Monday, 19 March 2018

Experience versus evidence, regarding Ian Harris

Professor Ian Harris, author of the book, "Surgery, the ultimate placebo", is a traumatologist who directs a research unit focused on the results of surgical practice in Sydney. Harris says in the book's introduction: "Lack of evidence allows surgeons to practice techniques for the simple reason that they have always been done, because they learned them from their mentors, because they are convinced that it works or simply because it does everybody. It's easier to have no problems if you behave like most colleagues, my argument, says the author, is that trusting tradition and perceptions often leads, in terms of clinical effectiveness, to unconvincing results."

The placebo effect

It’s only scarcely a century ago when surgeons practiced bloodletting to treat people who had diseases or manifestations as diverse as pneumonia, cancer, diabetes or jaundice. Bloodletting met all the requirements of a good placebo: it was an invasive, painful and a drastic technique based on pseudoscientific reasoning. Harris says that many of those who laugh at the lack of consistency and the real risk that the practice of bloodletting brought to humanity from the Mesopotamian civilizations until well into the 20th century, when you show them that there is evidence that what they do, doesn’t respond well to methodologically sound evaluations, they defend themselves with the arguments that it  has always been done in that way, assuming, from personal observations, cause-effect relationships that are not proven.

The placebo effect is the extra benefit generated by the perception of improvement, with a tendency to relate this sensation to the treatment received, especially if it has been invasive, painful, drastic and based on pseudoscientific arguments, disregarding the eventuality that perhaps that process would also have gone well without any intervention. Human nature makes us see what we want to see. When we believe in a treatment, we tend to attribute all the positive effects to it, whereas if they appear as negative, we associate them with other causes.

Ethics of surgical clinical trials (sham surgery)

When a surgical clinical trial is proposed, there is a certain ethical prevention arising from the concern for the people who are in the control group, since they will receive a sham surgery, that is, the skin will be opened and they will be sewn without having had any surgical procedure. Harris, however, defends studies with false surgery, since, he says, it’s less ethical to submit lots of people to treatments that have not been sufficiently evaluated, than not to get a few consents for a clinical trial, where the individual risk of the volunteers can bring many benefits to the community. Another aspect in favour of the rigorous evaluation is that in a systematic review of 53 clinical trials with placebo it was discovered that in half of the analyzed interventions, the operation was not better than the false surgery and that in those cases when it was, the difference was not significant.

It’s a fact that many patients improve after a real operation, but there’s also the fact that many patients also improve after a false intervention. Arthroscopies and vertebroplasties would be two of the examples cited by the author as techniques in which the false operated patients improved in the same way as those who actually had the real thing done. For this reason it’s worrisome that, according to a study by Ian Harris's research unit, of the 9,000 surgical procedures performed in orthopaedic and traumatology services of three public university hospitals in the Sydney area, only half are backed by consistent scientific evidence.

Experience versus evidence

The search for success via invasive precision techniques is one of the main motivations of many doctors when they choose a surgical specialty. This is clear, says the author, when we observe that surgeons tend to measure the results in objective terms: straightening of a bone after a fracture, the amount of tumour removed, etcetera; while patients tend to assess more subjective issues such as pain or functionality, and too often the two approaches are dissociated. The question, however, is that there is no greater satisfaction for a surgeon than to see how things improve after having worked hard within a body. In these circumstances, the association of cause and effect is much stronger than the coldness of some evidence based on work done by others with who knows what intentions.

Evidence documents of common procedures

Apart from the author's reflections on the scientific shortcomings of today’s surgery, the reader, if interested, will find small files on the degrees of evidence of many common interventions such as: vertebral fusions, shoulder surgery, hysterectomies, caesarean sections, appendicitis, laparoscopies peritoneal adhesions, angioplasties, venous filters for emboli, renal ptosis, tendon ruptures, fracture surgery, cancer surgery, etc. 

By way of closing, I’ll feature a famous phrase within the surgical environment as highlighted by Ian Harris in the book. "Any surgeon can operate, a good surgeon knows when he or she has to operate, but only the best know when they should not operate."

Jordi Varela

Monday, 12 March 2018

The myth of lack of adherence

Cristina Roure

It's not that they don’t know or don’t want to know, it's that they can’t

I recently read of a doctor complaining that when he began his career, he assumed that if a disease was treated, the patient would improve, but in reality the results were far from expectation. It isn’t surprising if we remember that adherence to advice and treatment in chronic patients is less than 50%, as shown by a recent survey conducted in Spain in a sample of 1,400 chronic patients.

Despite attempts to change the attitude and pardon the patient, such as calling those that don’t comply or adhere, the truth is that systems to increase adherence to treatment always focus on changing patients’ attitudes or aptitudes. Lack of adhesion is rarely viewed as a system problem.

Wednesday, 7 March 2018

Is it possible to design a health system without a narrative basis?

Salvador Casado

One of the most complex issues in health organizations is to design structures and processes that combine quality, effectiveness and user satisfaction. So far no one has found the holy grail of “the good, beautiful and cheap” in healing. Where I would like us to pause for a moment is in the analysis of the founding fact of any health system: the clinical act. The point of contact between patients and health professionals is the clinical meeting that will lead to a therapeutic relationship.

The problem is that nowadays this is very expensive and at the moment nobody dares to automate it using technology, algorithms or artificial intelligence. When you're sick, you want someone to treat you, not a robot.

Monday, 5 March 2018

Capacity, environment and diversity: changing the vision of aging

Marco Inzitari

Judging by appearances, one might think that health professionals build their fortune on the misfortune of others. Traditionally, in fact, we deal with risk, diseases and their negative impact, more or less catastrophically. And, in the face of an aging population, we focus on multi morbidity, chronic disease, geriatric syndromes, disability and the end of life.

The recent report of the World Health Organization (WHO), entitled "World Report on Aging and Health" (September 2015), is committed to a change of focus. The report, which is positioned as a reference of health policies on aging, is long and complex, and addresses many dimensions of aging, from prevention to manifestations and consequences, to the need for long-term care (not in the mere sense of resource, if not of necessity continued in time, no matter how it’s provided).