Sunday, 20 August 2017

Prius non tempore: first, do no time

The golden rule of surgery is: Primum non nocere - ‘First, do no harm’. There is another, competing rule that comes from practicing defensive medicine: Prius non tempore - 'first, do no time'.

Saturday, 19 August 2017

Surgical consent: permission or a decision?


So much emphasis is placed on the consent form; we are lectured about it’s importance from our first days as an intern. Like no other form, it is constantly being modified in order to make the form better reflect the role it is meant to play. But what is that role? Is the consent form simply a permission slip, designed to minimise the risk of surgeons being sued if complications occur? Or is it a statement by the patient that they have considered all the options and have come to a decision to have this treatment over all other options, despite the risks? Looking at the form, it is a bit of both, and it probably performs the latter function very poorly.

Sunday, 21 May 2017

SLAP in the face for shoulder surgery

I have always been sceptical of some shoulder procedures, and the increasing rate of shoulder surgery and the lack of high quality evidence worries me. I started a simple blog post about one particular operation (for “SLAP” lesions) and found a tale of research waste, bad science, overdiagnosis and overtreatment.

Wednesday, 17 May 2017

Steroid injections in the knee

Corticosteroid injections in the knee are VERY commonly performed for any knee pain, but particularly for osteoarthritis. They don’t provide significant benefit to people, and they cause harm.

Monday, 8 May 2017

Overcoming cognitive biases

A recent paper in the Medical Journal of Australia (here) provides a nice overview of the biases that lead doctors to overtreat and overinvestigate, but also offers useful solutions that we need to act on.

Saturday, 15 April 2017

Treating the numbers, not the patient

This story is a good example that goes along with a previous post about treating (and correcting) surrogate factors (like X-rays and blood tests) instead of treating patient health (see: The map is not the territory). In this case, hypothyroidism (low thyroid hormone levels) in older people comes under the spotlight. If patient don’t have any symptoms, it is still often treated in order to correct the ‘disease’ state. But as researchers found in this randomised trial, replacing their thyroid hormone (compared to placebo) definitely improved the thyroid hormone levels in the blood, but it did nothing to any other outcome measured. It didn’t help the people being treated.

This is a classic example of overdiagnosis – discovering an abnormality in some people (a low thyroid hormone level is common in older people) and labeling it a disease. Doing so then leads to overtreatment aimed at addressing the ‘abnormality’ rather than aimed at improving the health of the patient. This last part is the trick of overtreatment – correcting things in our body is surely good for us, right?  No, not always. It needs to be shown that it is – not assumed. And any benefit shown needs to outweigh any unintended consequences and direct harms from the treatment.


The other problem I have with the problem of overdiagnosis and overtreatment is that the research that shows them wrong comes so many years after the practice has become entrenched (like in this case), making it much harder to undo common practice than if the research was done before the treatment was introduced.

Wednesday, 22 March 2017

The 'otherness' of research in clinical practice

“Researchers don’t know what it’s like to deal with patients”. Research is meaningless to me – I know what works”. “Most research is rubbish.” I am concerned by comments about research that suggest it is something that can be separated from clinical practice – something that can be ignored when providing good clinical practice. I know several colleagues who just ‘don’t bother’ with research. This ‘otherness’ of research is a fallacy. It would not be so easy to distance oneself from research if we simply called it what it is: science.

Thursday, 2 March 2017

Saying "no" to medical cannabis

A state politician just defected to another party because that party agreed to support his stance on medical marijuana (cannabis). The politician stated that it was a moral decision because he wanted to save kids’ lives. Even if he was supporting it for other reasons, medical cannabis falls way short on effectiveness of just about anything, and it certainly doesn’t save kids’ lives. There is a real need for politicians to be more scientific in their information gathering and appraisal. This will make it less likely for them to make untrue statements, and bad decisions based on those statements. Let’s look at the evidence for the true effectiveness of medical cannabis.

Monday, 23 January 2017

Vitamin supplements: too much of a good thing?

Vitamins are vital amines, needed for everyday chemical reactions in our bodies. Deficiencies can be harmful, but that doesn’t mean that taking more than you need is beneficial. In fact, it can be very harmful yet the message that more is better prevails. Does vitamin supplementation help those who are not deficient?

Saturday, 14 January 2017

Don’t treat me, I’m a doctor

“Tennis elbow”, also known as lateral epicondylitis, is a common condition causing pain over the outside of the elbow, where the muscles to the wrist and fingers attach. I’ve got it, and I am doing absolutely nothing about it. Doctors often do not seek treatment, even treatments that they themselves recommend to others. What do these doctors know that makes them avoid treatment?

Sunday, 2 October 2016

Yes, you DO have to ‘live with it’, and that can be a good thing

A common ending to a consultation where I have explained to a patient that there is nothing that surgery/medicine can reliably or safely offer them for their symptoms (back pain, joint pain, limited joint movement etc.) is “So I just have to live with it do I?” A difficult question to answer but also a question that tells us a lot about the person asking it.

Saturday, 10 September 2016

The wisdom of wisdom tooth extraction

I have 4 kids, 3 of whom had their wisdom teeth removed on reaching adulthood on the advice of specialists. I had mine removed in my 30s for some reason and so did my wife. In the US and much of the world this is a billion dollar per year business, with millions of molars extracted every year in the US alone. With those numbers, even a small complication rate can add up to a lot of complications, and as a surgical procedure there are also significant costs. Yet it has been argued that the reasoning behind most of the extractions are flawed and that the procedure is often unnecessary.

Saturday, 9 July 2016

2 ½ litres of water per day - really?

Many people I know drink water constantly – they are always taking a swig out of a water bottle that never leaves their side. After having renal stones recently, I tend to try to drink more, but just don’t like drinking water, and I find that I am not thirsty most of the time anyway. Who’s right – those who tell me to drink water constantly, or my body, which rarely makes me feel thirsty?

Saturday, 18 June 2016

Treatment for pre-term rupture of membranes in pregnancy

Another large international trial is published, and another standard practice based on little more than our bias towards doing something rather than doing nothing is reversed.

Saturday, 12 March 2016

Book review, of my book: Surgery, the ultimate placebo.

This will be a test of how unbiased I am. Writing a review of my own book (regardless of any bias) seems like shameless self-promotion, but what the hell, it's better than just saying "Hey, I wrote a book".

Saturday, 13 February 2016

Knee arthroscopy for "mechanical symptoms"

I have previously written about the (non) role of arthroscopy for osteoarthritis or degenerative meniscus tears in the knee (here, here and here). Surgeons have continued to operate, based on a belief that (now) centres on the presence of mechanical symptoms. An analysis of the recent sham surgery trial of arthroscopic partial meniscectomy (APM), which showed APM to be no better than sham for patients with meniscus tears without arthritis, has shown that this procedure is no better than sham surgery for patients with mechanical symptoms.

Monday, 2 November 2015

Laparoscopy for bowel adhesions

Laparoscopy is keyhole surgery of the abdomen in which a camera and instruments are inserted through holes in the skin, into the abdomen to see the structures within (diagnostic laparoscopy) and to correct pathology where possible (therapeutic laparoscopy). In patients that have had previous pathology or surgery to the abdomen, adhesions can develop whereby loops of bowel can get caught up in scar tissue. If this causes an obstruction of the bowel, it can be very serious, but often people just have abdominal pain that coexists with adhesions.

Sunday, 4 October 2015

Prophylactic mastectomy

Prophylactic mastectomy reduces the risk of getting breast cancer (here), but does it reduce your overall risk of dying? And what are the other risks?

Sunday, 23 August 2015

Sham physical therapy

Paradoxically, it is easier to perform a sham trial in surgery, the most invasive physical act, than in physiotherapy because the patient is asleep when it is delivered. Physical therapy involves physical acts that are hard to imitate as placebo treatment, but the influence of the patient-therapist interaction makes it important to tease out any placebo effect. Researchers have, however, performed sham trials in physiotherapy.

Saturday, 15 August 2015

Fixing a hole

Migraine is common, affecting millions of people worldwide. A patent foramen ovale (PFO – a ‘hole in the heart’ that lets blood cross from the right heart to the left) is common as well, present in about 30% of people. When cardiologists started surgically closing PFOs, they noticed that many patients with migraine got better. As with the discovery of any association in medicine, theories of a causal link soon followed, and doctors started treating migraine by closing the hole in the heart; before properly testing it, of course.