Corruption or cognitive dissonance?

If you are a cynic, you might believe that ineffective medical procedures are based on the Upton Sinclair line that it is impossible to understand something “if your income relies on you not understanding it”. In the Dutch medical system, for example, doctors are paid > 200 Euro for performing cortisone injection for knee OA ¹ . If the procedure is harmful, then this lucrative income source is in jeopardy, so it is hard to believe that it is harmful. This is not just a Netherlands problem however – it is a similar problem in all Western countries.

I see no difference between the Orthopaedic Surgeons who refuse to accept the negative results of Arthroscopy in knee OA and claim it is still justified (and that the money they make performing it is therefore justified) to the Rheumatologists and other OA doctors getting paid to inject cortisone who refuse to accept the long-term negative results of cortisone in knee OA and claim it is still justified. But rather than write this all off as pure and simple corruption, it is fairer and more realistic to go back to Prasad and Cifu², Daniel Kahneman³ and Michael Lewis⁴ in order to explain it. If your brain is locked into believing that cortisone is the correct ‘medical’ treatment for knee OA, you can manage to disregard each and every negative study that comes out as being unable to prove you wrong.

How confident am I that I’m on the right side of history?

I’m happy to put my name to this series of blogs and run the proverbial naked lap around an Olympic Stadium in the 2030s if the decade of the 2020s come to the rescue of cortisone injections and find that they actually help in the long-term for knee OA after all. It is clear from the studies in Table 1 of my previous Blog (2/4) that they don’t help; they are actually harmful. And no I don’t believe we need “further studies” to prove what is now evident. And all of the co-authors of the current guidelines out there saying “use cortisone injections anyway” will be on the wrong side of history but will blend into the large crowd because they are all too scared to break rank from their colleagues and side with the evidence.

Cortisone for knee arthritis is a medical reversal that needs to happen, and we really need to critically assess not only medical education but also the process for expert consensus statements as to why there is so much resistance to admitting when we’ve got it wrong.

Doctors need to lead society by “adhering to science”

There is plenty of knock-on effect of doctors prescribing harmful treatment – it fuels righteousness of conspiracy theorists and leads to rejection of medical evidence where doctors are using highly beneficial treatment (e.g. vaccinations). With respect to knee osteoarthritis in particular, it is clear that the net benefit of mainstream medical treatment is harmful¹. Knee OA outcomes (such as the number of Total Knee Replacements required annually in Western countries) are worsening every year as patients are increasingly subjected to harmful interventions. Knee arthroscopy, cortisone injections, opiates, NSAIDs and advice to “rest” because of degenerative findings seen on imaging have really created a management disaster for the condition of knee OA.

Knee OA, back pain, depression and obesity: all linked by medical mismanagement

There are perhaps only three other conditions to rival knee OA for medical mismanagement in the past 50 years: back pain, depression and obesity, and not surprisingly these four conditions tend to co-exist and collectively worsen each other. Fortunately we have one powerful weapon in the armoury against these diseases: moderate exercise ⁵ and the only way we can turn this ship around (other than come up with therapeutics that actually help not harm) is to ditch all of the harmful management options in favour of moderate exercise regimes. That now includes ditching cortisone injections.

Author and Affiliations:

John Orchard @DrJohnOrchard AM MD PhD FACSEP FFSEM (UK) FACSM

References

1. Orchard J, Moen MH. Has reimbursement for knee osteoarthritis treatments now reached ‘postfact’ status? Br J Sports Med 2017;51(21):1510-11.
2. Prasad V, Cifu A. Ending Medical Reversal: Improving Outcomes, Saving Lives. Baltimore: John Hopkins University Press, 2015.
3. Kahneman D. Thinking, Fast and Slow: Farrar, Straus and Giroux, 2011.
4. Lewis M. The Undoing Project: A friendship that changed our minds: W. W. Norton Company, 2016.
5. Orchard JW. Prescribing and dosing exercise in primary care. Aust J Gen Pract 2020;49(4):182-86.