15 ms·

Surgery, the Ultimate Placebo

261 points by cpncrunch 6y ago

ngngngng 6y ago
I'm halfway through the talk right now (shoutout to Youtube 2x speed). This is fascinating and brilliant, but so frustrating, because there is no way for us to ethically use placebos for human benefit. I would love if every doctor I ever saw first treated me with placebo, and only tried something else once placebo treatment was ineffective, but can that ethically be done without me knowing? And if I know, the placebo won't work.
- chias 6y ago
  > And if I know, the placebo won't work. This is not a given: https://www.health.harvard.edu/blog/placebo-can-work-even-know-placebo-201607079926 https://www.health.harvard.edu/blog/placebo-can-work-even-kn... https://www.npr.org/sections/health-shots/2016/10/27/499475288/is-it-still-a-placebo-when-it-works-and-you-know-its-a-placebo https://www.npr.org/sections/health-shots/2016/10/27/4994752...
  - ngngngng 6y ago
    Well, this is life changing information. Thanks for it. I have knee pain when running with no physical explanation (MRI found nothing) I'm sure a placebic treatment would be helpful, but can I treat myself with a placebo? I wonder if an authority figure giving you an open placebo is more effective than me just telling myself that I'm cured, but I'm going to start with the latter.
    - tempestn 6y ago
      I recall reading that the placebo effect tends to be proportional to the perceived degree of intervention. So getting a shot would have more of an effect than taking a pill, and a surgery would have more effect than a shot. Presumably getting something from an authority figure would also do more than whatever you can do yourself, but that doesn't mean the latter would be useless. If you can find some kind of physio exercise that's claimed to potentially help, maybe that would have a decent placebo effect, if nothing else? Of course it's likely there is some kind of physical explanation for your pain, just not a known one (or even knowable, with current medicine). I'm in much the same situation with hip pain.
    - harry8 6y ago
      Just pick an "alternative" treatment that is (a) harmless and (b) you consider "could possibly work" For running pain in a knee someone I know had a course of laser accupuncture [1] with really good success. There's nothing scientific about the treatement, no studies, no data. But it is at worst harmless so, we probably don't need to care. I can see "I'm aware it might be just a placebo" as working better than "This /is/ just a placebo" [1] My undertanding of this was that a general practioner (Doctor) shined a low power laser at close quarters on various parts of the knee. Zero chance of burning, completely harmless at worst.
    - elil17 6y ago
      Perhaps instead of a placebo, try a healing ritual or some form of alternative medicine. You can easily have someone else administer the treatment, and you can even choose something like acupuncture where there is potentially some evidence that it actually works (I don't believe it but if you can convince yourself, all the better for the placebo effect).
    - sushisource 6y ago
      MRI isn't necessarily going to reveal reasons you'd have knee pain while running. For example, I know for a fact that if I don't routinely roll out my IT band, it gets too tight and that then results in pressure on the outer portion of the patella. It's rather unlikely that'd show up on an MRI, except perhaps for someone noticing "Hey, maybe your IT band is tight". Even then, probably not, since it tightens as I begin running. So, there's probably something real going on, and something real you can do to fix it. Consistent stretching, rolling, and low-weight exercises to build strength in muscles like your hip abductors makes a world of difference. If you're not doing those things, start there. Really do get a roller. The IT band cannot be stretched - since you can't exactly flex your femur.
    - masklinn 6y ago
      > I have knee pain when running with no physical explanation (MRI found nothing) That MRI found nothing only means there isn't clear damage no? Would it find e.g. short or tight tendons, or unbalanced muscle mass? > can I treat myself with a placebo? Nothing stops your from trying. You can just get some inactive pills (I don't know if it's possible to find excipients-only pills which would be the ideal but homeopathic crap or some innocuous supplements would do the trick) and take that on the regular as "treatment".
  - fooblat 6y ago
    Dr. Ted J. Kaptchuk is has been at this a long time. His agenda is pushing so-called alternative medicine. When you dig in just a little and do some research on him you will find a lot of reasons to question his assertions. In his studies, it is true that he tells people he is giving them a placebo. He also tells them that it can still help them. This is not really an "open label" placebo as people still have the expectation that it is some kind of treatment and will help. I also find it interesting that the placebo effect only helps with subjective conditions, such as pain and nausea. No placebo will set a broken bone or seal a laceration.
- andai 6y ago
  Well, there's always the DIY approach: positive thinking. (But it only works if you believe it will.)
  - NoodleIncident 6y ago
    There was a pretty serious-sounding contingent of commenters here in a recent thread about RSI. To them, the main cause of RSI was some sort of unconscious tension they were holding in the affected areas, and they needed to relax to make the pain go away. I wonder if that was placebo too
  - tstrimple 6y ago
    Placebo effect works even if you know it's a placebo. https://www.health.harvard.edu/blog/placebo-can-work-even-know-placebo-201607079926 https://www.health.harvard.edu/blog/placebo-can-work-even-kn...
- podiki 6y ago
  I believe the placebo effect can also work just by telling someone about it (and then giving them the sugar pill or whatever). However, the whole placebo effect may just be (poor understanding of) statistics, namely regression to the mean. Here's an article [0] (found via Wikipedia on placebo [1]) [0] https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2796.2004.01355.x https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2796.... [1] https://en.wikipedia.org/wiki/Placebo#Confounding_factors https://en.wikipedia.org/wiki/Placebo#Confounding_factors
- epmaybe 6y ago
  I thought placebos work even with open labels?
- ummonk 6y ago
  A lot of placebo effects still show up when the patient knows they're getting placebos. It probably has some ritualistic advantage in helping them mentally.
Ozzie_osman 6y ago
I've been told by more than one doctor (for chronic pain I had been having) to avoid seeing a surgeon unless absolutely necessary because they were worried the surgeon would recommend surgery even if it wasn't needed. I found it interesting. Seemed like they didn't trust their colleagues (or even they didn't trust me to make my own decision if I got the recommendation to undergo surgery).
- Peradine 6y ago
  There's also the perverse incentives in the american medico-legal system: surgeons get sued for not performing surgery, or performing surgery badly, but they rarely get sued for performing 'unnecessary' surgery unless its completely egregious. If the patient has a history/examination which could indicate a need for surgery, and the patient has given informed consent, the surgeon is very unlikely to be succcessfully sued for operating. I'm not implying this is a consious decision on their part, rather a subconscious influence of their training, anecdotes from other surgeons etc.
graemebenzie 6y ago
This is one trial I won't be volunteering for.
4778468d 6y ago
I know a surgeon, he says that he thinks it’s the enforced rest post surgery that is what really does the healing in some cases such as for example Surgery for back pain.
frereubu 6y ago
One of my favourite stories along these lines (this is from Ben Goldacre's great book Bad Science, and may be slightly misremembered in parts) is about Archie Cochrane, who gave his name to the Cochrane Collaboration, an organisation who rigorously analyse the evidence for medical treatments, even "obvious" ones. He set it up after being a Japanese prisoner of war, where he had to make decisions about medical treatment in the face of extremely callous treatment by the Japanese officers. They were often decisions you only hear about in philosophical games - e.g. do you save one person's life or the sight of ten people - and he realised that much of his medical training was not based on proper evidence. In the UK in the 1970s, hospitals started equipping expensive cardiac units, specifically designed for the treatment of heart attacks, full of expensive medical equipment (and if HN doesn't mind a good-natured tease, cardiac surgeons don't exactly shun the heroic mode of medicine). Part-way through a Cochrane study of their effectiveness, the data was pointing to survival rates being slightly higher when people were treated at home rather than in the cardiac units, but the results were not statistically significant. He decided to play a trick and annouced at an interim meeting that the data were pointing the opposite way - that treatment in cardiac units showed slightly higher survival rates, but were still not statistically significant. The doctors in the meeting were extremely angry that he insisted that the study should go on because the results were not statistically significant and therefore no conclusions could be drawn from the data. It wasn't until later in the meeting that he came clean, and told them that the data were pointing in the other direction. Funnily enough, none of the doctors still called for the study to be halted early in the face of identical evidence, just pointing to a different conclusion.
- saas_sam 6y ago
  This kind of thinking is so common I often wonder how the hell we manage to progress as a species. People seem to only ever look at the evidence that supports positions they originally adopted for bad reasons. I can't remember the last time I talked to anyone who could recall to me a single time they changed their mind based on seriously weighing evidence for & against their positions. People Google to find out why they're right and that's the end of it.
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resoluteteeth 6y ago
Yeah it's always seemed bizarre to me that surgical procedures aren't held to the same standard of evidence as drugs and surgeons are allowed to pretty much make things up and do whatever they want as long as they don't engage in clear malpractice.
- Latty 6y ago
  "The same standard" as in double-blind studies would clearly present issues when it comes to surgery. I can see the argument for a higher standard than is currently held to, but "the same" seems impossible to do in an ethical way, or even just practically.
  - Retric 6y ago
    Many double blind surgical procedures have been tested. Unless it’s limb removal you go in and either do the procedure or go in and don’t do the final setup. The ethics is interesting as surgical procedures can become common without any actual testing of effectiveness. Overall about 1/2 of surgical procedures have had double blind tests and of those about 1/2 passed the test. Which suggests something like 1/4 to 1/2 of surgery’s are ineffective.
- hamandcheese 6y ago
  It doesn’t seem that unreasonable to me — bad drugs can harm people at a much larger scale than a bad doctor.
  - whatshisface 6y ago
    They're the same when abstracted to the level of "the practice of doing knee surgery."
- ska 6y ago
  Doctors are free to use drugs off label also, so that is consistent. The constraints around producers (drugs, devices) are tight, but the clinicians can do what they think is worthwhile from there.
nwienert 6y ago
Anecdote. I had undiagnosed Familial Mediterranean Fever for years in my early 20s. Terrible, sickening abdominal inflammation attacks every few weeks. After about 5 years I was desperate and one doctor said my gallbladder did show signs of low functioning, and recommended taking it out. I did go into “remission” for about 8 months after. It eventually came back, but then faded soon after. It wasn’t until a few years later with a DNA test that I found the cause. But I did always wonder if the surgery, along with my desperate hope to be better / not be wrong, had such a strong placebo effect that it actually did help me out.
- fernly 6y ago
  > Familial Mediterranean fever (FMF) is a hereditary inflammatory disorder... an autoinflammatory disease caused by mutations in Mediterranean fever gene, which encodes a 781–amino acid protein called pyrin. https://en.wikipedia.org/wiki/Familial_Mediterranean_fever https://en.wikipedia.org/wiki/Familial_Mediterranean_fever
owenversteeg 6y ago
Does anyone have any examples of surgeries that are done today in modern medicine that are basically placebo? I'm surprised the article didn't give a single example.
- hnuser123456 6y ago
  Routine wisdom teeth removal, male genital mutilation, dentists giving fillings far before they are required, causing toothaches and sensitivity... But these all turn out to be easy money for someone, for some odd reason.
  - bsanr 6y ago
    I imagine that this gray area is where a lot of "unnecessary surgery" comes from. The vast majority of people have no medical need for circumcision (but some do). A lot of people don't need their wisdom teeth removed (but many probably should). You might need a filling eventually (just not now). Where do you draw the line, in a world where setting up studies to find conclusive evidence for binary medical decision-making ("Should this ever be done in the presence of x, or should it never be done?") is hard enough? I had two surgeries in 2019; in both cases the consulting doctor told me that it was 50/50 if I actually needed them or if they'd actually fix the issues that might have been associated with them. One was a pretty smashing success, the other (ironically more expensive) one was a 4-figure wash that had the surgeon dodging my inquiries as to what went wrong. Unfortunately, it turns out that medical decision-making entails taking a holistic view of the situation and giving advice that the doctor then has to take responsibility for. Good luck achieving that on a systemic level within the ever-dysfunctional structure of American healthcare.
  - jessaustin 6y ago
    I've assisted on numerous third molar extractions, on patients up to sixty years old. None of those people were glad they had neglected to get the work done in their twenties. If you're not sure about a recommended dental filling, just go to a different dentist for a second opinion. By the time a cavity causes you pain you'll need a root canal and possibly a crown.
chillwaves 6y ago
> Question: Is physical therapy noninferior to early surgery with arthroscopic partial meniscectomy for improving knee function among patients with nonobstructive meniscal tears? > Findings: In this noninferiority randomized clinical trial that included 321 patients, knee function that was measured by a self-administered questionnaire improved by 20.4 points in the physical therapy group vs 26.2 points in the early surgery group over a follow-up period of 24 months. The difference between the 2 treatment groups did not exceed the noninferiority margin of 8 points. > Meaning: These results demonstrate noninferiority of physical therapy compared with early surgery with arthroscopic partial meniscectomy for improving self-reported knee function in patients with nonobstructive meniscal tears. https://jamanetwork.com/journals/jama/fullarticle/2705186 https://jamanetwork.com/journals/jama/fullarticle/2705186
- TylerE 6y ago
  That doesn't really sound like non-inferiority to me as a layman. That's a difference of over 25%. Reading further in their additional conclusions, the surgery group also did better in both pain and general health.
  - Peradine 6y ago
    Look at the graph in figure 2 - the massive overlap in the interquartlie ranges suggests that any differene in the median values can be attributed to random variation within the samples, rather than a true difference in the populations. Also its better to quote an absolute rather than relative reduction, so the difference is really 3.6%
- rsync 6y ago
  "Question: Is physical therapy noninferior to early surgery with arthroscopic partial meniscectomy for improving knee function among patients with nonobstructive meniscal tears?" Vertical (deep, interior) meniscal tears can actually heal, since they have a blood supply, and the surgery for them is basically a coin flip - the results of which you only learn after a nine month recovery period. You should absolutely be pursuing a rigorous course of PT to heal such a vertical meniscal tear. You should specifically look into whether your adductors (inner leg) are weaker than, and being overpowered by, your abductors (outer leg) resulting in knee valgus.
varispeed 6y ago
This is dangerous thinking. For example when it comes to chronic pain, there is that belief being pushed that opioids are actually a placebo and they don't help. Then people are being sentenced to a talking therapies instead. These therapies try to implant the thought that all the pain people experience is in their heads and it is not real. If only they could just stop thinking about pain, then they wouldn't need to take any pills. This is one of the reasons why people turn to dealers, if doctors start to believe this and are made afraid of prescribing anything. Also organisations who get involved in such "therapies" promote them, because that is, let's be honest, rather easy money from the public health organisations. It fits the western perception of suffering, that it is noble and virtuous. I wish this topic was explored more by investigative journalists.
- frereubu 6y ago
  I don't think there are any doctors, except perhaps a handful of cranks, who believe that opioids are "a placebo". Perhaps you mean something else? There are definitely doctors who underprescribe pain medications to certain groups of people - as I understand it, women are notably underprescribed pain medications for example - but that doesn't mean that those people think opioids are a "placebo".
- MichaelZuo 6y ago
  And what if suffering does actually promote noble and virtuous thoughts? You left the most influential thought in the western tradition unexamined. From experience suffering, in any form, certainly enhances the idea of the golden rule, that is ‘Treat others as you would like others to treat you’.
- blix 6y ago
  What does it mean for pain to be "real" vs experienced in one's head? I don't think this is an easy question, which is why our medical system struggles to deal with chronic pain.
- schoen 6y ago
  I think there is evidence that people's attitudes toward pain can affect both the amount of pain that they feel and how much they suffer from it, and more generally that there are mental skills related to pain management and experience that are genuinely useful. (Also, there are cases where classic psychotherapy or psychoanalysis methods led to an alleviation or complete disappearance of somatic pain symptoms, even without focusing at all on the symptoms or pain themselves... although it doesn't seem ethically appropriate to somehow assume that that would be the best treatment for everyone.) I agree with the concern that this should not be seen as a substitute for helping reduce people's suffering with pain medication. But I think we also still have lots to learn about the mental component of pain and potentially identifying psychological interventions that make a difference in this area. I also agree that the "all the pain people experience is in their heads" angle isn't a constructive one, both because of its proximity to accusing people of lying or malingering, and because it doesn't seem like a helpful summary of any apparently-beneficial psychological techniques.
btilly 6y ago
This topic reminds me of a subthread of the last time we discussed Alzheimer's research. And more specifically about the great public tragedy caused by overconfidence on the part of medical researchers. The details are different, but the fundamental pattern is the same. https://news.ycombinator.com/item?id=24906758 https://news.ycombinator.com/item?id=24906758 was the discussion, and https://news.ycombinator.com/item?id=24910211 https://news.ycombinator.com/item?id=24910211 has the at times heated discussion that I am referring to.
gumby 6y ago
I have direct experience in the "doctor's know that under their care it works". In an earlier startup we developed a particular dissolving mesh that could be placed in situ in a surgical site to prevent adhesions. E.g. if you tear your rotator cuff, the healing of sewn up region will adhere not only to the cuff but other parts of your shoulder, preventing it from moving. The only fix is to (painfully) move the shoulder as it heals to tear those adhesions and form some scar tissue. Experiments in animals showed that they would recover full motion in their joints with no apparent discomfort. But when we interviewed doctors we discovered that they knew this was a terrible problem but blamed it on the techniques of other doctors. "When it's my turn on call I get these calls from patients, some in terrible pain. I am very careful and my patients never have this problem. This sounds like a great idea though I'd never use it myself." Of course we sometimes talked to multiple doctors in the same physician's group and they would say this about each other. We ended up using the technology in a different (medical) application.
hycaria 6y ago
Sometimes animals are in abdominal pain, supplementary exams leave us clueless and we resort to surgery to see whats happening, nothing looks wrong inside, we stitch them back and the patient gets better nonetheless.
atum47 6y ago
my brother had never water sky(ed) before, so after a month of vacation doing it, he felt his knees. he talk about it with two doctors and they both wanted to perform surgery on his knees. he went and got a third evaluation and the third doctor told him the truth: that he didn't needed surgery and the doctors were after his money. the doctor proceeded by putting my brother in physical therapy, which healed both of his knees. this is a real history. but there are plenty of other medical shows about the same subject - surgeons trying to force surgery on people that don't actually need it.
ishtanbul 6y ago
Microdiscectomy for treatment of sciatica, numbness and foot drop from a herniated disc is highly effective (most people see a 90-100% reduction in symptoms) and minimally invasive. However, the longer term outcomes are mixed because many patients dont stick to the required long term PT (maintaining excellent core strength and avoiding risky activities like lifting heavy objects) and end up reinjuring themselves. Many people dont need the procedure and can releive symptoms through conservative therapy, but some cannot and will benefit from surgery, especially if the condition is causing extreme pain, weakness or loss of function that make physical therapy almost impossible. Its misleading for him to say that surgery “doesn’t work” when there are so many complicating factors impacting the population-wide, long term efficacy of a treatment. Surgery is just one step of many that you would take in order to recover and stay better. Talk to multiple surgeons as well as other patients to understand if surgery is the best option for your particular situation.
ordinaryperson 6y ago
Without specifics this article is not helpful. I've had 5 orthopedic surgeries and they were transformative -- and this article is written by an orthopedist! There's some data [1] against these operations: - Arthoscopic knee surgery - Subacromial shoulder decompression - Acromioplasty for rotator cuffs - Vertebroplasty for the spine That's 4 techniques out of...how many exactly? It's just an n=1 anecdote but my surgeries absolutely changed my life for the better. I don't want to get into the gory details but I feel incredibly grateful to have had such talented surgeons. You can argue placebo but my years of ineffective physical therapy suggest otherwise. Instead of saying "Surgery, the Ultimate Placebo" this article should say "A handful of specific surgeries shown to be no better than a placebo" -- generically describing all surgeries as a placebo is clickbait, in my non-medical-professional opinion. [1] https://www.realclearscience.com/blog/2020/11/07/some_surgeries_are_performed_millions_of_times_per_year_even_though_they_are_no_better_than_placebo.html https://www.realclearscience.com/blog/2020/11/07/some_surger...
- OJFord 6y ago
  > It's just an n=1 anecdote but my surgeries absolutely changed my life for the better. [...] You can argue placebo but my years of ineffective physical therapy suggest otherwise. They don't though, do they. You can't disprove placebo with N=1. If the placebo is the act of surgery then anything not surgery not working doesn't mean that the surgery worked by not placebo means. But who cares how, it worked!
  - ordinaryperson 6y ago
    So cynical. I hope you're never in debilitating physical pain, only to have other people dismiss the effect of surgical intervention as a figment of your imagination. It's not just about the sample size, I could get into the anatomy of my injuries but I don't want to divulge more of my medical privacy than I already have. Suffice to say that when certain things are torn or detached surgical intervention is often the only way to re-attach or restore function to the affected joints. No mount of wishing it way mentally is going to change that.
zaptheimpaler 6y ago
To a man with a scalpel, everything looks like a surgery ;)
hughw 6y ago
Sloan-Kettering publishes a set of online predictive tools [1] patients can use to make statistical estimates of the outcomes of surgery and other treatments. They're based on data from thousands of patients. [1] https://www.mskcc.org/nomograms https://www.mskcc.org/nomograms
ckemere 6y ago
I think that an article like this that doesn't emphasize the fact that a placebo is still treatment is remiss. The naive reading is that surgery is useless, but that is not at all the conclusion if compared to a placebo. The neuroscience of placebo effect(s) are super cool and quite difficult to study. Pain-related ones which involve release of endogenous opioid receptor agonists are fairly well mapped out, and similar circuits for blood pressure and other physiological functions controlled by the brain can be imagined. I've read about placebo antibiotics, though, which presumably involve the immune system in cool ways. There have been big investments by NIH into the idea that we should be treating a lot more disease with neurostimulation, but I think so far this has not paid off...
- Ozzie_osman 6y ago
  Sure but if it's just a placebo, there are probably cheaper and safer ways of achieving that affect. Even a routine surgery can be really risk.
DoreenMichele 6y ago
This doesn't contain the details that would interest me. My understanding is modern surgery routinely involves significant antibiotics to prevent serious infection during the operation. If that's followed with both "sham" surgeries and real surgeries, then it points to the possibility that the strong antibiotics are more important in some cases than the procedure. There may be other medically significant details of sham surgeries that we overlook as not therapeutic. Many diagnostic exams involve not eating for x hours beforehand. Surgeries also can involve restrictions on diet during recovery or exposure to drugs like anesthesia that are given without intent to be therapeutic per se. You can't really rule out the possibility that those types of things are therapeutically significant but overlooked because they are done to be curative.
oarabbus_ 6y ago
There is an absolutely fantastic quote relevant to this in An Astronaut's Guide to Life by Chris Hadfield (a fantastic book). Unfortunately, I don't have the book handy and cannot do it proper justice, but the part I refer to involves dozens of years after a childhood appendectomy when Hadfield was beginning his "real" astronaut career. After experiencing severe abdominal pain at the surgical site, he was sent to a panel of surgeons for guidance. Going into surgery at this time would've been catastrophic to his career, as after a surgery one cannot fly into space for some extended period of time. At this point in his career Hadfield was relatively green, and there was a plethora of new astronauts as talented as he was just waiting to take his spot. Going into surgery at this point would have relegated him to a successful career at mission control, but not in space. To the best of my recollection, his physician's opinion was he didn't need a full surgery to investigate this abdominal pain. However, the panel of surgeons universally, unequivocally recommended the gastrointestinal surgery. He states infinitely more eloquently than I can how applicable "uf you only have a hammer, everything looks like a nail" in regards to the surgical panel. I recall he decided against the recommendations of the surgeon panel, and decided his abdominals wouldn't suddenly tear apart with potentially fatal results while orbiting earth in the ISS. It turns out he guessed right, and had one of the most prolific careers of any astronaut of the last few decades. While this anecdote may make it seem like I am some anti-surgeon, anti-surgery person, let me state that I have had one surgery (besides wisdom teeth, which "doesn't count" as it's so common). It was an orthopedic reconstructive ulnar collateral (thumb) surgery, and my repaired thumb is honestly almost indistinguishable from my left thumb. And in this case it was clear surgery was needed, but after reading Hadfield's book and the parent article here it was astounding how the surgeons were literally unable to see any mode of treatment which didn't involve surgery. I think just like overprescription of antibiotics, we as a society should look at the overprescription of surgeries for medical issues which can be treated without surgical intervention.
- rscho 6y ago
  > it was astounding how the surgeons were literally unable to see any mode of treatment which didn't involve surgery. Current medical practice is the definition of "when all you have is a hammer, everything looks like a nail", so no surprise here. This a result of hyperspecialization which most of the time is good (capable hands) but sometimes not so good (rigid mind).
choeger 6y ago
Maybe the categorization of the surgeries is too broad? Surgery is naturally an exploratory act and I would assume that what you find once someone is "opened" can vary massively. Maybe one should take that into account?
einpoklum 6y ago
The column is fudging the facts to justify its bombast title. Example: > A systematic review found that placebo was just as effective as surgery in over half of the cases studied, and all of the recent trials comparing surgery to placebo have found that surgery was no better than placebo. We note that that the text doesn't tell us...: 1. which kind of operation is supposedly not very helpful. 2. which kind of medical condition(s) were studied. 3. whether the relevant medical condition is transitory/accute or chronic; 4. whether the condition is known to be amenable to non-surgical treatment; 5. what review this was, exactly, and where one can read the details. 6. what, exactly, the review reviewed. 7. what happened in the less-than-half the cases. 8. what chances of success the surgery purports to have. i.e. it might be a surgery which proponents suggest solves the problem in 45% of cases and has little effect (but no significant negative effect) in 55% percent of cases - in which case you "get what it says on the label". Also, I would assume are almost no, or no trials comparing surgery to placebo where surgery is known, or reasonably assumed, to be efficacious. So those "recent trials" probably considered surgical procedures which are apriori under suspicion of not being efficacious. etc.
protontypes 6y ago
This is one of the best presentations I have seen in a long time.
thrwo4234234 6y ago
Is this allowed?! I thought we were all on the science-cant-be-questioned train and getting in line for our latest untested experimental drugs.
macawfish 6y ago
Surgery --> stem cells
teorema 6y ago
Different, but a related topic that I've come to be fascinated by are athletic tools and techniques that are held as canon that turn out to have no scientific support. The author talks about reactions of physicians dismissing convincing data — the befuddlement and dismissals — and it's the same reaction athletes and coaches give when they're part of some of a controlled trial.
theriddlr 6y ago
Had scoliosis-kyphosis fusion surgery when I was 14 and it was rapidly-progressing. All it did was cosmetic and bought me time until Functional Patterns was invented. Today I am 70% cured. It's basically strength training according to the body's myofascial slings (gait). Flat feet, knee valgus, scoliosis, jaw growth, forward head – it's all connected. Still, no surgeon in the world would undo (as in chip away the bone grafts limiting my spinal mobility) my fusion.

261 points by cpncrunch 6y ago

I'm halfway through the talk right now (shoutout to Youtube 2x speed). This is fascinating and brilliant, but so frustrating, because there is no way for us to ethically use placebos for human benefit. I would love if every doctor I ever saw first treated me with placebo, and only tried something else once placebo treatment was ineffective, but can that ethically be done without me knowing? And if I know, the placebo won't work.

chias 6y ago
> And if I know, the placebo won't work. This is not a given: https://www.health.harvard.edu/blog/placebo-can-work-even-know-placebo-201607079926 https://www.health.harvard.edu/blog/placebo-can-work-even-kn... https://www.npr.org/sections/health-shots/2016/10/27/499475288/is-it-still-a-placebo-when-it-works-and-you-know-its-a-placebo https://www.npr.org/sections/health-shots/2016/10/27/4994752...
- ngngngng 6y ago
  Well, this is life changing information. Thanks for it. I have knee pain when running with no physical explanation (MRI found nothing) I'm sure a placebic treatment would be helpful, but can I treat myself with a placebo? I wonder if an authority figure giving you an open placebo is more effective than me just telling myself that I'm cured, but I'm going to start with the latter.
  - tempestn 6y ago
    I recall reading that the placebo effect tends to be proportional to the perceived degree of intervention. So getting a shot would have more of an effect than taking a pill, and a surgery would have more effect than a shot. Presumably getting something from an authority figure would also do more than whatever you can do yourself, but that doesn't mean the latter would be useless. If you can find some kind of physio exercise that's claimed to potentially help, maybe that would have a decent placebo effect, if nothing else? Of course it's likely there is some kind of physical explanation for your pain, just not a known one (or even knowable, with current medicine). I'm in much the same situation with hip pain.
  - harry8 6y ago
    Just pick an "alternative" treatment that is (a) harmless and (b) you consider "could possibly work" For running pain in a knee someone I know had a course of laser accupuncture [1] with really good success. There's nothing scientific about the treatement, no studies, no data. But it is at worst harmless so, we probably don't need to care. I can see "I'm aware it might be just a placebo" as working better than "This /is/ just a placebo" [1] My undertanding of this was that a general practioner (Doctor) shined a low power laser at close quarters on various parts of the knee. Zero chance of burning, completely harmless at worst.
  - elil17 6y ago
    Perhaps instead of a placebo, try a healing ritual or some form of alternative medicine. You can easily have someone else administer the treatment, and you can even choose something like acupuncture where there is potentially some evidence that it actually works (I don't believe it but if you can convince yourself, all the better for the placebo effect).
  - sushisource 6y ago
    MRI isn't necessarily going to reveal reasons you'd have knee pain while running. For example, I know for a fact that if I don't routinely roll out my IT band, it gets too tight and that then results in pressure on the outer portion of the patella. It's rather unlikely that'd show up on an MRI, except perhaps for someone noticing "Hey, maybe your IT band is tight". Even then, probably not, since it tightens as I begin running. So, there's probably something real going on, and something real you can do to fix it. Consistent stretching, rolling, and low-weight exercises to build strength in muscles like your hip abductors makes a world of difference. If you're not doing those things, start there. Really do get a roller. The IT band cannot be stretched - since you can't exactly flex your femur.
  - masklinn 6y ago
    > I have knee pain when running with no physical explanation (MRI found nothing) That MRI found nothing only means there isn't clear damage no? Would it find e.g. short or tight tendons, or unbalanced muscle mass? > can I treat myself with a placebo? Nothing stops your from trying. You can just get some inactive pills (I don't know if it's possible to find excipients-only pills which would be the ideal but homeopathic crap or some innocuous supplements would do the trick) and take that on the regular as "treatment".
- fooblat 6y ago
  Dr. Ted J. Kaptchuk is has been at this a long time. His agenda is pushing so-called alternative medicine. When you dig in just a little and do some research on him you will find a lot of reasons to question his assertions. In his studies, it is true that he tells people he is giving them a placebo. He also tells them that it can still help them. This is not really an "open label" placebo as people still have the expectation that it is some kind of treatment and will help. I also find it interesting that the placebo effect only helps with subjective conditions, such as pain and nausea. No placebo will set a broken bone or seal a laceration.
andai 6y ago
Well, there's always the DIY approach: positive thinking. (But it only works if you believe it will.)
- NoodleIncident 6y ago
  There was a pretty serious-sounding contingent of commenters here in a recent thread about RSI. To them, the main cause of RSI was some sort of unconscious tension they were holding in the affected areas, and they needed to relax to make the pain go away. I wonder if that was placebo too
- tstrimple 6y ago
  Placebo effect works even if you know it's a placebo. https://www.health.harvard.edu/blog/placebo-can-work-even-know-placebo-201607079926 https://www.health.harvard.edu/blog/placebo-can-work-even-kn...
podiki 6y ago
I believe the placebo effect can also work just by telling someone about it (and then giving them the sugar pill or whatever). However, the whole placebo effect may just be (poor understanding of) statistics, namely regression to the mean. Here's an article [0] (found via Wikipedia on placebo [1]) [0] https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2796.2004.01355.x https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2796.... [1] https://en.wikipedia.org/wiki/Placebo#Confounding_factors https://en.wikipedia.org/wiki/Placebo#Confounding_factors
epmaybe 6y ago
I thought placebos work even with open labels?
ummonk 6y ago
A lot of placebo effects still show up when the patient knows they're getting placebos. It probably has some ritualistic advantage in helping them mentally.

Ozzie_osman 6y ago

I've been told by more than one doctor (for chronic pain I had been having) to avoid seeing a surgeon unless absolutely necessary because they were worried the surgeon would recommend surgery even if it wasn't needed. I found it interesting. Seemed like they didn't trust their colleagues (or even they didn't trust me to make my own decision if I got the recommendation to undergo surgery).

Peradine 6y ago
There's also the perverse incentives in the american medico-legal system: surgeons get sued for not performing surgery, or performing surgery badly, but they rarely get sued for performing 'unnecessary' surgery unless its completely egregious. If the patient has a history/examination which could indicate a need for surgery, and the patient has given informed consent, the surgeon is very unlikely to be succcessfully sued for operating. I'm not implying this is a consious decision on their part, rather a subconscious influence of their training, anecdotes from other surgeons etc.

graemebenzie 6y ago

This is one trial I won't be volunteering for.

4778468d 6y ago

I know a surgeon, he says that he thinks it’s the enforced rest post surgery that is what really does the healing in some cases such as for example Surgery for back pain.

frereubu 6y ago

One of my favourite stories along these lines (this is from Ben Goldacre's great book Bad Science, and may be slightly misremembered in parts) is about Archie Cochrane, who gave his name to the Cochrane Collaboration, an organisation who rigorously analyse the evidence for medical treatments, even "obvious" ones. He set it up after being a Japanese prisoner of war, where he had to make decisions about medical treatment in the face of extremely callous treatment by the Japanese officers. They were often decisions you only hear about in philosophical games - e.g. do you save one person's life or the sight of ten people - and he realised that much of his medical training was not based on proper evidence. In the UK in the 1970s, hospitals started equipping expensive cardiac units, specifically designed for the treatment of heart attacks, full of expensive medical equipment (and if HN doesn't mind a good-natured tease, cardiac surgeons don't exactly shun the heroic mode of medicine). Part-way through a Cochrane study of their effectiveness, the data was pointing to survival rates being slightly higher when people were treated at home rather than in the cardiac units, but the results were not statistically significant. He decided to play a trick and annouced at an interim meeting that the data were pointing the opposite way - that treatment in cardiac units showed slightly higher survival rates, but were still not statistically significant. The doctors in the meeting were extremely angry that he insisted that the study should go on because the results were not statistically significant and therefore no conclusions could be drawn from the data. It wasn't until later in the meeting that he came clean, and told them that the data were pointing in the other direction. Funnily enough, none of the doctors still called for the study to be halted early in the face of identical evidence, just pointing to a different conclusion.

saas_sam 6y ago
This kind of thinking is so common I often wonder how the hell we manage to progress as a species. People seem to only ever look at the evidence that supports positions they originally adopted for bad reasons. I can't remember the last time I talked to anyone who could recall to me a single time they changed their mind based on seriously weighing evidence for & against their positions. People Google to find out why they're right and that's the end of it.
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resoluteteeth 6y ago

Yeah it's always seemed bizarre to me that surgical procedures aren't held to the same standard of evidence as drugs and surgeons are allowed to pretty much make things up and do whatever they want as long as they don't engage in clear malpractice.

Latty 6y ago
"The same standard" as in double-blind studies would clearly present issues when it comes to surgery. I can see the argument for a higher standard than is currently held to, but "the same" seems impossible to do in an ethical way, or even just practically.
- Retric 6y ago
  Many double blind surgical procedures have been tested. Unless it’s limb removal you go in and either do the procedure or go in and don’t do the final setup. The ethics is interesting as surgical procedures can become common without any actual testing of effectiveness. Overall about 1/2 of surgical procedures have had double blind tests and of those about 1/2 passed the test. Which suggests something like 1/4 to 1/2 of surgery’s are ineffective.
hamandcheese 6y ago
It doesn’t seem that unreasonable to me — bad drugs can harm people at a much larger scale than a bad doctor.
- whatshisface 6y ago
  They're the same when abstracted to the level of "the practice of doing knee surgery."
ska 6y ago
Doctors are free to use drugs off label also, so that is consistent. The constraints around producers (drugs, devices) are tight, but the clinicians can do what they think is worthwhile from there.

nwienert 6y ago

Anecdote. I had undiagnosed Familial Mediterranean Fever for years in my early 20s. Terrible, sickening abdominal inflammation attacks every few weeks. After about 5 years I was desperate and one doctor said my gallbladder did show signs of low functioning, and recommended taking it out. I did go into “remission” for about 8 months after. It eventually came back, but then faded soon after. It wasn’t until a few years later with a DNA test that I found the cause. But I did always wonder if the surgery, along with my desperate hope to be better / not be wrong, had such a strong placebo effect that it actually did help me out.

fernly 6y ago
> Familial Mediterranean fever (FMF) is a hereditary inflammatory disorder... an autoinflammatory disease caused by mutations in Mediterranean fever gene, which encodes a 781–amino acid protein called pyrin. https://en.wikipedia.org/wiki/Familial_Mediterranean_fever https://en.wikipedia.org/wiki/Familial_Mediterranean_fever

owenversteeg 6y ago

Does anyone have any examples of surgeries that are done today in modern medicine that are basically placebo? I'm surprised the article didn't give a single example.

hnuser123456 6y ago
Routine wisdom teeth removal, male genital mutilation, dentists giving fillings far before they are required, causing toothaches and sensitivity... But these all turn out to be easy money for someone, for some odd reason.
- bsanr 6y ago
  I imagine that this gray area is where a lot of "unnecessary surgery" comes from. The vast majority of people have no medical need for circumcision (but some do). A lot of people don't need their wisdom teeth removed (but many probably should). You might need a filling eventually (just not now). Where do you draw the line, in a world where setting up studies to find conclusive evidence for binary medical decision-making ("Should this ever be done in the presence of x, or should it never be done?") is hard enough? I had two surgeries in 2019; in both cases the consulting doctor told me that it was 50/50 if I actually needed them or if they'd actually fix the issues that might have been associated with them. One was a pretty smashing success, the other (ironically more expensive) one was a 4-figure wash that had the surgeon dodging my inquiries as to what went wrong. Unfortunately, it turns out that medical decision-making entails taking a holistic view of the situation and giving advice that the doctor then has to take responsibility for. Good luck achieving that on a systemic level within the ever-dysfunctional structure of American healthcare.
- jessaustin 6y ago
  I've assisted on numerous third molar extractions, on patients up to sixty years old. None of those people were glad they had neglected to get the work done in their twenties. If you're not sure about a recommended dental filling, just go to a different dentist for a second opinion. By the time a cavity causes you pain you'll need a root canal and possibly a crown.

chillwaves 6y ago

> Question: Is physical therapy noninferior to early surgery with arthroscopic partial meniscectomy for improving knee function among patients with nonobstructive meniscal tears? > Findings: In this noninferiority randomized clinical trial that included 321 patients, knee function that was measured by a self-administered questionnaire improved by 20.4 points in the physical therapy group vs 26.2 points in the early surgery group over a follow-up period of 24 months. The difference between the 2 treatment groups did not exceed the noninferiority margin of 8 points. > Meaning: These results demonstrate noninferiority of physical therapy compared with early surgery with arthroscopic partial meniscectomy for improving self-reported knee function in patients with nonobstructive meniscal tears. https://jamanetwork.com/journals/jama/fullarticle/2705186 https://jamanetwork.com/journals/jama/fullarticle/2705186

TylerE 6y ago
That doesn't really sound like non-inferiority to me as a layman. That's a difference of over 25%. Reading further in their additional conclusions, the surgery group also did better in both pain and general health.
- Peradine 6y ago
  Look at the graph in figure 2 - the massive overlap in the interquartlie ranges suggests that any differene in the median values can be attributed to random variation within the samples, rather than a true difference in the populations. Also its better to quote an absolute rather than relative reduction, so the difference is really 3.6%
rsync 6y ago
"Question: Is physical therapy noninferior to early surgery with arthroscopic partial meniscectomy for improving knee function among patients with nonobstructive meniscal tears?" Vertical (deep, interior) meniscal tears can actually heal, since they have a blood supply, and the surgery for them is basically a coin flip - the results of which you only learn after a nine month recovery period. You should absolutely be pursuing a rigorous course of PT to heal such a vertical meniscal tear. You should specifically look into whether your adductors (inner leg) are weaker than, and being overpowered by, your abductors (outer leg) resulting in knee valgus.

varispeed 6y ago

This is dangerous thinking. For example when it comes to chronic pain, there is that belief being pushed that opioids are actually a placebo and they don't help. Then people are being sentenced to a talking therapies instead. These therapies try to implant the thought that all the pain people experience is in their heads and it is not real. If only they could just stop thinking about pain, then they wouldn't need to take any pills. This is one of the reasons why people turn to dealers, if doctors start to believe this and are made afraid of prescribing anything. Also organisations who get involved in such "therapies" promote them, because that is, let's be honest, rather easy money from the public health organisations. It fits the western perception of suffering, that it is noble and virtuous. I wish this topic was explored more by investigative journalists.

frereubu 6y ago
I don't think there are any doctors, except perhaps a handful of cranks, who believe that opioids are "a placebo". Perhaps you mean something else? There are definitely doctors who underprescribe pain medications to certain groups of people - as I understand it, women are notably underprescribed pain medications for example - but that doesn't mean that those people think opioids are a "placebo".
MichaelZuo 6y ago
And what if suffering does actually promote noble and virtuous thoughts? You left the most influential thought in the western tradition unexamined. From experience suffering, in any form, certainly enhances the idea of the golden rule, that is ‘Treat others as you would like others to treat you’.
blix 6y ago
What does it mean for pain to be "real" vs experienced in one's head? I don't think this is an easy question, which is why our medical system struggles to deal with chronic pain.
schoen 6y ago
I think there is evidence that people's attitudes toward pain can affect both the amount of pain that they feel and how much they suffer from it, and more generally that there are mental skills related to pain management and experience that are genuinely useful. (Also, there are cases where classic psychotherapy or psychoanalysis methods led to an alleviation or complete disappearance of somatic pain symptoms, even without focusing at all on the symptoms or pain themselves... although it doesn't seem ethically appropriate to somehow assume that that would be the best treatment for everyone.) I agree with the concern that this should not be seen as a substitute for helping reduce people's suffering with pain medication. But I think we also still have lots to learn about the mental component of pain and potentially identifying psychological interventions that make a difference in this area. I also agree that the "all the pain people experience is in their heads" angle isn't a constructive one, both because of its proximity to accusing people of lying or malingering, and because it doesn't seem like a helpful summary of any apparently-beneficial psychological techniques.

btilly 6y ago

This topic reminds me of a subthread of the last time we discussed Alzheimer's research. And more specifically about the great public tragedy caused by overconfidence on the part of medical researchers. The details are different, but the fundamental pattern is the same. https://news.ycombinator.com/item?id=24906758 https://news.ycombinator.com/item?id=24906758 was the discussion, and https://news.ycombinator.com/item?id=24910211 https://news.ycombinator.com/item?id=24910211 has the at times heated discussion that I am referring to.

gumby 6y ago

I have direct experience in the "doctor's know that under their care it works". In an earlier startup we developed a particular dissolving mesh that could be placed in situ in a surgical site to prevent adhesions. E.g. if you tear your rotator cuff, the healing of sewn up region will adhere not only to the cuff but other parts of your shoulder, preventing it from moving. The only fix is to (painfully) move the shoulder as it heals to tear those adhesions and form some scar tissue. Experiments in animals showed that they would recover full motion in their joints with no apparent discomfort. But when we interviewed doctors we discovered that they knew this was a terrible problem but blamed it on the techniques of other doctors. "When it's my turn on call I get these calls from patients, some in terrible pain. I am very careful and my patients never have this problem. This sounds like a great idea though I'd never use it myself." Of course we sometimes talked to multiple doctors in the same physician's group and they would say this about each other. We ended up using the technology in a different (medical) application.

hycaria 6y ago

Sometimes animals are in abdominal pain, supplementary exams leave us clueless and we resort to surgery to see whats happening, nothing looks wrong inside, we stitch them back and the patient gets better nonetheless.

atum47 6y ago

my brother had never water sky(ed) before, so after a month of vacation doing it, he felt his knees. he talk about it with two doctors and they both wanted to perform surgery on his knees. he went and got a third evaluation and the third doctor told him the truth: that he didn't needed surgery and the doctors were after his money. the doctor proceeded by putting my brother in physical therapy, which healed both of his knees. this is a real history. but there are plenty of other medical shows about the same subject - surgeons trying to force surgery on people that don't actually need it.

ishtanbul 6y ago

Microdiscectomy for treatment of sciatica, numbness and foot drop from a herniated disc is highly effective (most people see a 90-100% reduction in symptoms) and minimally invasive. However, the longer term outcomes are mixed because many patients dont stick to the required long term PT (maintaining excellent core strength and avoiding risky activities like lifting heavy objects) and end up reinjuring themselves. Many people dont need the procedure and can releive symptoms through conservative therapy, but some cannot and will benefit from surgery, especially if the condition is causing extreme pain, weakness or loss of function that make physical therapy almost impossible. Its misleading for him to say that surgery “doesn’t work” when there are so many complicating factors impacting the population-wide, long term efficacy of a treatment. Surgery is just one step of many that you would take in order to recover and stay better. Talk to multiple surgeons as well as other patients to understand if surgery is the best option for your particular situation.

ordinaryperson 6y ago

Without specifics this article is not helpful. I've had 5 orthopedic surgeries and they were transformative -- and this article is written by an orthopedist! There's some data [1] against these operations: - Arthoscopic knee surgery - Subacromial shoulder decompression - Acromioplasty for rotator cuffs - Vertebroplasty for the spine That's 4 techniques out of...how many exactly? It's just an n=1 anecdote but my surgeries absolutely changed my life for the better. I don't want to get into the gory details but I feel incredibly grateful to have had such talented surgeons. You can argue placebo but my years of ineffective physical therapy suggest otherwise. Instead of saying "Surgery, the Ultimate Placebo" this article should say "A handful of specific surgeries shown to be no better than a placebo" -- generically describing all surgeries as a placebo is clickbait, in my non-medical-professional opinion. [1] https://www.realclearscience.com/blog/2020/11/07/some_surgeries_are_performed_millions_of_times_per_year_even_though_they_are_no_better_than_placebo.html https://www.realclearscience.com/blog/2020/11/07/some_surger...

OJFord 6y ago
> It's just an n=1 anecdote but my surgeries absolutely changed my life for the better. [...] You can argue placebo but my years of ineffective physical therapy suggest otherwise. They don't though, do they. You can't disprove placebo with N=1. If the placebo is the act of surgery then anything not surgery not working doesn't mean that the surgery worked by not placebo means. But who cares how, it worked!
- ordinaryperson 6y ago
  So cynical. I hope you're never in debilitating physical pain, only to have other people dismiss the effect of surgical intervention as a figment of your imagination. It's not just about the sample size, I could get into the anatomy of my injuries but I don't want to divulge more of my medical privacy than I already have. Suffice to say that when certain things are torn or detached surgical intervention is often the only way to re-attach or restore function to the affected joints. No mount of wishing it way mentally is going to change that.

zaptheimpaler 6y ago

To a man with a scalpel, everything looks like a surgery ;)

hughw 6y ago

Sloan-Kettering publishes a set of online predictive tools [1] patients can use to make statistical estimates of the outcomes of surgery and other treatments. They're based on data from thousands of patients. [1] https://www.mskcc.org/nomograms https://www.mskcc.org/nomograms

ckemere 6y ago

I think that an article like this that doesn't emphasize the fact that a placebo is still treatment is remiss. The naive reading is that surgery is useless, but that is not at all the conclusion if compared to a placebo. The neuroscience of placebo effect(s) are super cool and quite difficult to study. Pain-related ones which involve release of endogenous opioid receptor agonists are fairly well mapped out, and similar circuits for blood pressure and other physiological functions controlled by the brain can be imagined. I've read about placebo antibiotics, though, which presumably involve the immune system in cool ways. There have been big investments by NIH into the idea that we should be treating a lot more disease with neurostimulation, but I think so far this has not paid off...

Ozzie_osman 6y ago
Sure but if it's just a placebo, there are probably cheaper and safer ways of achieving that affect. Even a routine surgery can be really risk.

DoreenMichele 6y ago

This doesn't contain the details that would interest me. My understanding is modern surgery routinely involves significant antibiotics to prevent serious infection during the operation. If that's followed with both "sham" surgeries and real surgeries, then it points to the possibility that the strong antibiotics are more important in some cases than the procedure. There may be other medically significant details of sham surgeries that we overlook as not therapeutic. Many diagnostic exams involve not eating for x hours beforehand. Surgeries also can involve restrictions on diet during recovery or exposure to drugs like anesthesia that are given without intent to be therapeutic per se. You can't really rule out the possibility that those types of things are therapeutically significant but overlooked because they are done to be curative.

oarabbus_ 6y ago

There is an absolutely fantastic quote relevant to this in An Astronaut's Guide to Life by Chris Hadfield (a fantastic book). Unfortunately, I don't have the book handy and cannot do it proper justice, but the part I refer to involves dozens of years after a childhood appendectomy when Hadfield was beginning his "real" astronaut career. After experiencing severe abdominal pain at the surgical site, he was sent to a panel of surgeons for guidance. Going into surgery at this time would've been catastrophic to his career, as after a surgery one cannot fly into space for some extended period of time. At this point in his career Hadfield was relatively green, and there was a plethora of new astronauts as talented as he was just waiting to take his spot. Going into surgery at this point would have relegated him to a successful career at mission control, but not in space. To the best of my recollection, his physician's opinion was he didn't need a full surgery to investigate this abdominal pain. However, the panel of surgeons universally, unequivocally recommended the gastrointestinal surgery. He states infinitely more eloquently than I can how applicable "uf you only have a hammer, everything looks like a nail" in regards to the surgical panel. I recall he decided against the recommendations of the surgeon panel, and decided his abdominals wouldn't suddenly tear apart with potentially fatal results while orbiting earth in the ISS. It turns out he guessed right, and had one of the most prolific careers of any astronaut of the last few decades. While this anecdote may make it seem like I am some anti-surgeon, anti-surgery person, let me state that I have had one surgery (besides wisdom teeth, which "doesn't count" as it's so common). It was an orthopedic reconstructive ulnar collateral (thumb) surgery, and my repaired thumb is honestly almost indistinguishable from my left thumb. And in this case it was clear surgery was needed, but after reading Hadfield's book and the parent article here it was astounding how the surgeons were literally unable to see any mode of treatment which didn't involve surgery. I think just like overprescription of antibiotics, we as a society should look at the overprescription of surgeries for medical issues which can be treated without surgical intervention.

rscho 6y ago
> it was astounding how the surgeons were literally unable to see any mode of treatment which didn't involve surgery. Current medical practice is the definition of "when all you have is a hammer, everything looks like a nail", so no surprise here. This a result of hyperspecialization which most of the time is good (capable hands) but sometimes not so good (rigid mind).

choeger 6y ago

Maybe the categorization of the surgeries is too broad? Surgery is naturally an exploratory act and I would assume that what you find once someone is "opened" can vary massively. Maybe one should take that into account?

einpoklum 6y ago

The column is fudging the facts to justify its bombast title. Example: > A systematic review found that placebo was just as effective as surgery in over half of the cases studied, and all of the recent trials comparing surgery to placebo have found that surgery was no better than placebo. We note that that the text doesn't tell us...: 1. which kind of operation is supposedly not very helpful. 2. which kind of medical condition(s) were studied. 3. whether the relevant medical condition is transitory/accute or chronic; 4. whether the condition is known to be amenable to non-surgical treatment; 5. what review this was, exactly, and where one can read the details. 6. what, exactly, the review reviewed. 7. what happened in the less-than-half the cases. 8. what chances of success the surgery purports to have. i.e. it might be a surgery which proponents suggest solves the problem in 45% of cases and has little effect (but no significant negative effect) in 55% percent of cases - in which case you "get what it says on the label". Also, I would assume are almost no, or no trials comparing surgery to placebo where surgery is known, or reasonably assumed, to be efficacious. So those "recent trials" probably considered surgical procedures which are apriori under suspicion of not being efficacious. etc.

protontypes 6y ago

This is one of the best presentations I have seen in a long time.

thrwo4234234 6y ago

Is this allowed?! I thought we were all on the science-cant-be-questioned train and getting in line for our latest untested experimental drugs.

macawfish 6y ago

Surgery --> stem cells

teorema 6y ago

Different, but a related topic that I've come to be fascinated by are athletic tools and techniques that are held as canon that turn out to have no scientific support. The author talks about reactions of physicians dismissing convincing data — the befuddlement and dismissals — and it's the same reaction athletes and coaches give when they're part of some of a controlled trial.

theriddlr 6y ago

Had scoliosis-kyphosis fusion surgery when I was 14 and it was rapidly-progressing. All it did was cosmetic and bought me time until Functional Patterns was invented. Today I am 70% cured. It's basically strength training according to the body's myofascial slings (gait). Flat feet, knee valgus, scoliosis, jaw growth, forward head – it's all connected. Still, no surgeon in the world would undo (as in chip away the bone grafts limiting my spinal mobility) my fusion.