By John Orchard
@DrJohnOrchard highlights the importance of the scientific method emphasising that it should be the rock on which all health practice is based. This blog is edited slightly from the canonical Sport Health co-publication. Sport Health is a member publication for Sports Medicine Australia (follow @SMACEO)
One of my favourite sayings from my medical education is “only 50% of what we do in medicine actually works, but you have to keep doing everything because you don’t know which 50% is helping”. The best part of the saying is the underlying admission that even the most genius- or god-resembling doctor has limited knowledge of the effects of many recommended medical treatments. One unfortunate part of the saying is that the 50% figure is totally made up, but it (the plucking from air of the figure ‘50%’) is almost self-parody. There is no doubt that the percentage of ‘fully effective’ medical treatments (i.e. options which are more effective than placebo or doing nothing) is lower than both practitioner and patient imagine. A better picture of health treatments (but which does not neatly fit into a one-liner) follows:
- Proven evidence-based interventions which we know are biologically effective beyond reasonable doubt because of the weight of scientific study demonstrating this;
- Possibly-effective interventions which have biological-plausibility of possible effectiveness but for which the jury is still out scientifically because of lack of high-quality studies;
- Placebo-effective interventions which actually work in the real world because they are non-harmful and because the patient thinks they will help actually achieve a better response than doing nothing;
- Ineffective interventions which have no biological effect and where the placebo effect does not deliver any bonus over doing nothing (and can be considered net negative not because of harm but because of opportunity cost/wasted resources);
- Placebo-harmful interventions (‘nocebo effect’) which have a negative effect because the patient was actually worried about the intervention and this negatively influenced recovery or for which the patient developed a side effect purely because of warning that it may occur (rather than any biological reason);
- Harmful interventions which actually end up making the patient worse because of biological damage done from the intervention.
Those of us working in health care know that almost no one (neither practitioner nor patient) ever tries to stick to category A interventions only and there is a good reason for this: category C (placebo-effective) interventions are helpful in so many cases you would be foolish to not utilise them. However, the key to getting a good category C response is that both practitioner and patient believe the intervention is in category B. So to summarise the three keys to being a good health practitioner are to:
- Believe in, and practise, evidence-based health care where possible;
- Embrace a modified version of Primum non nocere (which translates from Latin as “firstly, do no harm”), meaning only expose the patient to potential harm if it is very clear that the benefits outweigh the risks;
- Be optimistic; where the evidence-base is weak and you are relying on natural healing and the placebo effect, you should be optimistic, as it actually can be effective (moving category D interventions up to category C).
Just to throw a spanner in the works – in case everything described seems really simple so far(!)- is the likelihood (backed by scientific evidence) that more invasive and expensive procedures can give rise to a greater placebo effect than cheaper and less risky ones. Particularly if you are convinced that your problem is so bad that you need a pill/injection/operation to treat it! If exposing yourself to the risky effects of an invasive intervention is required to get a placebo effect then it may actually be worth it.
How does this apply to sports and musculoskeletal medicine?
First, our evidence-base is thin. Which should not surprise any of us, given the age of our specialty is. Most of what we do has a limited evidence-base (meaning that it is neither proven to be effective nor ineffective) and hence there is a heap of room for the selling of optimism. In moments of falling into despair, it might seem to be preferable to be working in an area of medicine or health care where there were more blockbuster treatments like vaccines, antibiotics or life-saving emergency treatments that definitely worked.
But a beacon emerging from that gloom is the certainty that exercise itself the closest thing that health care has to a miracle cure for just about everything. The true Panacea. Exercise prevents and/or treats cancer, cardiovascular disease, diabetes, osteoporosis, arthritis and depression (let’s just round it up to >75 per cent of all causes of mortality and morbidity in Western countries). The evidence-base about the value of exercise is extremely strong and further research needs to concentrate on ways to increase the uptake of exercise. This is where the sports and exercise medicine professions can come in. The “keep them on the park” mentality of the collective sports medicine professions is extremely valuable in terms of net outcome (more exercise) even if the means (applying placebo-effective interventions in many cases) is not always based on solid science.
Second, the interplay between the various placebo effects and health outcomes may lead patients to reject mainstream medicine for two different and opposite reasons:
On the one hand, mainstream medicine (when practised based on the evidence-base) may provide too little hope for some patients. A sports medicine example could be “sadly it looks like your knee osteoarthritis isn’t curable and we can only offer you suggestions to mitigate but not cure the pain and disability”. In this circumstance, some patients may seek an alternative practitioner who can offer the hope that mainstream medicine doesn’t profess to be able to give.
On the other hand, in mirror image circumstances, the reputation of mainstream medicine can be harmed when a widespread intervention gets discredited and revealed to have been only effective as a placebo and was maybe even harmful. We may be heading into an era where there is a group of patients who distrust mainstream sports medicine for having organised so many knee arthroscopies for arthritis prior to studies checking whether it was effective. Like any other area of life, there will be occasional scandals and corruption in health care and medicine.
So, like the cliche about the rock and the hard place, where there is no proven effective treatment, a clinician can be criticised for (a) not trying anything or (b) paradoxically for trying something that didn’t work and had no evidence-base.
What’s the solution?
Something needs to guide us out of this fog, and the saviour is the scientific method. In the glass-half empty world, it could be seen as a disgrace that so many ineffective knee arthroscopies for arthritis were done between 1980 to 2010 without scientific evidence to prove their efficacy. In the glass-half full world, which is where you need to live to be a successful health practitioner, it is a triumph of science that (eventually) a common procedure was assessed properly and found wanting. The disgrace will be if segments of the medical profession take too long to respond to the evidence, but it is not a disgrace to have tried a biologically-plausible treatment (knee arthroscopy for knee osteoarthritis) for a condition that is chronic and painful. Science moves along slowly but the scientific method should be the rock on which all health practice is based. One of my recent book readings I’ve enjoyed has been Shrinks: The Untold Story of Psychiatry by Jeffrey A. Lieberman. This excellent book has the underlying theme that evidence-based medicine is the way psychiatry progressed out of the dark ages.
Tie funding to evidence-based practice?
So fundamental is the scientific method that respect of it (or otherwise) should be the key criterion for health care funding and even registration. Because medicine is an inexact science, there is room for healthy skepticism about some of the controversial less-proven beliefs within it (with say, the replacement of the “stress” hypothesis of stomach ulcers with the Helicobacter pylori discovery being a great case in point). However when skepticism reaches a point that it involves rejection of a body of scientific knowledge that is beyond reasonable doubt, based on personal opinion, it becomes dangerous quackery. Within health-care, the anti-vaccination movement is the most prominent anti-science, anti-medicine movement at the moment. Being anti-vaccination is almost a calling-card for being anti-science and there is a good argument that you should not be licensed as a health practitioner if you reject the scientific method (i.e. practice on the basis that your personal experience and beliefs are more valid or accurate than anything that anyone has formally studied and published).
The field of Chiropractic gives rise to the debate between scientific and fundamentalist (called vitalistic within chiropractic circles) branches of the same profession. There has been recent debate at Macquarie University, Sydney about whether it is appropriate to teach Chiropractic degrees at the University. There has been a “soft” policy in the past of Sports Medicine Australia (SMA) that chiropractors should be discouraged from membership as an insufficient professional qualification, although this has been relaxed in recent years. I suggest a significant minority of chiropractors appear to be anti-science and anti-medicine. They may literally believe, for example, the original tenet of chiropractic that spinal malalignment is the underlying basis for all human disease, and therefore that the correct treatment of all medical conditions is spinal manipulation. This gets particularly touchy when some chiros allegedly ask their patients to reject, say, cancer chemotherapy in favour of spinal manipulation; or suggest that parents bring their ill newborns into chiropractic manipulation clinics rather than to GPs or emergency departments. That chiropractic is a refuge location for many in the anti-vaccination movement is also somewhat damning of the profession as a whole. For those who are fans of Twitter and anecdotes of chiropractic extremism, a ‘must follow’ is @Reasonable_Hank.
In defence of the (hopefully majority of) chiropractors, many in the real-world practice-wise have much in common with more mainstream professions. Chiropractors are part of sports medicine teams at major sporting events in reputable teams that practice according to evidence. Chiropractors may give evidence-based advice about return to physical activity wherever possible, and combine this with some effective treatment and doses of plenty of harmless but placebo-effective treatment which achieves this (very healthy) goal (of increased physical activity). There is an organised group of Chiropractors and Osteopaths called COCA (www.coca.com.au) in Australia which specifically is trying to move in the evidence-based medicine and science direction. Is it fair to tar these chiropractors with the brush of the rogue-end vitalists? There certainly would be physiotherapists and even medical doctors with ‘alternative’ anti-science mindsets, although their numbers may be less frequent. It does challenge the evidence-based chiropractors in groups like COCA to try to dissociate themselves from their fundamentalist colleagues, but it also challenges those of us in mainstream medicine to try to avoid, as much as possible, being pots calling the chiropractic kettle black.
Although I’ve tried to stay optimistic, a more distressing finish to this article has to be an acknowledgment that the anti-vaccination movement has many parallels outside health. It is terrific that the Australian government favours vaccination, but in other areas of science their policy stance is woeful. Climate change denial is the worst of it, but draconian cuts to the funding of basic science research in Australia and the removal of the portfolio of Minister for Science all point to an agenda against anti-science.
Comments on the USA
It gets far worse in the USA, the world epicentre of climate-change-denial and also where there are schools which are teaching creationism over evolution with political backing. There is evidence that politicians have interfered into science funding in the USA to not allow scientists to research public health benefits of gun control laws. Sadly there are two republican Presidential nominees who are specialist doctors by profession (Rand Paul and Ben Carson) but whose quoted political views on scientific matters seem incompatible with an understanding of the basic principles of the scientific method. Both apparently disbelieve basic scientific facts such as evolution and that the Earth is older than is stated in the Bible. Because of the openness of the democratic process, this does not disqualify them from being politicians. Obviously I have no information on their respective medical practices, but I’d be horrified if they had similar disregard for science when it came to decisions about whether to operate on a patient, for example. My concern is that it is too dangerous to run the libertarian “freedom of speech” arguments when it comes to medical staff. Healthcare professionals should have a limit placed on how much they can let any individual view override the scientific knowledge base, with the value of vaccination being a case in point. There is a good public safety argument that regulators should restrict healthcare licences to practice to those who respect the scientific method.
It is distressing that research on climate change, for example, is seen for the most part to be a left versus right wing political issue, when in reality it is a science versus quackery/corruption issue. I hope that I am preaching to the converted that the loyalty of modern health practitioner should not be to “God, king and country” (in that order) but to “science and medicine” in that order. Without science our health professions are worthless but because of it they amongst the most noble of all human pursuits. #ImWithScience (=I’m with science for Twitter)
@DrJohnOrchard is a sports physician located in Sydney, NSW. The opinions expressed are his own personal opinions.