Beware of mentioning psychosocial factorsBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39370.657130.59 (Published 18 October 2007) Cite this as: BMJ 2007;335:801
- Ben Goldacre, doctor and writer, London
Although we are constantly told to “engage with the public,” many doctors and academics avoid the media like the plague. This month, like many doctors before me, I walked into a broadcast studio a man and came out an ass.
The story was acupuncture. A major study had been published showing that acupuncture is more effective for back pain than conventional medical treatment, and as I sometimes write about complementary medicine and research methodology I was invited to discuss the study on BBC Radio 4, where nobody can tell that I look about 14.
The very interesting paper (Archives of Internal Medicine 2007;167:1892-8) had three arms. Results from the “sham” and “real” acupuncture arms were indistinguishable—make of that what you will—but both outperformed conventional medical treatment. The patients in the study, I should mention, were people who had already been failed by conventional medical treatment for an average of eight years.
If you're a doctor, you can probably imagine what I said. The important background information missing from the news reports didn't concern the study's methodological details or anything to do with acupuncture: what was missing was a wider understanding of back pain. Back pain isn't like tuberculosis or a fracture; it's one of the leading causes of sick leave and misery, but the simple fact that no clear cause is found itself exacerbates distress and causes conflict.
And just as many of the big risk factors for a niggle turning into chronic, longstanding back pain are personal, psychological, and social—things such as working conditions, depression, job dissatisfaction, unavailability of light duty on return to work, and so on—so are many of the interventions.
Anti-inflammatory drugs are undeniably better than placebo, at the cost of possible side effects, but if you were going to look at the evidence beyond pills, then resting in bed is actively harmful (specific exercises can be too), and trial data show that simple educational interventions such as giving advice to “stay active” can speed recovery, reduce chronic disability, and reduce time off work. In fact, in Australia they even put money into that notion, and a simple public information campaign (“Back pain: don't take it lying down”) was shown to reduce back pain significantly in the whole target population (Medical Journal of Australia 2001;175:456-7).
I talked about this kind of stuff, although I suspect that the Radio 4 people may have been hoping for some old duffer to say that acupuncture is “poppycock.” The acupuncture study raised important issues, I agreed. It's very important to think about whether and when doctors should go beyond merely prescribing pills, and we often do. But if we accept, in the case of back pain, that acupuncture may in part be a surrogate psychosocial intervention or theatrical placebo, then it's a pretty expensive one. Maybe we could consider pushing for other options, less expensive and less fashionable, such as brief education interventions, public health information programmes, perhaps cognitive behavioural therapy, and so on.
This all felt pretty sensible. Much of it was lifted from a bog standard review on back pain in the BMJ (2006;332:1430-4 doi: 10.1136/bmj.332.7555.1430). Working doctors are accustomed to thinking beyond the prescription pad, after all, and it's a peculiar side effect of the branding of alternative therapists that medicine is portrayed in mainstream media as crudely biomechanical.
So I was a bit surprised three days later to hear this read out, in a very angry voice, in the letters slot of BBC Radio 4's afternoon news programme PM, to a million people: “I would take issue with your speaker Ben Goldacre, who, if I recall correctly, said that 90% of back problems are psychosomatic disorders. What planet is he on? Whilst I would agree that there are a lot of schmucks out there that want to sit around and skive off work every day (and thereby make the problem even worse) . . . never tell me my backache of 20 years is imaginary. OKAY?”
Now I'm quite prepared to accept that I may not have expressed myself very clearly—obviously I don't think back pain is “psychosomatic,” and I accuse nobody of malingering—but something more interesting is happening here. The finer distinctions between concepts that doctors use to describe the multiple interactions between a person, their illness, and society have little purchase in the crudely dualistic world of popular culture, and sometimes it can seem that there is a hypersensitivity to anyone even mentioning psychosocial risk factors or interventions.
Perhaps it is a matter of who is permitted to discuss them: patients shop for advice, after all, and you don't go to a crystal therapist for steroids, any more than you go to a urologist for marital guidance. Perhaps even a biomedical doctor merely raising the question is seen as questioning the legitimacy of symptoms and suffering. Perhaps the problem is magnified because we live in a country with millions of people receiving sickness benefit, where many people perceive at least some claimants simply as rebranded “unemployed” people.
But this is a dark corner, framed only by the crude marketing claims of quacks and their notions of “holism.” In a culture where “psychosocial risk factors” can be heard as “psychosomatic illnesses,” and with a popular media where “psychosomatic” simply means “imaginary” and “malingering” (Psychosomatics 2004;45:287-90), these negotiations will never be easy.
Obviously I don't think back pain is “psychosomatic,” and I accuse nobody of malingering