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EDITORIALS: Jenny Doust and Chris Del Mar Why do doctors use treatments that do not work? BMJ 2004; 328: 474-475 [Full text]

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The use of Time

Campbell Murdoch   (27 February 2004)

Peer Pressure

David B King   (27 February 2004)

Buying Time

Louis B Jacques MD   (27 February 2004)

On Using Ineffective Treatments

Kshitij Mankad   (27 February 2004)

Medicine is a science of prediction and intervention

Ludovic Reveiz   (27 February 2004)

Small question with big answers

Tom P Marshall   (27 February 2004)

Pecunia

Pablo Rodriguez del Pozo   (27 February 2004)

Cushing’s syndrome following ‘Herbal therapies’ for Bronchial Asthma and Rheumatoid Arthritis in India.

Parvaiz A Koul   (28 February 2004)

It may be better sometimes to do nothing

John Hart, D.C.   (28 February 2004)

Cochrane’s fourth dimension: harm

Cynthia M Lewis   (29 February 2004)

Voltaire? Molière?

Joseph C. Watine   (29 February 2004)

The suppossedly Common Problem

Vijayashankara Chikkade Nanjegowda   (1 March 2004)

Re: Voltaire? Molière?

Kathleen I. E. Lane   (1 March 2004)

We do things, because

Malvinder S. Parmar   (1 March 2004)

Re: Re: Voltaire? Molière?

Joseph C. Watine   (2 March 2004)

Risk of litigation

Helen H G Handoll   (2 March 2004)

Possible additional factors

Steven Ford   (2 March 2004)

We know what THEY want us to know

Prabha S. Chandra   (4 March 2004)

Don't just stand there, hold my hand

Karen Forbes   (4 March 2004)

Why they think doctors use treatments that do not work?

Pisut Katavetin   (5 March 2004)

It needs the communication skills to do so

Malcolm I Thomas   (9 March 2004)

Changing times; changing perceptions!

Kirti M Marya   (10 March 2004)

Both science and art determine a strategy of treatment.

Graeme A Pollock   (13 March 2004)

Ideology can explain much physician decision making

david egilman   (14 March 2004)

CAST Study wrongly cited

Stewart Mann   (15 March 2004)

Changing times; changing perceptions!

Kirti M Marya   (16 March 2004)

Does the evidence presented really show the trreatment doesn't work?

Christopher P. Little, Ian McNab   (2 April 2004)

Missing Our Moral Imperative

Lawrence I. Silververg   (23 May 2004)

Why do doctors use treatments that don`t work?

Joaquim Palmeiro Ribeiro, Susan Marum   (15 June 2004)

Re: Pecunia

John P Heptonstall   (16 June 2004)

Primum Non Nocere

Dr. Herbert H. Nehrlich   (20 June 2004)

"There is gold in them there freckles...."

Dr. Herbert H. Nehrlich   (11 July 2004)

The use of Time 27 February 2004
Campbell Murdoch, Head of School Kalgoorlie Send response to journal: Re: The use of Time	Another reason for using so called ineffective treatments is to allow time to pass while the patients get better. Cough bottles were not treatments, they were like egg timers. You gave the patient or the parent an ineffective coloured liquid in a bottle and asked them to take 5 ml four times a day out of it. By the time the bottle was empty, the patient was better, not because the contents worked, but because time had passed. It was effective , but for the wrong reason. Competing interests: None declared
Peer Pressure 27 February 2004
David B King, Lecturer Centre for General Practice, University of Qld 4006, Australia Send response to journal: Re: Peer Pressure	Surely one of the greatest barriers to changing ones practice in light of evidence of harm or ineffectualness is the fear of being different from ones peers in a relatively conservative profession. It takes brave clinicians to adopt practices outside of what the 'body of medicine', and thus medico-legal rulings, deem to be current accepted practice. The discipline of medicine needs to support the 'innovators' and 'early adopters' if their behaviour is supported by good evidence, and not lump them together with 'quackery' that operates at the fringes of evidence. Competing interests: None declared
Buying Time 27 February 2004
Louis B Jacques MD, Clinical Faculty Baltimore MD 21244 Send response to journal: Re: Buying Time	A senior colleague used to give students the following advice. When instructing patients about things to do before their return appointments, always include one task that is so complex or onerous that the patients will never actually do it. Thus, when they are not completely healed by the time of their return visit, the doctor can ask if the patient has complied fully with the instructions. On hearing that they of course had not, the physician could attribute their continuing symptoms to their failure to adhere to the instructions. Competing interests: None declared
On Using Ineffective Treatments 27 February 2004
Kshitij Mankad, SHO, Medicine Northern General Hospital, Sheffield S5 7AU Send response to journal: Re: On Using Ineffective Treatments	One of the factors responsible for the use of ‘ineffective treatment’ is the injudicious use of ‘blanket treatment’ in the name of ‘evidence based practice’- A practice that needs to be continually questioned, analysed, audited and most importantly, individualised, each time it is used. With the rising awareness levels of our patients and the unprecedented and relentless information explosion that grips the modern age, the physician is left with little explanation for not ‘trying anything’- The World Wide Web has an answer for all questions- from laser therapy for thin nails to special ‘natural remedies’ for organ enhancement - technology strains the ability of traditional morality to provide authoritative guides to medical consumerism. The need for adequately ‘powered’ randomised trials is imperative- nevertheless, what is perhaps more important is to have the judiciousness to individualise care, to rely on experience more than print, and for the physician to be able to discern and foresee whether a new therapy or objective has any conviction in the short and long run. That comes through proper clinical training received in a doctor’s formative years. Medical students should be encouraged more into the ‘practice of being doctors’ rather than allowed to spend half a decade trying to pass examinations based on sublime textbook knowledge. We are denizens of the brave new world. We need to nurture the power to discern and to develop the confidence to be able to say ‘no’ when nothing needs to be done. A feeble mind wrapped up by layers of bookish matter probably lacks all of it. Let us refuse to merely play attention to the wanton desires of an unquestionably paced technology. The NHS still holds on to these idealisms to a major extent when compared to its other capitalistic counterparts in the western hemisphere where cutthroat modernisation continues to mar the eros and ethics of medicine. We forget where to draw the lines when we stop questioning ourselves about our actions. Competing interests: None declared
Medicine is a science of prediction and intervention 27 February 2004
Ludovic Reveiz, Co-ordinator of General Practice, Specialist in Epidemiology, Colsánitas, Cons. Clínica Reina Sofía, Bogota Colombia Send response to journal: Re: Medicine is a science of prediction and intervention	In epidemiological studies assessing effectiveness and benefit involves several levels of imprecision and uncertainty at the individual level while its estimator is defined at the population level. A single disease entity may have varied manifestations in different patients, several disease status, and divergent outcomes.(1) As Anderson and Groves emphasize(2), Archie Cochrane posed three key questions to ask about a healthcare intervention: "Can it work?" "Does it work in practice?" and "Is it worth it?". We usually use rules to decide between an answer of “yes”, "not sure" and "no". By doing this we assume the Aristotelian logic and the classic current view of disease define as that “health and disease are opposites and that they are dual and contradictory attributes”.(1) Why do doctors use treatments that do not work?(3) People usually do not require precise numerical information input, and yet they are capable of making decisions; they accept noisy and imprecise input(4); so do doctors. Having a huge number of input variables (patient background, expectations behavior and beliefs, disease manifestations, laboratory test, etc) physicians use “fuzzy logic” algorithms (membership grades of studies evidence, personal knowledge, cost, ritual and mystique etc) to decide treatments. Evidence is one of the most important piece of the complex system, but not the only one. “Fuzzy logic” has been developped to deal with concept of partial truth values between completely true and completely false. “Fuzzy logic” mimics human control logic and may be applied to improve knowledge in epidemiological and medical problems.(1,4) 1- Massad E, Ortega NR, Struchiner CJ, Burattini MN. Fuzzy epidemics. Artif Intell Med. 2003 Nov;29(3):241-59 2- Alderson P, Groves T. What doesn't work and how to show it. BMJ 2004;328:473 3- Doust J, Chris Del Mar C. Why do doctors use treatments that do not work? BMJ 2004;328:474-475 4- Kaehler SD. Fuzzy Logic Tutorial. Accessed in Feb 2004. Available at: http://www.seattlerobotics.org/encoder/mar98/fuz/flindex.html Competing interests: None declared
Small question with big answers 27 February 2004
Tom P Marshall, Harkness Fellow in Health Policy Boston MA 02120 Send response to journal: Re: Small question with big answers	Why do doctors use treatments that do not work? This is one of the simplest and most profound questions in health care. Already it has stimulated some interesting responses. If the questoin is broadened to include all health-related professionals it becomes apparent that all are guilty - and doctors less guilty than some. There are many answers. 1. Because we pay doctors to do this - eg: reimbursement is unaffected by efficacy 2. Because doctors are taught to "practise medicine" not to "help the patient". Clearly the two often overlap, but they may not do so. When they do not we are guided by adherence to professionally accepted theories about what we should do as much as by evidence of benefit. This is odd. We do not expect plumbers and mechanics to "practise plumbing", we expect them to get results. I still remember being told that to conduct a very detailed neurological examination on a stroke patient was "good medicine" even when all the carefully elicited (but probably inaccurate) localising signs would be ignored as soon as the MRI had been carried out. 3. There are limits to diffusion and uptake of knowledge. We are overloaded with irrelevant information (on the minutae distinguishing one NSAID or antihypertensive from another) but have little access to information on things we have been doing for years but do not work eg: analgesics for post-herpetic neuralgia 4. There is a tension between short-term relief and long term attempts to "help the patient". Some things provide instant relief but little long-term benefit (or even harm) eg: anxiolytics, loop-diuretics for oedema (or even for heart failure), long-acting bronchodilators. 5. Justification of effort - some fairly basic psychology suggests if we take a lot of effort to achieve something we tend to justify our efforts by attaching value to what we achieved. Who ever climbs to the top of a mountain only to say it wasn't worth it? We spend years learning to offer some treatments that don't work, this makes it harder for us accept that it may have no value. 6. The myth of "pathophysiological models". Students are taught medicine as if we first learned how the body works, then learned how it went wrong and finally deduced how to fix it. So when we see a plausible pathophysiological model we think we can predict what will work. This makes us resistant to to evidence from clinical trials that contradicts our cherished pathophysiological model. We rarely teach that the reality medical knowledge is often discovered in reverse. We first identify an illness. Then accidentally find that something works to cure it. We then infer from this how the treatment works and elucidate the underlying disease mechanism. Competing interests: None declared
Pecunia 27 February 2004
Pablo Rodriguez del Pozo, Assistand Professor, Medical Ethics Weill Cornell Medical College in Qatar - PO. Box 24144 Send response to journal: Re: Pecunia	The authors seem to have overlooked economic incentives, direct or indirect. Fee-for-service payments that favor multiple visits and the induced demand of diagnostic and therapeutic practices, from imaging to surgery. Capitated systems that favor a broad base of patient enrollment and penalize patients turnover (so patients must be kept happy at any price), or that leave some practices out-of-capitation, therefore incentivating its prescription. Managed care systems that impose protocols doctors must follow strictly under the penalty of receiving a devalued paycheck, or being directly dropped from the list of providers. Monetary or other type of incentivations from third parties, either the pharmaceutical industry, or colleagues or centers where patients are referred for specialized or high-tech treatment. These are only the most obvious examples, mostly legal, in the list of economic incentives that keep doctors using treatments that do not work. Competing interests: None declared
Cushing’s syndrome following ‘Herbal therapies’ for Bronchial Asthma and Rheumatoid Arthritis in India. 28 February 2004
Parvaiz A Koul, Additional Professor of Internal and Pulmonary Medicine SKIMS, Soura, Srinagar 190011, Kashmir Send response to journal: Re: Cushing’s syndrome following ‘Herbal therapies’ for Bronchial Asthma and Rheumatoid Arthritis in India.	Apart from standard allopathic treatments, multiple traditional treatments are available for chronic disorders like the rheumatoid arthritis and bronchial asthma in India. These treatments have included various herbs, fish treatments, Yoga in many forms, etc. While all practitioners of such treatments claim ‘side-effect-free’ cure they have not been put to scientific scrutiny. A number of ‘famous’ hakims (practitioners) dispense magical cures in the form of sachets of crushed medicines and corticosteroids are used to effect a quick response for the problems. We report on 12 cases of Cushing’s syndrome who developed the same after being on ‘herbal’ treatment for treatment of rheumatoid arthritis and bronchial asthma. The patients included 8 females and 4 males with ages ranging from 15-55 years (median 34). Eight patients had rheumatoid arthritis and 4 had asthma that was poorly controlled on routine management for the two disorders. The patients had started taking the ‘magical’ treatment that was dispensed in the form of small sachets containing 25-30 grams of the medicine for a period lasting 3-6 years (median 4 years). All the patients reported an immediate amelioration of their symptoms of breathlessness, morning stiffness and arthritis after starting the treatments. But lately they had observed a need for increase in the consumption of the sachets. The patients reported with facial mooning, weight gain, swelling of legs, inability to get up from a sitting position. Clinical signs included clinical cushingoid features in all the cases, hypertension (n=5) with proximal myopathy in 8 cases. Plasma cortisol was low suggestive of exogenously administered steroids. Four patients had bone mineral density in the osteoporotic range though all had evident osteopenia upon DEXA-scanning. The physical characteristics of the sachets revealed multiple poorly ground tablets amidst a finely ground powder. Analysis of the dispensed drugs in 3 cases revealed steroids. All the patients were put on conventional therapy for the disorders and an empiric dose of 0.5mg/kg body weight of prednisolone. All but one were taken off the steroids after gradual tapering and there was a gradual reversal of the cushingoid features over 6-9 months. One patient with rheumatoid arthritis needed to be on a 10 mg dose of prednisolone to remain symptom free. This report goes only to emphasize that not infrequently hapless and unsuspecting patients are started on high and unknown doses of steroids in the garb of starting herbal ‘magical and innocuous’ therapies and the patients can report with frank Cushing’s syndrome. Cushing’s syndrome has also been reported following use of Chinese medication for gout and other arthritides in the seventies of the last century (1,2). Our report emphasizes the continued occurrence of such events in the Indian subcontinent. The use of such therapies needs to be seriously deprecated and regular patient education programs held in order to obviate such unfortunate occurrences. Somebody has to ask questions and this form of harmful prescription could stop. REFERENCES 1. Edwards CJ, Lian TY, Chng HH. Cushing's syndrome caused by treatment of gout with traditional Chinese medicine. Q J Med 2002; 95:705 2. Forster PJG, Calverley M, Hubball S, McConkey B. Cheui-Fong-Tou-Geu- Wan in rheumatoid arthritis. Br Med J 1979; 2:308 Competing interests: None declared
It may be better sometimes to do nothing 28 February 2004
John Hart, D.C., Instructor Spartanburg, South Carolina 29304 Send response to journal: Re: It may be better sometimes to do nothing	Drs. Del Mar and Doust are to be congratulated for their thought- provoking editorial. One of their comments, that "We find it difficult to do nothing (the aphorism "Don't just do something, stand there!" seems ludicrous)" reminds me of a saying Herbert Ratner, M.D. use to say: "the thoughtful physician, in many instances, decides to do nothing" (1). John Hart, D.C. Reference 1. Northup GW. Viewpoint: Herbert Ratner, M.D. The D.O. 1967;7(11):76-82. Reprinted in Child and Family1973;12(2):149-158. Competing interests: None declared
Cochrane’s fourth dimension: harm 29 February 2004
Cynthia M Lewis, Retired DE4 5HS Send response to journal: Re: Cochrane’s fourth dimension: harm	The articles in this theme issue about ineffective treatment discuss the potential for harm, but is this consideration given enough weight? And I wonder if Archie Cochrane is responsible. To his key questions about a healthcare intervention: "Can it work?" "Does it work in practice?" and "Is it worth it?" should be added "IS IT HARMFUL"? Clinicians want to relieve suffering and find it difficult to do nothing. Doust and Del Mar quote Voltaire, "The art of medicine consists in amusing the patient while nature cures the disease". Such placebos may fool the patient - but isn't the doctor also being fooled? Doust and Del Mar have an 8-point list of reasons for using ineffective treatment – “clinical experience” is number one. But what is clinical experience and how is it gained? For many, experience is learned behaviour - it is copied from teachers and peers. If it were to be knowledge gained from patient experience, the placebo would dominate. So, in this era of evidence based, scientific medicine, doctors learn not to listen to patients - the doctor knows best. Is this why harmful side effects are ignored? The paradox is that a patient’s experience may be placebo driven and therefore scientifically invalid. But is it reasonable to discount a patient’s complaint about harmful side effects? If the procedure in question has even the slightest chance of harm there should be no dilemma about "what to do". But it appears that measuring harm is even more difficult to measure than benefit. Why is this? How do we measure harm? And should harm be the judgment of the doctor? All too often the patient's views are dismissed and the patient has to resort to media publicity in order to alert the medical profession. A patient may tell a doctor that something is "no good", but when a bedridden patient declares that their problems were caused by treatment; how do we react? How many useless knee arthroscopy procedures have been carried out in the last year? There is no evidence that such lavage and debridement plays a useful part in treating osteoarthritis 1. So how is a GP to react when a patient declares it has made their knee worse? Is the comment, "It willl soon settle down", a euphamism for, "I'm sorry, with luck the injury caused by the procedure will soon heal"? Or is the doctor suspicious that the patient’s complaint is an attempt to queue jump for arthroplasty. And what about the ageing fit and healthy woman who was persuaded some five years ago that HRT would help her maintain good bones and cardiovascular function 2. How is she to be comforted, now that breast cancer has been diagnosed? Statistics suggest that for a woman with serious menopausal symptoms, the slight increased risk of breast cancer is worth it. But how do we quantify these risks and benefits for individual patients? Epidural steroid injections for sciatica are still commonplace, despite growing evidence about their ineffectiveness 3 4, 5, 6. Any epidural injection carries a significant risk but why are unlicensed drugs so frequently used? How does the General Practitioner then explain to a patient, bedridden with intractable neuropathic pain, that a dubious form of treatment has "irritated" their spinal nerves? McPherson and Hemminki maintain that application for drug licences should include adequate data on harms and ineffectiveness. But would this help? Many doctors quite happily use drugs off-licence even when such use is specifically contraindicated. The question, “Why?” is easily answered - a patient suffering pain will try anything to obtain relief. Is such treatment ineffective if the patient believes it will help? It is deemed to be common practice, "clinical experience", call it what you will. But just because everybody's doing it doesn't mean to say it is right. Patient experience of harm must also be considered. References. 1. Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8. 2. Minelli C, Abrams KR, Sutton AJ, Cooper NJ. Benefits and harms associated with hormone replacement therapy: clinical decision analysis. BMJ. 2004 Feb 14;328(7436):371. 3. Valat JP, Giraudeau B, Rozenberg S, Goupille P, Bourgeois P, Micheau-Beaugendre V, Soubrier M, Richard S, Thomas E. Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial. Ann Rheum Dis. 2003 Jul;62(7):639-43. 4. Price C, Rogers P, Stubbing J, Michel M, Arden N. The Wessex Epidural Steroids Sciatica Trial (WEST) Study - a cost effectiveness study of epidural steroids in the management of sciatica: 12-month effectiveness data. Anaesthesia. 2003 Sep;58(9):939-40. 5. Carette S, Leclaire R. Marcoux S. Morin F, Blaise GA, St-Pierre A. Truchon R, Parent F. Levesque J, Bergeron V, Montminy P, Blanchette C. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997; 336(23):134-40 6. Andersen KH, Mosdal C. Epidural application of cortico-steroids in low-back pain and sciatica. Acta Neurochir (Wien) 1987;87(1-2):52-3 Competing interests: None declared
Voltaire? Molière? 29 February 2004
Joseph C. Watine, Consultant, Laboratory Medicine Hôpital de Rodez, France Send response to journal: Re: Voltaire? Molière?	Jenny Doust and Chris Del Mar identified seven reasons explaining why doctors use ineffective or harmful treatments: Clinical experience, Over- reliance on a surrogate outcome, Natural history of the illness, Love of the pathophysiological model that is wrong, Ritual and mystique, A need to do something, No one asks the question, and Patients' expectations - real or assumed [1]. One could probably add some other reasons, e.g. Doctors being told what to prescribe by the drug industry and/or by other sorts of corrupted people such as some politicians, Paternalism, Doctors’ pride, Will of power - doctors’ will of power. I do not know if it is Voltaire or Molière who wrote: "The art of medicine consists in amusing the patient while nature heals him... or kills him." Anyhow, isn't this definition too opitimistic sometimes? Isn't also medicine about killing the patient quicker than nature would do it? [1] Doust J, Chris Del Mar C. Why do doctors use treatments that do not work? BMJ 2004;328:474-475. Competing interests: None declared
The suppossedly Common Problem 1 March 2004
Vijayashankara Chikkade Nanjegowda, Professor and HOD, Pediatrics SDUMC, Kolar , India, 563101 Send response to journal: Re: The suppossedly Common Problem	Sir, In India and probably in the other third world countries,it is a common practice to think of Tuberculosis as a cause or as a part of differential diagnosis for most of the common problems in children.Every child with recurrent chest problems and weight loss are routinely put on anti tubercular treatment even though the Mx testing and chest X-ray are normal.Very rarely doctors here think of asthma as a possibility.Even the teachers at medical schools are responsible for the confusion. Until there is a change in the way we think,teach and practice,the children continue to get the treatment they do not require. Competing interests: None declared
Re: Voltaire? Molière? 1 March 2004
Kathleen I. E. Lane, Research Associate University of East Anglia, Norwich NR4 7TJ Send response to journal: Re: Re: Voltaire? Molière?	The “art of medicine” quotation comes from Voltaire. Molière, on the other hand, observed that “medicine is only for those who are fit enough to survive the treatment as well as the illness”. I do not feel qualified to judge which of the two comments is the more optimistic. Competing interests: None declared
We do things, because 1 March 2004
Malvinder S. Parmar, Medical Director, Internal Medicine Timmins & District Hospital, Timmins, Ontario, Canada Send response to journal: Re: We do things, because	We [doctors] do things, because other doctors do so and we don’t want to be different, so we do so; or because we were taught so[by teachers, fellows and residents]; or because we were forced [by teachers, administrators, regulators, guideline developers] to do so, and think that we must do so; or because patient wants so, and think we should do so; or because of more incentives [unnecessary tests (especially by procedure oriented physicians) and visits], we think we should do so; or because of the fear [by the legal system, audits] we feel that we should do so [so called covering oneself]; or because we need some time [to let the nature takes its course], so we do so; finally and more commonly, that we have to do something [justification] and we fail to apply common sense, so we do so. Competing interests: None declared
Re: Re: Voltaire? Molière? 2 March 2004
Joseph C. Watine, Consultant, Laboratory Medicine Hôpital de Rodez, France Send response to journal: Re: Re: Re: Voltaire? Molière?	Many thanks Kathleen for the info. Voltaire's definition of medicine seems slightly more optimistic than Molière's. Do you believe that medicine has changed very much since the 18th century? Competing interests: None declared
Risk of litigation 2 March 2004
Helen H G Handoll, Senior Lecturer School of Health & Social Care, University of Teesside, Middlesbrough, TS1 3BA Send response to journal: Re: Risk of litigation	I suggest one further reason for doctors using ineffective or harmful treatments is a perceived or actual risk of litigation. Doust and Del Mar pointed to the immobilisation of any suspected scaphoid fracture as inappropriate treatment, and attributed this practice to an undue emphasis on pathophysiology (here, the risk of non-union due to compromised blood supply) [1]. I suggest that given non-union is a recognised, often serious and not-infrequent complication of scaphoid fracture, some attention to the pathophysiology does seem appropriate here. However, the main problem may be that the diagnosis of a scaphoid fracture can be challenging and that the failure to identify scaphoid fracture has resulted in successful and substantial claims for negligence; for example in the USA [2]. This has perhaps shifted the focus of treatment to “not missing the fracture rather than on treating the patient” [3]. Finally, claims that treatments do not work should be underpinned by reliable evidence. The quality of the supportive evidence cited by Doust and Del Mar in this example is actually quite weak; especially notable is the inadequate follow-up in the more relevant of the two trials [4]. In such situations, where there is insufficient evidence to support current practice or a change of practice, other factors such as the risk of litigation inevitably come to the fore when selecting treatment. 1. Doust J, Del Mar C. Why do doctors use treatments that do not work? BMJ 2004;328:474-5. 2. Pollack ME, Barron OA, Glickel SZ, Patterson AH. The natural history of malpractice cases involving the wrist [abstract]. 56th American Society for Surgery of the Hand meeting 2001, 4th-6th October, Baltimore, Maryland (www.assh.org). 3. Dias J. Scaphoid fractures. In: Bulstrode C, Buckwalter J, Carr A, March L, Fairnbank J, Wilson-MacDonald J et al., editors. Oxford Textbook of Orthopaedics and Trauma. Oxford: Oxford University Press, 2002:1890- 1907. 4. Sjolin SU, Andersen JC. Clinical fracture of the carpal scaphoid - Supportive bandage or plaster cast immobilization? J Hand Surg Br 1988;13:75-6. Competing interests: None declared
Possible additional factors 2 March 2004
Steven Ford, GP Haydon & Allen Valleys Medical Practice Send response to journal: Re: Possible additional factors	Editor To those listed in the box as reasons for using ineffective or harmful treatments, I offer the following additions: Information overload - despite (or perhaps, because of) the Sisyphean efforts of the BMJ and others, it remains very difficult to be correctly informed of the clinical 'flavour of the month'. Cynicism - The woman who today finally relinquished her long term HRT observed that her GP of 25 years ago, who had refused to 'interfere with nature' by giving her HRT, had been vindicated in the end. Medicine is horribly prone to adopting the 'greatest breakthrough since lunchtime' - who knows what will become of today's clinical optima. We know the answer already of course - there will be egg on faces and much supercilious sniggering down the retrospectoscope. The wheel will have turned full circle and guess what? We're back where we started. Distraction - when can we expect a thorough scholarly exploration of the effects of taking clinicians away from clinical work for such a large part of their (increasingly limited) working time? Is it time to recognise that involvement in and being subject to current forms of management (and contract) is actually harmful to patients. Only supermen (sorry - persons) can do many complex tasks both simultaneously and successfully. To what degree is clinical expertise being impaired by management? Dejection and despair - no matter what you do or don't do, there is always someone, somewhere waiting to crap all over you. The effect is particularly acute when the professional journals are so relentless in proffering lacerating self-criticism. Judith Langfield's filler is especially apposite. Yours sincerely Steven Ford Competing interests: None declared
We know what THEY want us to know 4 March 2004
Prabha S. Chandra, Additional Professor of Psychiatry National Institiute of Mental Health and Neurosciences , Bangalore, India Send response to journal: Re: We know what THEY want us to know	One of the major sources of learning today, specially about pharmacotherapy are pharmaceutical companies! It is a sad tale but the fact remains that most meetings are sponsored by pharmaceuticals and so are most drug trials. However balanced a speaker might want to be, there is often a bias towards a particular drug. If its not any better than the others in efficacy- the focus is then on side effects! Two junior doctors in the last month have told me that their major source of learning on drugs is from drug reps! Obviously, we dont get any information on negative trials or on aspects where the drug doesnt help. It is time that we learn to sift the wheat from the chaff and not remain pasive recipients of knowledge from any source. It is also important for pharmaceutical companies to read this issue of the BMJ to understand their responsibility, report negative trials and results with the positive ones and not focus exclusively on commercial gains! Competing interests: None declared
Don't just stand there, hold my hand 4 March 2004
Karen Forbes, Consultant and Macmillan Senior Lecturer in Palliative Medicine United Bristol Healthcare Trust, Bristol, BS2 8ED Send response to journal: Re: Don't just stand there, hold my hand	“The aphorism ‘Don’t just do something, stand there!’” seems ludicrous. Does it? Reading this reminded me of something one of our students wrote in a reflective piece at the end of the University of Bristol’s fifth year PRHO shadowing course. She was confronted on an SHO ward round with an extremely unwell, very breathless man. The house officer and SHO sprung into action. She looked at him and realised he was dying, and dying soon. Whilst everyone else examined him, gave him oxygen and arranged investigations she looked on and wondered if she would be capable of such actions when she qualified. She also described feeling powerless, and that there was nothing she could do. She wrote “And then the words of a particular palliative care consultant came into my mind. ‘If there is nothing else to do, you can hold their hand.’ So I did. He died shortly afterwards”. Sometimes there is nothing to do, or there is nothing we should do, in terms of management or treatment. There was nothing she could do. Medicine does entail “ritual, custom, and the expectations of doctors and society”. But it also involves our compassion and our humanity, the ability to be with someone and to give of yourself as a human being. And that is what our student did. Sometimes the aphorism might read “Don’t just do something, hold my hand”. And that would not be ludicrous. Competing interests: None declared
Why they think doctors use treatments that do not work? 5 March 2004
Pisut Katavetin, Internist Bangkok, Thailand Send response to journal: Re: Why they think doctors use treatments that do not work?	Sir, Doust and Del Mar gave many reasons why doctors use treatments that do not work.(1) As a doctor, I think the most important reason is the doctors think the treatments they used DO work. The question 'Why do doctors use treatment that do not work?' reflects discordant belief between one who asks the question and the doctors who use the treatments. Why some doctors think the treatment work while the others think it do not work? Because we are in the world of uncertainty. We all do not know the truth. Data and facts are gathered and used to approximated the truth, and in this processes we almost alway include our preexisting belief. If result of the studies show that new treatment have beneficial effects, doctors who have preexisting belief that it should work will use this new treatment while who have preexisting belief that it do not work may lessen their confidence about their belief but will not use this treatment. In another way, if studies show that current treatment do not work, doctors who have preexisting belief that it should work may lessen their confidence about their belief but will continue to use this current treatment while who have preexisting belief that it may not work will not use this treatment anymore. This seem to be a non-scientific process but it is probably appropriate. In search for the truth, we can view the result of the study as a result of the dianostic test. As shown by Sterne and Smith(2), power of the study is similar to sensitivity of the diagnostic test and level of significant of the study is similar to specificity of the diagnostic test (p=0.05 correspond to specificity of 95%). Like the diagnostic tests, 'Positive predictive value' of the significant studies and 'negative predictive value' of non-significant studies are depend on the pre-study probability of the result. Sometime this pre-study probability is objective, based on result of the previous studies. But manytimes it is subjective, based on individual concept of pathophysiological model and clinical expirience. Different subjective pre-study probability or discordant belief may expained "Why do doctors use treatments that do not work?" and "Why they think doctors use treatments that do not work?" 1. Doust J, Del Mar C. Why do doctors use treatments that do not work? BMJ 2004; 328: 474-475 2. Sterne JAC, Smith GD. Sifting the evidencewhat's wrong with significance tests? BMJ 2001; 322:226-231 Competing interests: None declared
It needs the communication skills to do so 9 March 2004
Malcolm I Thomas, Associate Director of Postgraduate GP Education, Northern Deanery Postgraduate Institiute for Medicine and Dentistry, 10-12 Framlington Place, Newcastle, NE2 4AB Send response to journal: Re: It needs the communication skills to do so	Doust and Del Mar's article is effectively written and thought provoking. Having been involved in communciation skills training for fifteen years, it is my obesrvation that most doctors have a shrewd idea when it would be appropriate not to intitiate a treatment. Why, then, are they unable? I think the answer lies in the difficulty of communicating this option in a postive way. We know that doctors assumptions about patients' expectations of the consulation are frequently inaccurate (1). It is my experience that uncoached doctors NEVER routinely ask patients for their expectations. Add to this the difficulty in achieving good shared decision making with patients (2) and it seems clear that "doing nothing" requires significant communciation skills that many doctors do not possess. Fortunately, these can be acquired. Seek a skills based training programme, ideally based on review of video tapes of your own consultations with patients in this area (3). (1) Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients. 1997. Radcliffe Medical Press, Oxford. (2) Say R, Thomson R. The importance of patient preferences in treatment decisions - challenges for doctors. BMJ 2003; 327: 542-545 (3) Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002; 325: 697-700 Competing interests: Managing Director of "Effective Professional Interactions" - training in interpersonal communication, with an emaphasis on effectiveness and risk reduction, for doctors, nurses and allied professionals
Changing times; changing perceptions! 10 March 2004
Kirti M Marya, Assistant Professor Department of Orthopaedics, SSR Medical College, Belle Rive, Mauritius Send response to journal: Re: Changing times; changing perceptions!	Sir Although most (if not all) doctors aim to treat the patients (I am sure nobody intends to keep the patient ill), the modality of treatment varies. Human body is not like a machine. It responds differently to similar (not same) drugs and for the same drug, response of differnt humans is dissimilar. The same holds true for surgical management. People have varied rate of healing after similar surgeries. All medical practitioners tend to apply that treatment to a particular patient with which they are either comfortable with (experience), have knowledge about (Medical literature) or have no other clear better option (something is better than nothing). If placebo can work for the benefit of patient, why not try it!! As medical field is constantly evolving, our perceptions to various treatment modalities go on changing. An average practioner follows what is fed to him through his medical education, books, journals or other sources of information. Every decade, we find that our concepts just take a reverse swing. Doctors dont use treatments that dont work - they use them simply because they are told that the particular treatment works. Every practitioner learns from those who research and prove things. That these researches prove wrong after few years, is a different story, having strong implications on our perceptions to various treatment modalities (drugs and surgeries including!!!). Competing interests: Practising Teaching Surgeon in a Medical School
Both science and art determine a strategy of treatment. 13 March 2004
Graeme A Pollock, Manager, Lions Corneal Donation Service Department of Ophthalmology, The University of Melbourne, East Melbourne, 3002, Australia Send response to journal: Re: Both science and art determine a strategy of treatment.	Doust and Del Mar’s (1) question “Why do doctors use treatments that do not work?” highlights the relationship between a doctor’s technical expertise and their interpersonal skills, or as some would put it “the science and art of medicine”. Donabedian (2) argues that these two skills are intimately intertwined and that while technical ability may be sound, the interpersonal process is the vehicle by which technical care is implemented and on which its success depends. Donabedian also acknowledges that the interpersonal process must also meet individual and societal expectations and standards, whether these aid or hamper technical performance. We can conduct randomised controlled trials and make readily available sources of information about what does work, thus somewhat addressing the Doust and Del Mar issues of over reliance on clinical experience, surrogate outcomes and ritual. But how do we expect these issues to be assimilated in clinical practice if we don’t address the issues of patient expectations and the innate desire of the doctor to actively intervene and do something? Indeed, is this interpersonal dimension of clinical practice a major contributor the continued variations in clinical practice we still see today; a variation this still persists more than thirty years after Wennberg and Gittelsohn (3) first fuelled the quality of care debate? Analyses of such issues are not only important from an individual safety/harm perspective but also from the perspective of care received by the community as a whole. Inappropriate and inefficient treatments have a flow on effect in monetary costs, opportunity costs and ultimately access to healthcare. Doust and Del Mar emphasise that medicine is not just a science but entails ritual, custom, and the expectations of doctors, patients, and society. Perhaps, by its very nature, not all of the “art of medicine” can be scientifically analysed to any useful outcome. Perhaps the refinements of the art cannot even be taught. However a major component of interpersonal skills, the art of communication between doctor and patient, is open to analysis and improvement. 1. Doust J, Del Mar C. Why do doctors use treatments that do not work? BMJ 2004; 328: 474-475. 2. Donabedian A. The quality of care: how can it be assessed? JAMA 1988; 260: 1743-1748. 3. Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973; 182: 1102-1108. Competing interests: Submitted towards assessment of Master of Public Health
Ideology can explain much physician decision making 14 March 2004
david egilman, Brown University 8 N. Main St., Attleboro Ma. 02703 Send response to journal: Re: Ideology can explain much physician decision making	As Gramsci first noted ideological hegemony impacts all levels of society. Medicine is no different. We have a belief system that includes specific ideas about cause and treatment. It has been heavily influenced by some dominant scientific theories and these in turn have been influenced by other cultural factors including capitalism and religion. Our practices are influenced by these beliefs. The most dangerous belief of all is the belief that our practice is based on "neutral" unbiased objective science. Nothing could be farther from the truth and nothing else is as powerful hegemonic block to real progress. Competing interests: None declared
CAST Study wrongly cited 15 March 2004
Stewart Mann, Associate Professor of Cardiovascular Medicine Wellington School of Medicine and Health Sciences, PO Box 7343, WELLINGTON SOUTH, NEW ZEALAND Send response to journal: Re: CAST Study wrongly cited	Three cheers for the theme of this editorial and issue. However, one potentially serious error needs correction. The CAST Study was indeed a landmark in the history of cardiovascular trials in demonstrating harmful results from what seemed a logically beneficial treatment. Flecainide (and encainide) were however used to treat post-infarction ventricular arrhythmias (frequent ventricular ectopics and short bursts of non- sustained ventricular tachycardia), not "supraventricular" as stated in the editorial. Competing interests: None declared
Changing times; changing perceptions! 16 March 2004
Kirti M Marya, Assistant Professor Department of Orthopaedics, SSR Medical College, Belle Rive, Mauritius Send response to journal: Re: Changing times; changing perceptions!	Sir Although most (if not all) doctors aim to treat the patients (I am sure nobody intends to keep the patient ill), the modality of treatment varies. Human body is not like a machine. It responds differently to similar (not same) drugs and for the same drug, response of differnt humans is dissimilar. The same holds true for surgical management. People have varied rate of healing after similar surgeries. All medical practitioners tend to apply that treatment to a particular patient with which they are either comfortable with (experience), have knowledge about (Medical literature) or have no other clear better option (something is better than nothing). If placebo can work for the benefit of patient, why not try it!! As medical field is constantly evolving, our perceptions to various treatment modalities go on changing. An average practioner follows what is fed to him through his medical education, books, journals or other sources of information. Every decade, we find that our concepts just take a reverse swing. Doctors dont use treatments that dont work - they use them simply because they are told that the particular treatment works. Every practitioner learns from those who research and prove things. That these researches prove wrong after few years, is a different story, having strong implications on our perceptions to various treatment modalities (drugs and surgeries including!!!). Competing interests: Practising surgeon in a teaching hospital
Does the evidence presented really show the trreatment doesn't work? 2 April 2004
Christopher P. Little, Clinical Lecturer Nuffield Dept. of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Windmill Rd., Headington, Oxford, Ian McNab Send response to journal: Re: Does the evidence presented really show the trreatment doesn't work?	Editor, We read with interest the editorial “Why do doctors use treatments that do not work?”(1). An example of this practice was that of prophylactic plaster immobilisation of patients with wrist injuries where clinically a fracture of the scaphoid is suspected but radiographically no such injury is detected, for fear that an “occult fracture” might fail to unite. However, the papers cited in support of their opinion that the practice (of prophylactic immobilisation) is unnecessary do not prove the argument against plaster treatment for this group, however desirable this course of action may be. The paper by Sjolin and Anderson (2) presents a prospective series of patients who presented with “symptoms suggestive of a fractured carpal scaphoid but without radiological evidence of fracture”, randomised to treatment with either a below elbow plaster slab or a supportive bandage pending clinical and radiographic review at about two weeks. 7 of the 97 patients reviewed were found to have scaphoid fractures, of whom 6 had been randomised to initial plaster treatment, including all 4 of the patients who had sustained fractures of the waist of the scaphoid (i.e., the type of fracture that, along with proximal pole fractures, causes most concern to hand surgeons); the other three fractures were of the scaphoid tubercle. While all the scaphoid fractures went on to unite, as 6/7 were immobilised from the moment of presentation, the conclusion that active mobilisation is not deleterious to these patients cannot be drawn from this paper for patients with an initially occult scaphoid fracture. The second paper cited (3) presents a prospective series of patients with proven scaphoid fractures that were randomly allocated to below-elbow plaster treatment with the thumb immobilised up to the interphalangeal joint, or the thumb left free, finding that the incidence of non-union at six month clinical and radiographic review was independent of the type of cast used. They specifically excluded patients where plaster immobilisation was delayed by more than two weeks, and those with fractures of the scaphoid tubercle. This paper has no bearing on the initial treatment of clinically suspected scaphoid fractures baring the more general conclusion that inclusion of the thumb in a cast is unnecessary for scaphoid injuries. Patients in whom there is clinical suspicion of a scaphoid fracture, but no initial radiographic evidence of such an injury do represent a special group. The majority of these patients will not ultimately prove to have an injury that requires plaster treatment. However, the suggestion that active mobilisation of a wrist where clinical suspicion of a scaphoid fracture exists is a safe practice, is not a course presently supported by the literature. We feel that doctors who initiate treatment of these patients should be wary of discarding initial plaster immobilisation, unless patients are being entered into trials that have been approved by their local Ethics committee. Yours faithfully, Chris Little FRCS (Tr & Orth) Clinical Lecturer. Ian McNab FRCS (Orth) Consultant Hand Surgeon & Hon. Senior Clinical Lecturer. Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford. 1. Doust, J & Del Mar, C. Why do doctors use treatments that do not work? BMJ 2004;328:474-5 2. Sjolin SU, Andersen JC. Clinical fracture of the carpal scaphoid - Supportive bandage or plaster cast immobilization? J Hand Surg Br 1988;13:75-6 3. Clay, NR, Dias, JJ, Costigan, PS et al. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial J Bone Joint Surg Br 1991;73:828-32 Competing interests: None declared
Missing Our Moral Imperative 23 May 2004
Lawrence I. Silververg, Associate Clinical professor PCOM 9380 Baltimore Nt'l Pike Ellicott City, MD 21042 USA Send response to journal: Re: Missing Our Moral Imperative	Dr. Del Mar skillfully highlights the issues surrounding usage of “non” evidence based medicine. His manuscript evokes the need for immediate and ongoing evaluation of our daily tasks. His examples are treasures. Although current platforms exist within our government (AHRQ and medical specialty institutions) in my opinion, infiltration by the pharmaceutical and medical testing and equipment suppliers industry are making the entire adventure circumspect. I personally have witnessed 30 years of such groups attempts to seduce physicians and now ancillary practitioners and staff. Their efforts use the newest, latest, and greatest whether or not the patients best interests are at heart. Unfortunately this dynamic is part of our culture. Under pressure, members of Congress and officials at the National Institutes of Health are scrambling to respond to allegations of improper funding and financial conflicts of interest involving pharmaceutical companies. This was the focus of a Senate hearing scheduled for Thursday, January 22nd, 2004 and is currently continuing. (Washington Post Staff Writer Monday, January 19, 2004; Page A19) My recent visit to the NIH found the nursing staff excited about all the tchotchkes (gifts-pens, flashlights and various toys emblazoned with proprietary company names) they had just received from the drug company who had sponsored a lecture they recently attended. I would caution that these companies have now embraced the concept of evidence based medicine and it will be sold to health care providers as being legitimate. This current dynamic also serves to pressure physicians to “do or use something.” A sincere initiative by medical educators might stem this tidal wave. Lawrence I. Silverberg, DO Competing interests: None declared
Why do doctors use treatments that don`t work? 15 June 2004
Joaquim Palmeiro Ribeiro, Department ICU Director Hospital Curry Cabral, ICU; Lisbon, Susan Marum Send response to journal: Re: Why do doctors use treatments that don`t work?	In the daily discussion at the Intensive Care Unit, we frequently say that we give the organic support while the patients react with their own defense mechanisms. In some cases, that are not infrequent, we don´t understand the underlying physiopathological mechanisms of the patient's illness. In intensive medicine, this occurrence is probably more frequent and we know why. In some cases we think we understand the physiopathological mechanisms, but these are not those we imagine, or if they are, do not respond. There is much to say about this although we ignore much of what occurs, and therefore treat patients empirically. We agree with Voltaire and other opinions, about treating the unknown. Many times we aggravate the patients condition, and other times the patients improve on their own! Competing interests: None declared
Re: Pecunia 16 June 2004
John P Heptonstall, Director of the Morley Acupuncture Clinic Leeds LS27 8EG Send response to journal: Re: Re: Pecunia	Sir Pablo Rodriguez del Pozo rightly cites a realistic aspect of the meting out of 'unworkable treatment' by doctors - from economic incentives, managed care systems, protocols, penalties, desire for huge paychecks, industiral bullying and economy with truth... I can happily state that as a practitioner of Traditional Chinese Medicine modalities I have no such pressures nor incitements to 'doctor'. I follow ages old tried and tested practices without fear or favour; I charge modestly for my work; I deny no patient treatment, pay or no pay. I am not coerced by patient or industry; I refuse to supply goods from 'pushy profit-first' companies on principle. I do what I do because I believe it is as right as I can make it for any individual; I find patients respect my decisions, I do not accept demands or dictats over treatment other than in that, as my Chinese teachers taught me I must be sure that it is the right treatment for the right person at the right time. I do not treat in any way unless I believe it is right to do. I accept no inducements as I do not believe it is an acceptable way to work. I am sure most physicians would gratefully practice as unshackled and unencumbered, such that they can put their knowledge and experience to best use. I am not sure how many would be prepared to live modestly to that aim. Therein lies a solution in part, train them well then let physicians use their expertise without fear or favour from industry and patient. Treat only those it is right to, when it is right, with the treatment the physician believes is right at the time. What more can a patient or doctor ask? Regards John H. Competing interests: None declared
Primum Non Nocere 20 June 2004
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507 Send response to journal: Re: Primum Non Nocere	Thank you, Dr. Doust and Professor Del Mar for a very informative article ! (It took me a while to find it). Also John Heptonstall's usual perceptive observations are appreciated. One thing puzzles me, however: Why mention leeches among the treatments that do not work and why not elaborate on chemotherapy which should occupy the thus created vacancy? Leeches have been making a come-back in many parts of the world and the authors can find thousands of them in the Lamington National Park (Bina Burra) which is a wonderful area to visit, and within reach of Brisbane. Chemotherapy, however, is such a cruel treatment and often only used because the doctor does not want "to just stand there...", but what is the number of patients who are actually helped by it? Does it change the outcome? I tend to agree with Ernst Wynder who puts its effectiveness at 3 %. Finally, look at the practice of psychiatry as it concerns mental illness. Abram Hoffer developed an effective treatment for schizophrenia in the 1950's yet modern practice relies on ever more potent and exotic antipsychotics. Clearly, these drugs are not the answer, their success rate is no better than "just standing there" and they can cause considerable harm to patients. Yes, it took the British Navy 40 years to press limes and lemons into service, it seems that therapeutic success alone was not enough to justify action. The element of controversy of a new treatment plays an important role, anything new is suspect precisely because it is, by its nature, controversial. BUT, things appear to be changing, thanks to Big Pharma! No more waiting, take your pills now and forever. John Heptonstall mentions the pecuniary side of choosing treatment over inaction. He is simply relaying what he observes in daily life. He probably looks at 'Pro-Active Medicine', at screening and has perhaps read Petr Skrabanek's term "Coercive Medicine". As long as there is money to be exchanged in the practice of 'healing' it will be a rare sight to see a doctor just standing there. Competing interests: None declared
"There is gold in them there freckles...." 11 July 2004
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507 Send response to journal: Re: "There is gold in them there freckles...."	Thank you Dr. Doust, for a very informative article !(It took me a while to find it). Also, John Heptonstall's usual perceptive observations are appreciated. One thing puzzles me, however: Why mention leeches among the treatments that do not work and why not elaborate on chemotherapy which should occupy the thus created vacancy? Leeches have been making a come-back in many parts of the world and Dr. Doust can find thousands of them in the Lamington National Park (Bina Burra) which is a wonderful area to visit, and within reach of Brisbane. Chemotherapy, however, is such a cruel treatment and often only used because the doctor does not want to "just stand there ..." but what is the percentage of patients that are actually helped by it? Does it change the outcome? I tend to agree with Ernst Wynder who puts its effectiveness at 3%. Finally, John H. is correct when he mentions the pecuniary side of choosing treatment over inaction. He has probably met a doctor similar to one I have heard about who -on principle- takes out ANY and ALL skin lesions "to make sure". He probably owns a big yacht though. Competing interests: None declared