Although interesting, the title way overstates the claims of the article. The article is focusing on surgery to reduce pain. Pain can't be measured externally, it's subjective.
Most surgery is not like that, it involves some objective condition. Such as before you had an appendix, now you don't. Before your bone was broken in the wrong shape, now it's the right shape.
The title doesn't overstate the claim, its simply false. The statement "most surgeries to relieve pain are ineffective" and "most surgeries are ineffective" are completely different largely unrelated statements.
> Most surgery is not like that, it involves some objective condition.
Are you sure about that? My impression in the US is that most surgeries are of the subjective nature. And surgeons are far too eager to perform surgery. That was my own experience - I visited an ENT for sleep problems, and the first thing he suggested was surgery, even turning down my suggestion for a sleep study first. I later found out this person lives in a giant mansion, has a nice yacht, etc. and performs a large number of surgeries. I think in the US there are large incentives to perform surgery since it is so profitable.
> 7/ For sure, there are many studies that study variations of surgical methods. That is, they try to find out whether an incision from the left is better or from the right.
> But very few studies try to find out whether the incision does anything at all for the patient. Shocking, but that’s the truth.
Assuming that those studies do not always conclude "neither is better than the other", this implies one or both of these:
1. At least one of the two options is better than the placebo.
2. At least one of the two options is worse than the placebo.
In other words, finding differences in effectiveness of different intervention approaches must mean that either some of these interventions are better than placebo, or that all (except maybe the best one) are measurably worse than performing no surgery at all.
> "the severity of your symptoms does not change the effectiveness of the operation"
I hate the word "effectiveness" because it can mean anything. Effectiveness at what? Measured how? Surely the severity of my symptoms ("my toe hurts" vs "half my leg has been shot off") plays a role in determining whether amputation is an "effective" remedy? Or you could argue that it is equally effective at "removing" the symptom in both cases. But then killing the patient would be peak effectiveness - no more pain at all, guaranteed! It's just pointless to discuss such a thesis - if you talk about "effectiveness", your statements very quickly become unfalsifiable.
> In other words, finding differences in effectiveness of different intervention approaches must mean that either some of these interventions are better than placebo, or that all (except maybe the best one) are measurably worse than performing no surgery at all.
That doesn't tell you anything useful about them vs. placebo though? And "all (except maybe the best one)" seems to be entirely gut instinct not logic. You don't need to even try the surgeries to know that either all, some, or none will be better than placebo.
If both types of surgery perform the same, they could both be better, both be worse than, or both be the same as placebo. If one type is better than the other then maybe they're both better than placebo in different amounts, maybe both worse in different amounts, maybe one better the other worse than placebo, maybe one is same as placebo and other better, or one the same and other worse.
Knowing that two surgical approaches give different results gives no hint as to where placebo would perform in comparison, just that it can't be the same as both of them. It can still be better than both, or worse than both, with no reason to suspect one more than the other without other priors or actually testing vs. placebo.
There is always the third possibility: random statistical fluctuations make one option seem better than the other when this is not true.
Which breaks down to two more possibilities in relation to placebos:
1. Both are as effective as placebo.
2. Both are equally effective and better than placebo.
4. The seemingly worse option is actually better than placebo (but statistical fluctuations masked this).
Given that there are very few studies and that publication bias is a thing, these possibilities are conceivably more likely than the p-value would lead one to believe.
The benefit of placebo testing in the first place is that you end up with a simpler possibility matrix (the neither is better than the other outcome also breaks down into a whole slew of cases).
Of course, patients get better after surgeries. But the rate at which they get better is not much better than if surgery wasn't performed (or a placebo surgery was done).
I have spent some time in emergency receptions at hospitals waiting to be treated, often in severe pain. Here is what gave me hope every time: If it can wait, it can’t be that bad.
There are a number of injuries for which treatment has severely changed during my short lifetime. A torn ligament used to be operated on in the past but now you are often told to wear a cast for some weeks, take painkillers only when necessary to sleep so you avoid movements detrimental to healing during the day (it’s painful) and to just wait it out. Not X-ray, no surgery, just time to heal.
E: added an all important if to the third sentence.
Same with clavicle fractures, I shattered mine and they used to immediately plate and pin it back in place, but I was given a sling and 7 weeks latter it had pulled it's myriad pieces back together without surgery .
The doctor said had he got that result from an operation operation he would have been thrilled.
Worth noting my hospital is a learning hospital, so it was a hot debate topic amongst the doctors and most of them were surprised they hadn't operated.
Same in Sweden. I’d love to learn about how long queues are when health care is financed with tax (you are not a customer) like in SV/NO vs by the user like in Switzerland (you are a customer)
In fact this is not even unsaid. My mom suffered a transient ischemic attack last week.
To quote the surgeon: statistically she had a 15% chance of issues in the coming weeks. An operation has a 5% risk of complications, so normally we don't perform one. But 5 is lower than 15%, so let's do it.
Not sure of the math, because I assume the 15% is spread (non-linear) over the 2 weeks, and she was operated at the end of the window, but it is still amazing that all of this is possible.
> 11/ But because it’s costly and risky to perform surgeries, the urgent question is: what surgical procedures are today’s equivalent of bloodletting? And those that we know are bloodletting, how do we get rid of them as a society?
Instead of thinking of these surgeries as ineffective and looking to restrict their use, we can think of the placebo as effective in many cases, and try to lower their cost.
In America, high healthcare costs are partly driven by the fact that Americans are over medicated and doctors are incentivized to intervene. If "alternative" (placebo) medicines were more available, I wonder if we would have lower costs and similar healthcare outcomes.
> For such surgeries, randomized control trials have found that if you make an incision in the knee but don’t do anything, it’s as effective as actually conducting the surgery of the knee.
This is pretty crazy. I would suggest it shows that the vast majority of people having knee surgery didn't need it in the first place, or haven't tried alternatives.
If your knee is genuinely shot to bits and needs replacing with a artificial part, I can't see any scenario where placebo surgery would relieve pain anywhere close to an actual arthroplasty.
But that's the point, these people are in genuine pain, their knee is shot, surgeons were performing real surgery.
Surgeons knew it worked because they were cleaning all this gunk out of knees, and patients were recovering and having better quality of life.
For years surgeons refused to try RCTs to test this because to them it was so obvious that it worked.
It was only when trials were run that surgeons started to accept that maybe it's a bit more complicated. They say that the same type of knee would respond to sham surgery as well as real surgery.
This, by the way, is a real problem for pain treatment. We split people up into groups of "this is real pain" and "this is in your head". We need to stop that because it's harmful.
Pain is a complex phenomena. Most people have a complicated interplay between the physical and psychological components. Many people in pain will experience some relief from pain, and a large increase in quality of life and function, with psychological treatment.
Those people aren't faking it; their pain is real; they deserve better treatment.
Are they though? They are no better than placebo. But are they better than doing nothing? And if they are, what are the alternatives? “Placebo effect” won’t work if you just tell the patient “we are giving you placebo”.
So the industry still needs to exist, research and marketing still needs to be done and surgeries still need to be performed if “placebo” is more effective than doing nothing at all.
I have a torn meniscus. The surgeon looked at it and said: " you can have surgery if you want but it won't make much difference, if you can live with it now". 5 years later, no problems, and no more knee locking. Touch wood...
Seems obvious to me that the strong "placebo" effect would be largely because it makes the person rest properly. Especially with knees and backpain etc. I didn't watch the video, he doesn't talk about that?
A "placebo surgery", if it involves incisions to the point of being indistinguishable to the patient, isn't really a placebo since it will still require healing and recovery.
You had nothing to say in the first place, let alone more.
The management by metrics piece doesn't try to say that the concept of counting is pointless.
How does that very piece itself conclude that anything is "astray" except by assessing a result and concluding it is less desirable than another? That's a metric.
Most surgery is not like that, it involves some objective condition. Such as before you had an appendix, now you don't. Before your bone was broken in the wrong shape, now it's the right shape.