Comments on: Suppose You Write the Times to Fix an Error (part 2) http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/ Self-Experimentation, Scientific Method, the Shangri-La Diet, etc. Thu, 18 Mar 2010 21:43:44 +0000 http://wordpress.org/?v=2.0.7 by: Johann http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-390163 Sun, 07 Feb 2010 23:20:14 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-390163 About the hernia problem, you are in good company. Clinical Evidence, the database of evidence-based medicine run by (I think) the British Medical Journal, has a monograph on "expectant management" (doing nothing) compared to repairing an inguinal hernia: "We found no systematic review, RCTs, or cohort studies of sufficient quality" to say which strategy is better for improving symptoms. Also from Clinical Evidence: "Compared with expectant management (in people with minimally symptomatic hernia) Open mesh repair may be no more effective at reducing mortality (very low-quality evidence)." But the bigger problem is that most people have no idea how much of our clinical practice is not guided by solid evidence, and never will be because there are just too many questions and good studies are so hard to do. As a physician I often tell people "nobody really knows what the right thing to do is," but I think it tends to make many patients uncomfortable so I find myself trying to gauge whether someone just wants my advice or is really interested in hearing my evaluation of the evidence as it may apply to them. I certainly try to be as complete as possible if people ask, and I have often been prompted by patients' questions to do literature searches, but I don't print out studies for people even if they ask because I don't have the time. If they are that motivated they can do it themselves. About the hernia problem, you are in good company. Clinical Evidence, the database of evidence-based medicine run by (I think) the British Medical Journal, has a monograph on “expectant management” (doing nothing) compared to repairing an inguinal hernia: “We found no systematic review, RCTs, or cohort studies of sufficient quality” to say which strategy is better for improving symptoms. Also from Clinical Evidence: “Compared with expectant management (in people with minimally symptomatic hernia) Open mesh repair may be no more effective at reducing mortality (very low-quality evidence).”

But the bigger problem is that most people have no idea how much of our clinical practice is not guided by solid evidence, and never will be because there are just too many questions and good studies are so hard to do. As a physician I often tell people “nobody really knows what the right thing to do is,” but I think it tends to make many patients uncomfortable so I find myself trying to gauge whether someone just wants my advice or is really interested in hearing my evaluation of the evidence as it may apply to them. I certainly try to be as complete as possible if people ask, and I have often been prompted by patients’ questions to do literature searches, but I don’t print out studies for people even if they ask because I don’t have the time. If they are that motivated they can do it themselves.

]]> by: Seth’s blog » Blog Archive » Gatekeeper Syndrome http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-362350 Tue, 17 Nov 2009 20:49:50 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-362350 [...] Shades of my surgeon claiming the existence of studies that didn’t exist. But that’s not the point. The point is this: After reading Atul Gawande’s article about mirror therapy for phantom limb pain, she and her husband tried it. “Within 2-3 days, his pain was down to zero.” It stayed there so long as they continued the mirror therapy. Soon after this they were able to eliminate his pain medication. [...] […] Shades of my surgeon claiming the existence of studies that didn’t exist. But that’s not the point. The point is this: After reading Atul Gawande’s article about mirror therapy for phantom limb pain, she and her husband tried it. “Within 2-3 days, his pain was down to zero.” It stayed there so long as they continued the mirror therapy. Soon after this they were able to eliminate his pain medication. […]

]]> by: seth http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-353178 Mon, 19 Oct 2009 06:15:57 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-353178 IV. Is the current emphasis on "evidence-based medicine" helpful or harmful? I don't mind that a doctor recommends a treatment for which there is no study showing it works. That is okay. It was that my doctor claimed the existence of non-existent studies that bothered me. IV. Is the current emphasis on “evidence-based medicine” helpful or harmful? I don’t mind that a doctor recommends a treatment for which there is no study showing it works. That is okay. It was that my doctor claimed the existence of non-existent studies that bothered me.

]]> by: Dennis http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-353111 Sun, 18 Oct 2009 22:34:04 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-353111 Seth: Here is a good PhD thesis topic: "I. What proportion of medical treatment or procedures have a basis in evidence? II. Looking at the universe of ailments, what proportion of treatments in [1950] are recognized to be (a) harmful; or (b) useless today? III. Given II., what should we infer about accepted treatments today that are not evidence-based?" Seth:

Here is a good PhD thesis topic:

“I. What proportion of medical treatment or procedures have a basis in evidence? II. Looking at the universe of ailments, what proportion of treatments in [1950] are recognized to be (a) harmful; or (b) useless today? III. Given II., what should we infer about accepted treatments today that are not evidence-based?”

]]> by: Seth’s blog » Blog Archive » The Price of an Unnecessary Operation http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-352574 Fri, 16 Oct 2009 11:21:12 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-352574 [...] A few years ago, a Berkeley surgeon named Eileen Consorti, to whom I was referred by my primary-care doctor, recommended that I have an operation to repair a hernia so small I couldn’t detect it. I have already written about how she kept saying there was evidence such operations were beneficial but as far as I can tell no such evidence exists. (Dr. Consorti has yet to provide the evidence she still seems to think exists.) Okay, she overstated benefits. What about costs? [...] […] A few years ago, a Berkeley surgeon named Eileen Consorti, to whom I was referred by my primary-care doctor, recommended that I have an operation to repair a hernia so small I couldn’t detect it. I have already written about how she kept saying there was evidence such operations were beneficial but as far as I can tell no such evidence exists. (Dr. Consorti has yet to provide the evidence she still seems to think exists.) Okay, she overstated benefits. What about costs? […]

]]> by: Heather http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-261010 Mon, 19 Jan 2009 06:51:10 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-261010 While I did not have a hernia, I just wanted to say I had a horrible experience w/ Dr. Consorti. I had extra breast tissue removed from my armpit, and she did a horrible job. First off, I would like to say how insulted I was that she did not have a paper gown in her office to adequately fit my breasts. She showed up late for my surgery, did it in half the time she said it would take, and stitched me up like a one-armed blind person who'd never been to med school. I used to be self-conscious about my underarm breast, but it's nothing compared to the hideous clown smile under my arm now. Oh yeah, and the puckers at both ends of the incision look like the nipples of a girl just entering puberty. DR. CONSORTI SUCKS! While I did not have a hernia, I just wanted to say I had a horrible experience w/ Dr. Consorti. I had extra breast tissue removed from my armpit, and she did a horrible job. First off, I would like to say how insulted I was that she did not have a paper gown in her office to adequately fit my breasts. She showed up late for my surgery, did it in half the time she said it would take, and stitched me up like a one-armed blind person who’d never been to med school. I used to be self-conscious about my underarm breast, but it’s nothing compared to the hideous clown smile under my arm now. Oh yeah, and the puckers at both ends of the incision look like the nipples of a girl just entering puberty. DR. CONSORTI SUCKS!

]]> by: seth http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-219542 Sat, 13 Sep 2008 01:48:51 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-219542 Eileen, to call my question "scientific" curiosity is highly unfair. I'm sure everyone, not just scientists, cares whether a proposed surgery will do more good than harm. My question is not "why" my hernia should be fixed -- it's <em>whether</em> it should be fixed. My calls that have gone unanswered were not about my "ambivalence" -- they were trying to determine what happened to the studies you said, several months ago, you would find and copy for me. But thank you for finally responding. Eileen, to call my question “scientific” curiosity is highly unfair. I’m sure everyone, not just scientists, cares whether a proposed surgery will do more good than harm. My question is not “why” my hernia should be fixed — it’s whether it should be fixed. My calls that have gone unanswered were not about my “ambivalence” — they were trying to determine what happened to the studies you said, several months ago, you would find and copy for me. But thank you for finally responding.

]]> by: eileen consorti http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-219500 Fri, 12 Sep 2008 22:33:59 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-219500 Seth, While I am in the process of finding papers in the literature to satisfy your scientific curiosity on why this hernia should or should not be fixed I am additionally trying to care for around 30 new patients referred to me for their new cancer diagnosis in the last 3 months. This may or may not explain why I have not been motivated to answer your call regarding your ambivalence about fixing your hernia. Yes, it is small and runs the risk of incarceration at some time. I will call you once I clear my desk and do my own literature search. Thanks for the update. Eileen Consorti Seth, While I am in the process of finding papers in the literature to satisfy your scientific curiosity on why this hernia should or should not be fixed I am additionally trying to care for around 30 new patients referred to me for their new cancer diagnosis in the last 3 months. This may or may not explain why I have not been motivated to answer your call regarding your ambivalence about fixing your hernia. Yes, it is small and runs the risk of incarceration at some time. I will call you once I clear my desk and do my own literature search. Thanks for the update. Eileen Consorti

]]> by: Gordon http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-216362 Wed, 03 Sep 2008 23:18:24 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-216362 Sean, I'd like a reference to the key articles by Deming if you have them. Regarding the question of whether or not one can trust a doctor's recommendation, what about dentists? In the early 20th there were some in the profession who made claims that dentistry had reached the point in history where it was about to start doing more good than harm. Were they right? Have we ever reached that point? How can we know? Sean, I’d like a reference to the key articles by Deming if you have them.

Regarding the question of whether or not one can trust a doctor’s recommendation, what about dentists? In the early 20th there were some in the profession who made claims that dentistry had reached the point in history where it was about to start doing more good than harm. Were they right? Have we ever reached that point? How can we know?

]]> by: sean http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-214383 Sat, 30 Aug 2008 15:13:51 +0000 http://www.blog.sethroberts.net/2008/08/29/suppose-you-write-the-times-to-fix-an-error-part-2/#comment-214383 The dirty little secret is that some doctors are not as driven by evidence as we might hope. That is why the evidence-driven medicine movement is gaining momentum. Remember how medical journals initially refused to published evidence that <i>helicobacter pylori</i> was a cause of ulcers and not stress? A number of doctors pretend to be driven by evidence, but they are much more driven by a god complex that says, I'm the expert listen to me. The sampling question is another example of enumerative versus analytic thinking in the world of statistics. Most people think that all statistics is enumerative. Refer the journalist to any of the key articles by Deming. The dirty little secret is that some doctors are not as driven by evidence as we might hope. That is why the evidence-driven medicine movement is gaining momentum. Remember how medical journals initially refused to published evidence that helicobacter pylori was a cause of ulcers and not stress?

A number of doctors pretend to be driven by evidence, but they are much more driven by a god complex that says, I’m the expert listen to me.

The sampling question is another example of enumerative versus analytic thinking in the world of statistics. Most people think that all statistics is enumerative. Refer the journalist to any of the key articles by Deming.

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