs, it is likely that your health care provider will ignore these recommendations and do what they have always done, even if the scientific evidence is that it is not effective.

See:

• Treatments that don't work
• Resistance to using the best treatement
• Ultracrepidarian Doctors and Back Pain
  

These new guidelines are is not particularly new but nice to see.

SMP

Ultracrepidarian Doctors and Back Pain

An ultracrepidarian is a person who professes expertise the they do not posses. This is an epithet not often used but I am fond of and have used in presentations and my ethics column. Some might say that fondness is because it should be applied to me. Nevertheless, I like it because I find so many experts who pontificate on that which they know so little. Think of my earlier blog entry about Katz.

There is a classic paper that sort of tested the prevalence of this disorder amongst very smart college students. The title says it all, "Unskilled and unaware of it: How difficulties in recognizing one's own incompetence lead to inflated self-assessments". (The link goes to free full text)

A new study, published in today's Spine by Buchbinder et al could be called ultracrepidarian doctors and back pain. The paper, "Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain" details a study that surveyed general practitioners about their interest and knowledge regarding how to treat back pain. The results are counter-intuitive because those with the greatest interest in treating back pain had the poorest knowledge of the current best evidence of how to treat it. Thus, they were ultracrepidarians.

It was almost comical but the doctors with a special interest in back pain thought that guidelines are very helpful in determining how to treat patients with back pain, yet they choose treatments, such as bed rest, that are clearly bad for patients. Bed rest in particular has been known to be harmful for a long time.

This paper is very similar to one published quite a while ago also showing that doctors choose treatments that are ineffective and avoid ones that are effective such as spinal manipulation.

Buchbinder and colleagues previously published studies that showed that public education reduces disability from workers compensation type claims. Sometimes the public is teachable and their doctors aren't. I wish I could give patients hope that the doctor they go to really is up-to-date but clearly if the doctor says they are does not mean that they actually are.

SMP

Resistance to using the best treatment

The NYTimes reports on the battle against the use of the best evidence in health care. Once again it is reported that one of the biggest problems in getting good health care is the resistance of health care providers to changing the voodoo that they do to treatment that actually works.

This article talks about the Agency for Health Care Policy and Research's guidelines on treating lower back pain. (1) Spine surgeons were so upset that it excluded their favorite treatment - surgery - that they tried to kill the agency. As the Times article reports the reason that surgery was not recommended: research didn't show it was effective but it did show that spinal manipulation was effective.

But as Max Planck said: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it."

The problem is that people have a hard time changing. Most hate change. Personally I thrive on it. Most don't like finding out they were wrong. I used to be like that. I think the change was when I read the first study that suggested that spinal manipulation might be effective for treating some people's symptoms who have spinal stenosis (2)

This paper came out 2 years after I had told a patient who came in with CT showing the stenosis (he'd been symptomatic for ~10 years) that I couldn't help him and he should have the surgery he had scheduled. The study isn't what I'd call compelling evidence of clinical effectiveness of spinal manipulation but IF it had been published two years earlier I could have told this man he might have a 36% chance of getting better after two weeks of care. Given the fact he'd lived with the pain for 10 years he might have been willing to try two weeks of care instead of "going under the knife". For a while I beat myself up over this and then I realized, you can't know what isn't known. That liberated me to be comfortable with saying that was wrong. As W.V. Quine and J. S. Ullian wrote in The Web of Belief (Random House, New York, 2nd edition, 1978, p. 133) my favorite quote:

The desire to be right and the desire to have been right are two desires, and the sooner we separate them the better off we are. The desire to be right is the thirst for truth. On all accounts, both practical and theoretical, there is nothing but good to be said for it. The desire to have been right, on the other hand, is the pride that goeth before a fall. It stands in the way of our seeing we were wrong, and thus blocks the progress of our knowledge.

The Times article suggests that most doctors are more interested in having been right, rather than being right.

SMP

1. Bigos S, Bowyer R, Braen R, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994.
2. Kirkaldy-Willis WH, Cassidy JD. Spinal manipulation in the treatment of low-back pain. Can Fam Phys. 1985;31:535-40.
   

Treatments That Don't Work

If there is a fundamental question in biomedical research it is does a treatment "work". By "working" most people mean is the treatment clinically effective. The first time this question was asked in a rigorous scientific way is often cited as the work of the British Naval physician James Lind, MD (1716 - 1794). Lind, a Scotsman, one might say is personally responsible for the British being nicknamed, Limeys. His research showed that citrus juice "worked" as a treatment for scurvy, which of course we now know is due to a Vitamin C deficiency that the citrus provide a good supply of.

Lind was ignorant of vitamins, which weren't discovered until early part of the 20th century. It is interesting to note that he thought that the cause of survey was putrefied food. So his experiment centered on acidic "foods" to prevent the food one ate from putrefying. He tried having sailors consume the following in six experimental groups : cider, sulfuric acid, vinegar, seawater, oranges and lemon, and a spicy paste plus barley water. In 1753 he published his A Treatise of the Scurvy. Despite his work the addition of citrus to the diets of sailors of the British Royal Navy was not universally accepted. Three lessons we can learn from Lind's work.

1. Rigorous scientific experimentation can discover effective treatments (ones that "work")
2. An effective treatment does not validate ones theory about why the treatment is effective.
3. People will often continue to believe that ineffective treatments are actually effective, even after compelling research has been published.
   

Dr. David Newman blogs for the NY Times (you've probably guessed I like The Times) writes about believing in treatments that don't work. There is an allure to treatments that one knows or is good at providing. When one starts along the path of evidence based practice one is constantly amazed by both patients and doctors of all types (medical, chiropractic, osteopathic etc.) who continue to use or advocate treatments that compelling research shows are ineffective and sometimes even more harmful than beneficial.

There is a great anecdote about Dr. Paul Glasziou. Dr. Glasziou had published a systematic review (SR) on otitis media (inner ear pain).(1) The most common treatment for this is to prescribe antibiotics. However, the SR found that "watch and wait" is the best approach. So what does Glasziou do when his 2 year old develops acute otitis media? The experience of so many parents and pediatricians with the antibiotics is that the children get better when they take them. Well Glasziou's review suggests that this is because the drug is often given when the pain is at its worst and that the condition will improve shortly on its own. However, doctors and patients ascribe the improving clinical situation to the antibiotics. Thus if we do not know the natural history of the disorder (what happens without treatment) we are all deluded into believing the treatment is what helped the patient. So what did Dr. Glasziou do? He gave his son analgesics only and he got better on his own.(2)

I think what Dr. Glasziou did is a good example of faith. It is faith that the best evidence will in the majority of cases result in the best outcome. Will it every time. No but it is more likely to result in a better outcome than using a treatment that the best evidenced shows is unlikely to help even if personal anecdotes suggest otherwise.

In this blog, Dr. Newman, notes: "More than a half million Americans per year undergo arthroscopic surgery to correct osteoarthritis of the knee, at a cost of $3 billion." This is despite a rare type of research study. The study was a placebo controlled clinical trial of surgery. This means that people who were not in the treatment group still had surgery but surgery that wasn't effective. The results showed a comparable outcome in both groups. Thus, the surgery that so many Americans are having is worthless.

What is interesting about this study using placebo surgery is that the last time placebo surgery was used the outcome was the same that the surgery was no better than placebo.(3) This was in the 1950s with a procedure that at the time was thought to be the best treatment for angina pectoris, internal mammary artery ligation. Some people say that the beginning of evidence based practice was with the publication of two placebo controlled studies comparing internal mammary artery ligation and sham operation for angina pectoris. After the publication of these two studies the use of this well loved procedure went away.(4, 5)

The Obama administration proposes that in health care reform that we place evidence ahead of belief, anecdote, profit, etc. Unfortunately, I fear that the First Amendment will get in the way. The right "... to petition the Government for a redress of grievances." I fear that lobbing will trump evidence.

SMP

1. Glasziou PP, Del Mar CB, Sanders SL, Hayem M. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2004(1):CD000219.
2. Tovey D. Evidence gets personal. BMJ Clinical Evidence. 2007;September 17.
3. Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8.
4. Cobb LA, Thomas GI, Dillard DH, Merendino KA, Bruce RA. An evaluation of internal-mammary-artery ligation by a double-blind technic. N Engl J Med. 1959;260(22):1115-8.
5. Dimond EG, Kittle CE, Crockett JE. Comparison of internal mammary artery ligation and sham operation for angina pectoris. Am J Cardio. 1960;5:483-6.

Pot calling the kettle black

When I started chiropractic college chiropractors were, according to the AMA, an "unscientific cult". Heck, some essentially still say that (see my Blog entry on Katz and Dogma). Nevertheless, Sharon Begley's column in Newsweek points out that standard medical practice is often unscientific. Looks like the pot calling the kettle black.

But I figure a double standard is the norm, and just get over it.

SMP