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Pragmatic Studies and Cinderella Medicine

Explanatory studies are done under controlled conditions to determine whether a treatment has any efficacy compared to a placebo. Pragmatic studies are designed to assess how the intervention performs in everyday real world practice. Pragmatic studies measure practical success but don’t determine actual efficacy: that requires a proper randomized controlled trial (RCT) with an appropriate control. Pragmatic studies have their place, but they can sometimes make an ineffective treatment look good: a phenomenon I have christened Cinderella Medicine.

Research studies don’t always predict how a treatment will perform post-marketing. A study might be done on men aged 30 to 70 with no other illnesses. Once the drug is out on the market, it will probably be taken by women, by people who are under 30 or over 70, and by those who have concurrent diseases like diabetes or atherosclerosis or are taking a lot of other medications; and the dose or frequency may vary from the study protocol.

A good example is the clot-busting drug t-PA. In clinical trials, it clearly improved the outcome of stroke patients, but in actual use in community ERs the death rate was almost twice as high in patients who received it as in patients who did not. There are many possible explanations: perhaps it was offered to patients with more severe strokes, perhaps the protocol wasn’t followed as carefully, perhaps some patients were mis-diagnosed, perhaps they had confounding factors that were not present in the research studies.

Pragmatic studies are useful for the questions they are designed to answer: how a treatment performs outside the limited environment of a research study, which of two treatments should be preferred by doctors, patients, and policymakers, deciding how limited resources can be best utilized. They are an integral part of comparative effectiveness research.

But they have limitations. They are unblinded and the patients are generally self-selected. Larger studies are needed to compare two active treatments than to compare an active treatment to a placebo. Lack of compliance and a high drop-out rate can skew results. Patient self-assessments of subjective outcomes are not as reliable as objectively measurable outcomes.

Pragmatic trials can’t determine which components of a “package” of care are essential, and they can’t assess the contributions of the therapeutic relationship. When used for studying a treatment with a strong placebo effect, they may make an ineffective treatment look better than an effective one. CAM proponents like pragmatic studies because they are often the only studies that seem to support them. They are attempting to bypass good science by showing that, in practice, their methods seem to work.

Cinderella didn’t look very pretty in her rags and ashes. Imagine that her Ugly Stepsister had a complete makeover, with hair styling, expertly applied cosmetics, jewels, and a beautiful designer dress. Maybe tooth whitening or even orthodontia, charm school, modeling classes, and elocution lessons. If you entered her in a beauty contest along with the unadorned, dirty Cinderella in her original rags, the Ugly Stepsister might win hands down. But it wouldn’t be a fair beauty contest unless both were in their original unenhanced state or unless you compared the makeover-enhanced stepsister to the Fairy-Godmother-enhanced Cinderella. (Or if, for a really well-controlled study, you managed to persuade the FG to do her magic on both of them.)

Acupuncture’s makeover

Studies comparing acupuncture to standard treatment have shown that acupuncture works better. Standard treatment is like the original Cinderella in her rags: plain and unenhanced in any way. The doctor may only see the patient for one visit and tell him “You have a common garden variety backache; we don’t know why people get these, but they usually resolve spontaneously in a few weeks; while it is going away on its own, I could offer you a prescription for pain pills or a referral to physical therapy.” He doesn’t spend much time with the patient and may seem bored and unsympathetic.

Acupuncture is like the Ugly Stepsister after her complete makeover. The treatment itself (insertion of needles) is like the Ugly Stepsister before her makeover. It doesn’t have any specific effects (it is no more effective than touching the skin with a toothpick). But the acupuncturist surrounds the treatment with all kinds of enhancements that produce “nonspecific effects” that are not due to the treatment itself, but rather to the interaction with the provider.

  • The acupuncturist assures the patient that he knows how to relieve the back pain, and he provides a complicated explanation with all kinds of impressive, esoteric oriental terminology.
  • He explains that his system is derived from ancient Chinese wisdom and that his needles will adjust the flow of qi through the patient’s meridians to restore health.
  • He takes the patient into a quiet back room, has him lie down and relax, and spends half an hour or more doing up-close-and-personal hands-on treatment.
  • He is charismatic, shows great interest in the patient, asks a lot of questions, and may uncover another unrelated problem that needs treatment.
  • After treatment, he prompts “You feel better now, don’t you?” and the patient feels a social pressure to agree.
  • Instead of dismissing the patient with a prescription, he asks him to return over and over, maybe 3 times a week for several weeks; and when the initial course of treatment is finished, he may want the patient to keep seeing him for treatments to maintain health and prevent future problems. He develops a strong, caring doctor-patient relationship.

The plain needle insertion has been given the Cinderella treatment and transformed into an enhanced package of suggestion, expectation, relaxation, ancillary psychological effects, personal interactions, etc. Acupuncture treatment is ready to go to the ball and wow the prince. It is the ideal placebo package; it’s hard to imagine how anything could be devised that would be better at eliciting placebo responses.

So acupuncture, with no specific effects but many nonspecific treatment effects, will appear to outperform a standard treatment that offers some small specific effects but little in the way of nonspecific enhancements.

The common argument is that it doesn’t matter how a treatment succeeds: it should be used because patients report feeling better faster than with standard care, that it is more effective in a practical sense. But fooling patients with nonsense about imaginary meridians, qi, and acupuncture points amounts to lying. Using placebos and offering fantastic explanations undermine the doctor-patient relationship; and this kind of thing leads people to think non-critically, to accept other kinds of pseudoscience, and to reject science-based treatments that might help them objectively or even save their life in the future.

Cinderella treatments: beautified and dressed up with added enhancements. Why not add as many as possible of these Cinderella enhancements to standard, science-based treatments? Without lying or misrepresenting our knowledge? These pragmatic trials don’t show that acupuncture works; they show that the way standard treatments are offered provides fewer nonspecific effects and could stand a bit of a makeover. That should be our goal.

Posted in: Acupuncture, Clinical Trials

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36 thoughts on “Pragmatic Studies and Cinderella Medicine

  1. nybgrus says:

    An excellent piece Dr. Hall. This clearly and succinctly sums up the mish-mash of thoughts that I have been developing on the topic. I use your “tooth-fairy science” analogy when I tutor the 1st year students and now I will add “Cinderella Medicine”

  2. BillyJoe says:

    Actually, I’m confused by the analogy.
    CAM is not like Cinderella dressed up by the Fairy Godmother.
    It’s like the ugly stepsister with a makeover.

    I know it loses something, but shouldn’t it be “Ugly Stepsister Medicine”?

  3. Interesting article. Thank you. Our approach to patients and how we present the efficacy of the treatment has a lot to do with how well the treatment will work. I’m guessing that acupunture is very well presented as a treatment modality.

    Dr Sam Girgis
    http://drsamgirgis.com

  4. HH “But it wouldn’t be a fair beauty contest unless both were in their original unenhanced state or unless you compared the makeover-enhanced stepsister to the Fairy-Godmother-enhanced Cinderella. (Or if, for a really well-controlled study, you managed to persuade the FG to do her magic on both of them.)”

    I love this line! Very nice.

    If I might add something to the fairy god mother treatment for Conventional medicine…

    People on this site often talk about adding more sympathetic demeanor and touch to conventional medicine. One thing I would add in addition (that varies a lot, between doctors) is making the patient aware of the process of treating a complaint.

    To use your example, the patient sees a doctor for backache. The doctor says, oh these kinds of backaches usually go away in 1 to 3 weeks, end of visit. What does the patient do if the backache doesn’t go away? Do they go back to the uninterested doctor? Or do they assume that if the doctor could do something for their backache they already would have. Do they go to a chiropractor or an acupuncturist? Many generally healthy people really don’t have good idea how to proceed through a multi-step diagnostic/treatment process within conventional medicine. Giving the patient a road map of the process is helpful. (whoops mixed Cinderella/travel metaphor).

    If the doctor offers more information, such as “80% of the time these backaches go away in 1 o 3 weeks. If you find it’s still bothering you in 4 weeks, then I’d like to see you again – or phone in and we will give you a referral to specialist, physical therapist, etc, (whatever the next step in the process is).

  5. BillyJoel, metaphor stickler, I see.

    I think the Cinderella Medicine analogy relates to the Cinderella story,not the character, where something good can look unappealing and something unappealing can look good. Cinderella is dressed poorly, but is sweet and kind. The step-sisters are generally dressed well, but are rude and spoiled.

    So the idea is let’s be the Fairy God Mother, wave our magic wand, put SBM (Cinderella) in a nicer gown and send her out to the ball so she can meet prince charming (the patient).

    That way the poor prince (the patient) won’t have to marry one of the step-sisters (CAM) for lack of seeing Cinderella (SBM).

    Yes, No?

    I’m actually not very good at complex metaphors.

  6. windriven says:

    “He doesn’t spend much time with the patient and may seem bored and unsympathetic.”

    Your selection of backache is apt. Medical schools and medical centers have fallen over each other to set up Departments of Quackery. I suspect that the medical industry would serve its patients’ interests as well as its own far better by folding a bit more gestalt into the medical education curriculum.

    When a patient presents with idiopathic backache, don’t just prescribe vicodin and/or send her off to the chiroquackster down the hall. Prescribe a therapeutic massage.

    When physicians are perceived by their patients to be ‘blowing them off’, being ‘bored and unsympathetic’, doesn’t that elevate the chance that the patients will take matters into their own hands and potentially seek out quacks who will blow smoke up their lower GI tracts?

    And let me anticipate those in the community of physicians here who will huff that they do this now: you might but many of your colleagues don’t.

  7. Scott says:

    I’d love to see a pragmatic trial comparing acupuncture with a visit to a spa. The latter could even be done ethically:

    “It doesn’t do anything specific for back pain, but some pleasurable pampering in a relaxing environment often makes people feel better overall.”

  8. daedalus2u says:

    Scott, you know what the acupuncturists will say then.

    Spas work too!

  9. Scott says:

    Unlikely, since that’s not something they can leverage to make money themselves.

    But it’s irrelevant; having a demonstrated effective ethical option to offer in place of the nonspecific effects of woo would be valuable IMO.

  10. Anthro says:

    “The common argument is that it doesn’t matter how a treatment succeeds…….”

    I’m going to try to commit this paragraph to memory because this is the discussion I inevitably end up having with “woo-people”–who I seem to come into contact with almost incessantly. It can be difficult to get people to see the ethical dilemma that is inherent in providers using the placebo effect.

    Thanks for this, Dr. Hall; there’s a lot of identification of the problem here and elsewhere, but not so much practical solution (not that there’s an easy answer to scientific ignorance).

  11. Mark Crislip says:

    I have a non evidence based pragmatic rule of thumb. In the real world all diagnostic and theraputic interventions are half as effective as the literature would indicate. That would most SCAMs even more useless than published.

  12. # Mark Crislip
    “I have a non evidence based pragmatic rule of thumb. In the real world all diagnostic and theraputic interventions are half as effective as the literature would indicate.”

    I think this is offtopic, but…

    That’s funny, I have a patient’s (or parent of patient) rule of thumb. In the real world most procedures are about twice as painful as your surgeon or other practitioner will indicate.

    I understand why they do it (I think) but couldn’t they at least use a thersarus? “Uncomfortable” gets a little old.

  13. windriven says:

    @ Mark Crislip and micheleinmichigan

    I have a corollary rule of thumb: in the real world most procedures are at least twice as expensive as you expect them to be.

    I understand that quality medical care is expensive. But I don’t understand why repair of a right inguinal hernia cost about $13k including surgeon and anesthesiologist (though most was for the 4 hours I spent in the hospital, most of that cooling my heels waiting for the OR to free up) while a complete hysterectomy and oophorectomy* including IVs and diprivan anesthesia cost $400. Both were done at first class institutions. The hernia repair was performed on me. The hysterectomy and oophorectomy were performed on an 8 month old yellow Lab. Both survived and are doing well ;-)

    I’m not suggesting that medical care for humans and animals are equivalent. I am suggesting that food for thought can be found in comparing and contrasting the two.

  14. @windriven, you probably already know this, but The Economist has lots of interesting articles on health care costs.

    Although I don’t think they have the homo sapien vs canine comparison break down. :)

    One difference is insurance companies. I always wondered what percentage of our health care costs is providers dealing with a huge diversity of insurance companies, paperwork, billing, letter writing, etc.

  15. daedalus2u says:

    Scott, going to a spa (if it is the right kind of spa) can have more than non-specific effects.

    Many thermal springs are inhabited by ammonia oxidizing bacteria, the kind that I am working with. Essentially every spring that has nitrate or nitrite in the water that comes from it has these bacteria. Bathing in such water will inoculate your skin and will provide you with all the natural health promoting goodness of the natural ammonia oxidizing bacteria biofilm.

    I think in a trial of acupuncture vs going to a spa that has ammonia oxidizing bacteria in the water, the ammonia oxidizing bacteria will win hands down. For absolutely everything.

  16. Josie says:

    “These pragmatic trials don’t show that acupuncture works; they show that the way standard treatments are offered provides fewer nonspecific effects and could stand a bit of a makeover. That should be our goal.”

    It’s good to continually improve…but it might not be as necessary as SCAMmers would have us believe.

    Outside of the special cases of overburdened military hospitals and understaffed student health centers I’ve had the pleasure of going to UCSD Thornton’s ER/urgent care 4 times in the past 6 years.

    Every single time the support staff is polite, the nurses overtly caring (they give me warmed blankets to use in the x ray room!!) and the doctors are no nonsense and all about the facts of whatever injury I have given myself.

    I actually feel pampered when I go there. While the doctors are very straight up professional with very little extra fluff to make me feel ‘special’, the rest of the team makes sure that I am as comfortable, informed and not frustrated as possible.

    UCSD might be unique in this regard but if it is in fact representative then woo-apologists just need to quit their whining.

  17. windriven says:

    @michele

    “One difference is insurance companies. I always wondered what percentage of our health care costs is providers dealing with a huge diversity of insurance companies, paperwork, billing, letter writing, etc.”

    I’m sure it is a factor though truth be told in most practices those details are handled by billing clerks.

    My personal observation is that hospital charges seem to consume a disproportionate share of health care dollars. My surgeon and anesthesiologist submitted charges that were perfectly reasonable it seemed to me. I did not get an itemized bill from the hospital this time around but many years ago I got a detailed hospital bill that included a $19 charge for a nasal cannula (that they in fact didn’t use). A nasal cannula costs around $0.40 wholesale. Even the least astute hospital on the planet wouldn’t be paying more than $.95.

    Agreed on the Economist. It is the only general news magazine to which I still subscribe.

  18. nybgrus says:

    @michelle/BillyJoe: That was what I was thinking in regards to the analogy.

    in general: I find that patients very much like to hear what will happen next, why certain tests are (or aren’t) being done, and some (at least semi-) concrete plans for follow up. When I worked in the ER I would always explain what an EKG was and why I was doing it. Some patients even got curious and asked a few more questions so I would give them a 60 second lesson on what the squigly lines actually meant. In traumas especially, explaining what was going to be happening to them for the next 30-40 minutes visibly drained tension and anxiety from their faces. And yes, in the case of back pain, clearly explaining that it is overwhelmingly likely to resolve on its own, that movement and motion is a good thing, and that the drugs you are prescribing are only there to help make the first couple of days more bearable are vital. And easily as vital is the follow up plan – patients who view you as abandoning or turfing them are more likely to be unhappy and any non-specific “fairy godmother” effects will be negated in a flash.

    @michelle on 11:01am: In the ER I used to help reduce dislocations and long bone fractures, set bones in splints, and otherwise do things that would frankly hurt. I would always tell my patients exactly what was going to happen, and let them know it was going to hurt. Almost verbatim I would always say, “My intention in not to hurt you, and in fact I am pretty good at this so it probably won’t hurt as much as you are worried it will, but I would be lying if I said it wouldn’t hurt. After we are done though, I promise you will feel a LOT better.” And I would say 90% of the time, everyone (from kids to adults) would say, “Hey, that wasn’t so bad! It hurt, but now it feels SO much better! Thank you!” And that’s it. I’ve always wanted to cull realistic expectations and be completely up front with patients. And I have never once had anyone yell at me after because of it.

    I’ve long been commenting that these are changes that can and should be made in medicine. That, coupled with a general increase in critical thinking and education of the populace, would (IMHO) essentially knock CAM out of business.

  19. pmoran says:

    I normally oppose pragmatic studies of CAM for all the usual reasons but I would encourage them if they could be designed in such a way as to give us a clearer evidence base concerning the true clinical worth of “all the other things” (placebo responses etc, etc) that can go on within medical interactions.

    We certainly don’t need more of the loosely designed, entirely subjective end-point, multiple outcome, short-term studies that used to be performed to try and vindicate CAM modalities as medically active agents.

    We would need highly sophisticated studies, focusing on as objective and clinically significant end-points as we can measure, and in as cunning a way as we can design, so as to avoid reporting biases. Can it even be done? Perhaps not.

    It would be a worthy field of study simply as pure science, but it would also help resolve my personal moral dilemma concerning how best to react to CAM in all the various ways in which it can confront us. Those concerns apply even if we decide to distance ourselves utterly from CAM.

  20. Mark Crislip says:

    When huge swaths of the community can’t or doesnt pay for health care, those costs get shifted to those who can. In my own small neck of the woods

    “Charity care” is the term for taking care of people who come into
    one of our hospitals with limited ability to pay. Legacy’s cost of charity care was more than $33 million in fiscal year 2005, compared with approximately $15 million in 2004 and $7.5 million in 2003.

    Charity care doesn’t include “uncompensated care” and “bad debt.”
    Uncompensated care results when the costs to provide care exceed the reimbursement from Medicare and Medicaid. In FY 2005 we absorbed $53.7 million in this category.
    Bad debt represents care provided to patients who are unwilling to pay. In fiscal year 2005 we absorbed $25 million in bad debt write-offs.

    In total, that’s $87 million in costs for charity care and uncompensated care, plus $25 million in bad debt charge.”

    And I marvel at what it costs just to pay the electric bill at my hospitals (it is not as if we can turn off the monitors and ventilators to save electric costs), much less the rest of the infrastructure. Walk through a hospital asking the question: how do they pay for all this? and you will soon realize just how much it costs to keep the doors open.

    http://www.legacyhealth.org/documents/Employment/community_report2005.pdf

    And thats my little hospital system in Portland.

  21. wales says:

    You’re missing an important part of the Cinderella story, perhaps the most important part. The prince was convinced that she was the real thing, so he married her and she became an actual princess….

    then there’s the wikipedia interpretation of unjust oppression followed by triumphant reward…

    somehow, Cinderella doesn’t seem like the best metaphor here.

  22. wales says:

    That’s the problem with these metaphors/analogies…they don’t always translate as the speaker intends. For example, DG’s fondness for Star Wars metaphors, with the “dark side” of alternative medicine represented by the Star Wars villains.

    Presumably then the Star Wars victors represent the heroes of science based medicine, but since the Jedi worship/preside at Jedi Temples and win the battle of good vs. evil via a mystical “Force”, an intangible energy source, I can’t see how this metaphor helps science based medicine.

  23. @mark crislip

    but, but, at least we’re not socialists .

    Also. You are in the wrong fairy tale, Rumpelstiltskin is down the hall and to the right.

  24. windriven says:

    @Dr. Crislip

    You make an interesting point about uncompensated charity care. Except that it isn’t really uncompensated. It is simply amortized over those of us who are willing and able to pay our own way.

    If you carefully read my earlier comment you will note that I did not claim that hospitals are profit machines. They most certainly aren’t. There are fewer than 4500 hospitals in the US today, down from more than 7000 just a couple of decades ago. That isn’t because the hospital business is particularly lucrative.

    Hospitals have an ethical (and legal) obligation to stabilize patients before moving them out. Many go much farther. And they cost shift this largess to the insured and to those who pay cash. I don’t know how it works at Legacy but at many hospitals those who pay cash are charged list price – prices that no insurance company would ever dream of paying. How much of Legacy’s $25 million in bad debt is a paper write-off after accommodations are made to those who can’t pay full sticker price – an arbitrarily high price that only they are charged?

    I would be the last person to argue that basic medical care shouldn’t be available to everyone who needs it. But I would be the first person to argue that charity patients and paying patients deserve different levels of care.

  25. BillyJoe says:

    Michele,

    I was confused by the following:

    Harriet: “Pragmatic studies have their place, but they can sometimes make an ineffective treatment look good: a phenomenon I have christened Cinderella Medicine.”

    The conjunction of “they can sometimes make an ineffective treatment look good” and “Cinderella medicine” makes it sound like Cinderella refers to CAM.
    I was still confused by the time I read the following (and hence I didn’t pick up on the intended analogy):

    Harriet: “If you entered her in a beauty contest along with the unadorned, dirty Cinderella in her original rags, the Ugly Stepsister might win hands down. But it wouldn’t be a fair beauty contest unless both were in their original unenhanced state or unless you compared the makeover-enhanced stepsister to the Fairy-Godmother-enhanced Cinderella.”

    This clearly explains that SBM is Cinderella, and CAM is the ugly stepsister.
    But nowhere nearly as clearly as your version:

    “I think the Cinderella Medicine analogy relates to the Cinderella story, not the character, where something good can look unappealing and something unappealing can look good. Cinderella is dressed poorly, but is sweet and kind. The step-sisters are generally dressed well, but are rude and spoiled.
    So the idea is let’s be the Fairy God Mother, wave our magic wand, put SBM (Cinderella) in a nicer gown and send her out to the ball so she can meet prince charming (the patient).
    That way the poor prince (the patient) won’t have to marry one of the step-sisters (CAM) for lack of seeing Cinderella (SBM).”

    So congratulations on explaining something better than the originator of the idea. And, in case that is seen as a slight on Harriet, let me add that that is no mean compliment.

    :)

  26. TsuDhoNimh says:

    @michelle – I used to help pathologists collect bone marrow specimens, which is one of the procedures for which “uncomfortable” doesn’t apply. Being knifed in the back by one of the Borgias is closer to what it feels like.

    One was very cheerfully up-front about it, explained the steps, the purpose, told the patient that they would feel one very sharp pain (when the needle plunger is pulled back to suck a bit of marrow out), but by the time they felt that, it would be over and there would be no further pain, maybe a bit of bruising at the puncture site. The other tried to avoid the questions and didn’t give straight answers.

    No surprise – the first doc had most people report “that wasn’t too bad”. Mostly because as he was explaining things, he was also doing the site prep and gave them no time to think about what was happening. Distraction is a powerful tool.

    1. Harriet Hall says:

      @TsuDhoNimh,
      I recently had a bone marrow aspiration and biopsy. They routinely used conscious sedation with IV drugs, but I refused that and had only local anesthesia. I did not feel anything I could call pain, only an uncomfortable pressure sensation that didn’t last long. The only part of the procedure that involved any pain was the needle for the local anesthetic. I was comfortable with the idea of bone marrow tests, understood what was happening, and had no fear, because in my training I had done them myself on unsedated patients who tolerated it well. I wonder how much of the pain patients feel is due to their own fear and to the doctor’s explanation that it will be painful.

  27. Regarding how doctors handle communicating the pain or discomfort of a procedure (nybgrus, TsuDhoNimn, Harriet Hall)

    To be fair, my initial comment was somewhat off the cuff and I should insert that I, my son, and daughter have had several procedures that were no more uncomfortable that the practitioner indicated they would be. My comment may have shown my unfortunate habit of generalizing for effect, I’m afraid. My apologies there.

    I can think of about five times that I believe the doctors were not entirely accurate in predicting the amount of pain or discomfort involved in a procedure.

    Two of those time, I would say that the Doctors were discounting pain that I reported experiencing, that they didn’t seem to think should be associated with the procedure. The first was when I required a tube inserted into my stomach (esophagus?, I don’t know) for a night to siphon off intestinal gases that were causing pain. The doctor insisted this was merely an uncomfortable procedure, while I felt pretty sure that the tube actually caused a reasonable amount of pain in my face and throat (somewhat like a bad sinus headache and sore throat). I would have liked a little something for that pain, didn’t have to be narcotics, even some Tylenol might have helped. To be honest, I just don’t think he was a very good doctor, Ditto for the other discounting doctor, but I’ll save space by not going on.

    The other three occurrences were quite different. My daughter had a finger injury at age two and a plastic surgeon reattached her finger tip. When the doctor instructed us on the twice daily washing of the injured area, he stated. ‘She’ll feel some discomfort, you may need one person to wash and one person to hold her hand.’ This was clearly a euphemism used so as not to scare my daughter, because when you wash a finger that has just been stitched on, it hurts. The doctor was good about prescribing an appropriate pain medicine to get my daughter through the worst of the pain, so I don’t feel he was discounting the pain of the washing process.

    My son has had two plastic surgeries for his cleft and I also feel that the surgeon somewhat downplayed the discomfort of those surgeries. Yet (like my daughter’s doctor) I don’t necessarily believe he was wrong in doing so.

    Why? Well, firstly, I believe downplaying may have been necessary to avoid creating additional pain or stress through the power of suggestion. Unlike a ER procedure, plastic surgery is arranged well in advance and the surgeon answers all those ‘is it going to hurt?’ questions a couple of weeks or even months ahead of the surgery. I think the doctors want to avoid causing undue ruminations on how bad an experience the surgery will be, thereby creating a self-fulfilling prophesy.

    Secondly, The surgeon is often giving an answer based on everything going well…but there are a many little things that may not go well, if an incision opens up a bit, if the child refuses to drink, if they have nausea, vomiting caused by the pain meds, etc Doctors aren’t fortune tellers, I understand that.

    Thirdly, sometimes I suspect that surgeons are giving an answer based on their experience rather than a typical person’s experience. So when they say that a surgery is generally only uncomfortable, that means in comparison to some of the other surgeries they do, not in comparison to what I would consider uncomfortable (slightly bad shoes).

    Again, with my son, I believe every attempt was made to address any pain or discomfort he had. That is the most important thing, in my mind, that the doctor does what he can to address the pain that the patient is reporting and isn’t dismissive of those reports.

    So I realize that doctors have a big job in deciding how the portray a procedure. Patients then have the job of deciding how to interpret that doctor’s portrayal.

    I know there aren’t easy answers. I didn’t intend to come across as overly critical, merely repeating a joke that my husband and I occasional make.

  28. nybgrus says:

    michelle: fair enough, though I think we weren’t so much bashing on your comment as merely using it as a way to broach the topic. Being open and honest with patients is vital, and that includes an “I don’t know” or “I’m not certain but…” which in the case of your son with the cleft surgeries could have been included. “Everyone is different, and there will be some discomfort and pain but it is generally less than you’d think. But if it becomes more, we will be there to help you in every way we possibly can.” Or something to that effect.

    As for your tube in the stomach (sounds like an NG or nasogastric tube) – well, I’m widely considered crazy for this one but…. I used to help place a lot of those, and watching patients writhe in discomfort and pain whilst listening to the nurses and doctors say “it’s not that bad, it’s ok” made me feel odd. Occasionally we would get the patient complain of amazingly sharp pain that was unbearable and the stock response was to the effect of “that shouldn’t be happening, it’s only uncomfortable not painful.” I didn’t like discounting the patient experience, but I wanted to have a subjective understanding of how much was actual pain and how much was a psychological manifestation. So… on a slow night, I placed an NG tube in myself. When I first attempted, in my left nostril, I immediately felt a searing pain that felt like a hot knife going through my head. So I stopped and backed out. I then tried the other nostril with more success and no pain, but certainly discomfort. I managed to place the tube and put it to suction and felt what that was like. Then I removed it and now I can understand better what a patient is going through when we have to do that to them and I will certainly take complaints of a sharp pain much more seriously.

    I have also sutured myself (I’m pretty active and have gotten a number of lacerations on my lower limbs and rather than take up a physician or PA’s time I just snagged the supplies and did it myself) as well. And, since we often tell parents of children with scalp lacerations that the lidocaine injection is often worse than the staples we are going to use and thus recommend just doing a really fast stapling job, I actually placed about 10 staple in the skin of my forearm with no anesthetic or analgesia of any kind (after properly and thoroughly cleaning the skin with surgical prep, of course).

    Yeah, that is all probably a bit crazy, and I don’t think I would advocate every future doctor do that, but I do feel like it gave me some extra insight, a little more confidence, and a touch more authority and sympathy when I am back on the doctor side of things. Obviously I wouldn’t go for much more high risk procedures, and I never asked anyone else to do those things to me in order to keep the responsibility solely on myself, but I ultimately value those crazy experiences of mine and bear them in mind when dealing with a patient who is frightened and/or in pain.

  29. nybgrus “I think we weren’t so much bashing on your comment as merely using it as a way to broach the topic.”

    Broach all you want, I don’t take it as bashing*. If you’re referring to my apology, that was because I realized my gross generalization after I posted the comment. Since I admonish my kids about 8 zillion times a day for saying things like “He always gets the downstairs tub.” I thought I should point out my mistake before the gods in charge of monitoring parenthood hypocrisy put me on their list for retribution.

    I think that our discussion with my son’s surgeon was similar to your description, but probably with less qualifiers. It’s kinda hard to communicate the gestalt of a conversation in a comment box.

    As to whether it is crazy or not to put a tube down your nose to see how a patient feels, if it’s only supposed to be uncomfortable, then why would it be crazy? :)

    Stitching yourself up makes sense as long as you feel comfortable with it and your angle is good. But the stapling? All I can say is, ‘you kids these days with your piercings and your tattoos and your arm staples…what’s next?’ ;)

    *Somehow it makes me quite happy that conversation on the internet sometimes resembles a particularly polite Chip n’ Dale sequence.

  30. nybgrus says:

    michelle: lol… fair enough. I think you have said it more eloquently than I ever have – the gestalt of a conversation is certainly lost in retelling it through small posts and comments.

    As for your footnote… I see no reason why internet conversation need be anything but civil, though I certainly do indulge in the anonymity from time to time. However, you certainly make it easy to be genial and conversational. I wish I could hold you up to the world as a perfect example of someone whose expertise is not in medicine or science and yet can still critically think and apply skpetical principles to a multitude of topics. One pmoran might in fact like to view you as an example of the sort of education and depth of science knowledge I advocate as being useful and necessary to eradicate fanciful CAM modalities and magical thinking.

    As for the, ahem, self performed medical interventions… my ER colleagues thought me crazy for subjecting myself to the NG tube, my roommates and girlfriend cringed and thought me crazy for the self suturing (and they’ve all healed quite nicely I might add!), and whilst I do not have tattoos or piercings the staples were only temporary – I took them out after about 30 minutes. No scars from those either – believe me when I say those suckers are SHARP! And indeed, the pain was pretty minimal.

  31. kulkarniravi says:

    “*Somehow it makes me quite happy that conversation on the internet sometimes resembles a particularly polite Chip n’ Dale sequence.”

    Until a party pooper like me gate crashes.

    My motto is simple, if it works for you, use it, all the scientism (Sciencism?) and naysayers, not withstanding. There is a lot of woo in the world and it works for a lot of people (at least they seem to think so). So you are fighting a losing battle.

    Just see what you get for believing that doctors absolutely know what they are doing:

    http://www.npr.org/2011/05/16/136249810/reporting-on-hidden-dangers-of-medical-radiation

    It is your life (generic you, not michelle) you are talking about. So don’t trust anyone completely but yourself. Double check your doctor’s diagnosis and prognosis, don’t believe everything he or she says. Look for natural alternatives.

  32. kulkarniravi says:

    People on this blog never tire telling us the diet doesn’t matter all that much. Just look at the following story:

    http://www.latimes.com/health/boostershots/la-heb-prostate-cancer-20110518,0,5881134.story

    If coffee could affect our health so much, why couldn’t other foods? More evidence that medical professionals need to take their nutrition study more seriously – or we need more nutritionists and less doctors.

  33. Harriet Hall says:

    @kulkarniravi,
    “My motto is simple, if it works for you, use it”

    Translation: “If I think I feel better after a treatment, I’m going to believe it works. I don’t need no stinkin’ science.”

    Explanation: ignorance of human psychology, unwillingness to consider other possible explanations, falling prey to the post hoc ergo propter hoc fallacy, complete lack of understanding of what science is all about and why we need it to “sequester our biases so that we may better understand reality,” as P.A. Lipson so eloquently put it.

    You just don’t get it. Keep reading this blog and maybe some day you will.

  34. Harriet Hall says:

    @kulkarniravi,

    You found one study about a correlation of coffee and prostate cancer, and on the basis of that one example you expect us to accept your thesis that diet is more important for health than we think? When you don’t even understand what we think? When our provisional conclusions about diet are supported by our reviewing the whole spectrum of published evidence?

    If I showed you one study where patients following dietary beliefs had worse outcomes, would you accept that as evidence that diet is less important for health than you think? If I cited one study showing toxic effects from a natural remedy, would you accept that as evidence that natural alternatives are harmful and that your whole approach is misguided?

  35. marcalbe says:

    Great article, Dr. Hall. It does make me wonder if how much the rise in CAM interest correlates to the increasing role of insurance companies in standard medical practice, though. I am not a physician but my father was for 45 years. I know he complained that as the 70s went to the 80s went to the 90s the piecemeal character of insurance payments and how it forced him to do shorter and shorter consultations with his patients if he wanted to maximize his return. As he stayed outside of group practice for his entire career, the overhead caused by the insurance also dramatically changed the character of his practice in favor of quick turnover. Even though backs weren’t his specialty, it does seem like his practice morphed into the equivalent of the “it will go away in a couple weeks” approach you highlight.

    Obviously my one data point here is anecdotal, so I’m curious as to whether others out there think the insurance system we have is a big part of the problem with CAM’s growth.

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