Most surgery is no better than Placebo

[DrCommonSense]

http://www.listener.co.nz/current-a...re-no-better-than-placebo-says-a-top-surgeon/

http://www.regenexx.com/bmj-chimes-scandalously-poor-evidence-for-orthopedic-surgery/


Soon, if EBM continues there will be nothing to really offer surgically based upon randomized control study "evidence" for patients. Procedures that would be out include

1) Spinal Fusion
2) Coronary Stents for Stable CAD
3) Almost every procedure in ortho including ACL tears, meniscus, arthroscopic surgeries, rotator cuff tear repairs and 80% of hip/knee replacements
4) Prostate Surgeries
5) Most appendix surgery

BMJ just wrote an article saying that almost nothing in Orthopedic surgery has evidence outside of maybe trauma cases where IM nails.

Crazy times.

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[bedrock]

http://www.listener.co.nz/current-a...re-no-better-than-placebo-says-a-top-surgeon/

http://www.regenexx.com/bmj-chimes-scandalously-poor-evidence-for-orthopedic-surgery/


Soon, if EBM continues there will be nothing to really offer surgically based upon randomized control study "evidence" for patients. Procedures that would be out include

1) Spinal Fusion
2) Coronary Stents for Stable CAD
3) Almost every procedure in ortho including ACL tears, meniscus, arthroscopic surgeries, rotator cuff tear repairs and 80% of hip/knee replacements
4) Prostate Surgeries
5) Most appendix surgery

BMJ just wrote an article saying that almost nothing in Orthopedic surgery has evidence outside of maybe trauma cases where IM nails.

Crazy times.

You are misreading the article. It's not suggesting that all these procedures would be "out", it's just saying that surgeons shouldn't go directly to surgery in these situations.

The article states and I agree that ACL repair is often needed, but just shouldn't be done automatically. First do aggressive rehab and if that fails, then yes get the ACL repair. Same thing with appendix, don't go directly to surgery, first do abx, if those don't work, take it out.

What are you talking about with hip replacements? It's one of the most successful orthopedic procedures out there. The overwhelming majority of hip replacements are indicated and successful. Knee replacements have a lower success rate, but still 80%, and still indicated for lots and lots of people.

The article states and I agree that arthroscopic surgeries are indicated.........for young active patients, just not for degenerative issues for patients older than 35.

I do agree with you that coronary stents aren't needed for stable CAD and that 95% of lumbar spinal fusions aren't indicated.

 

[DrCommonSense]

You are misreading the article. It's not suggesting that all these procedures would be "out", it's just saying that surgeons shouldn't go directly to surgery in these situations.

The article states and I agree that ACL repair is often needed, but just shouldn't be done automatically. First do aggressive rehab and if that fails, then yes get the ACL repair. Same thing with appendix, don't go directly to surgery, first do abx, if those don't work, take it out.

What are you talking about with hip replacements? It's one of the most successful orthopedic procedures out there. The overwhelming majority of hip replacements are indicated and successful. Knee replacements have a lower success rate, but still 80%, and still indicated for lots and lots of people.

The article states and I agree that arthroscopic surgeries are indicated.........for young active patients, just not for degenerative issues for patients older than 35.

I do agree with you that coronary stents aren't needed for stable CAD and that 95% of lumbar spinal fusions aren't indicated.

Actually, the BMJ article confirms that ACL surgery hasn't been empirically proven to offer superior results over placebo either in randomized trials. Read the BMJ article about ortho procedures.

I am skeptical about the appendix stuff myself as well though.

 

[DrCommonSense]

You are misreading the article. It's not suggesting that all these procedures would be "out", it's just saying that surgeons shouldn't go directly to surgery in these situations.

The article states and I agree that ACL repair is often needed, but just shouldn't be done automatically. First do aggressive rehab and if that fails, then yes get the ACL repair. Same thing with appendix, don't go directly to surgery, first do abx, if those don't work, take it out.

What are you talking about with hip replacements? It's one of the most successful orthopedic procedures out there. The overwhelming majority of hip replacements are indicated and successful. Knee replacements have a lower success rate, but still 80%, and still indicated for lots and lots of people.

The article states and I agree that arthroscopic surgeries are indicated.........for young active patients, just not for degenerative issues for patients older than 35.

I do agree with you that coronary stents aren't needed for stable CAD and that 95% of lumbar spinal fusions aren't indicated.

Do we have studies on Arthroscopic surgery under 35?

Do we have evidence for Knee Replacement surgeries in all age groups with all comorbidities? I am not as convinced of the evidence as you are on a "level 1" basis.

 

[bedrock]

Actually, the BMJ article confirms that ACL surgery hasn't been empirically proven to offer superior results over placebo either in randomized trials. Read the BMJ article about ortho procedures.

I am skeptical about the appendix stuff myself as well though.

I don't have online access to BMJ. I'd like to see that article and the parameters of the study.

The key thing that I bet wasn't included in that study was comparing the rest of rehab vs surgery in young athletes. ACL repair is definitely indicated for a young athlete that has failed PT.

Do you have articles disproving the use of arthroscopic surgery under 35?

Do you have articles proving that knee replacements don't improve pain and function at least 80% of the time when performed on non-obese, non-diabetic patients over 60?

I agree that you can't just do knee replacements on anyone and knee replacements are done too often on young, overweight, diabetic, or otherwise sick patients.

 

[DrCommonSense]

I don't have online access to BMJ. I'd like to see that article and the parameters of the study.

The key thing that I bet wasn't included in that study was comparing the rest of rehab vs surgery in young athletes. ACL repair is definitely indicated for a young athlete that has failed PT.

Do you have articles disproving the use of arthroscopic surgery under 35?

Do you have articles proving that knee replacements don't improve pain and function at least 80% of the time when performed on non-obese, non-diabetic patients over 60?

I agree that you can't just do knee replacements on anyone and knee replacements are done too often on young, overweight, diabetic, or otherwise sick patients.

1) I don't need articles to "disprove" something that isn't proven. The onus is on you to prove ACL confers benefit for under 35 patients since you claim there is benefit for these treatments.

2) The TKR/THR you just added many caveats to including non obese, non diabetic (probably also not vasculopathic and non smoker as well) for >80% benefit. I would agree in a fully functional person with almost no comorbidities in their 60s, there should be a high success rate. The question occurs, how many of the patients getting THR/TKR aren't obese, smokers, diabetic, etc?

 

[bedrock]

1) I don't need articles to "disprove" something that isn't proven. The onus is on you to prove ACL confers benefit for under 35 patients since you claim there is benefit for these treatments.

2) The TKR/THR you just added many caveats to including non obese, non diabetic (probably also not vasculopathic and non smoker as well) for >80% benefit. I would agree in a fully functional person with almost no comorbidities in their 60s, there should be a high success rate. The question occurs, how many of the patients getting THR/TKR aren't obese, smokers, diabetic, etc?

You are the one postulating that 90% of surgery is useless, so you prove it. Frankly I'm not going to do a bunch of pubmed searches to disprove you anymore than I would find articles to disprove someone who disagreed with some of my other opinions. I really don't care.

Lots of patients get THR/TKR. Are you a pain physician ? I have seen countless patients who had prior appropriate joint replacements as part of their medical history before seeing me for their spine.

You have a huge ax to grind against surgeons. If you are a pain doc, I can understand why your so opposed to spinal fusions, but not all surgery is evil.

 

[Ducttape]

Actually, the BMJ article confirms that ACL surgery hasn't been empirically proven to offer superior results over placebo either in randomized trials. Read the BMJ article about ortho procedures.

I am skeptical about the appendix stuff myself as well though.

1. I am an advocate of ACL repairs, from personal experience.

my knee would slip and pseudo-dislocate, unless I wore a cumbersome custom fit Donjoy knee brace. it was difficult even to ride a bicycle, or anything more strenuous. while playing baseball once, I couldn't make it to first base because it gave out on me.

I was never mistaken for an athlete, unless you consider competitive eating to be a real sport (not hot dogs, but I think I could have given Joey Chestnut a run for his money in Jiao xi).

2. if I were you, I might not look too hard at these studies. you might not like the results when the microscope is put on IPM...

3. and fyi, quoting an article from a site by a competing treatment, that has also generated questionable results, puts your judgement into question. read the original article, not Centeno's.

4. the blame for this overuse are not the procedures themselves - it is a fact that most of modern medicine is a. focused on a cure including surgical attempts to do so, and b. fee for service model that encourages doctors to perform more surgeries for financial gain.

 

[DrCommonSense]

1. I am an advocate of ACL repairs, from personal experience.

my knee would slip and pseudo-dislocate, unless I wore a cumbersome custom fit Donjoy knee brace. it was difficult even to ride a bicycle, or anything more strenuous. while playing baseball once, I couldn't make it to first base because it gave out on me.

I was never mistaken for an athlete, unless you consider competitive eating to be a real sport (not hot dogs, but I think I could have given Joey Chestnut a run for his money in Jiao xi).

2. if I were you, I might not look too hard at these studies. you might not like the results when the microscope is put on IPM...

3. and fyi, quoting an article from a site by a competing treatment, that has also generated questionable results, puts your judgement into question. read the original article, not Centeno's.

4. the blame for this overuse are not the procedures themselves - it is a fact that most of modern medicine is a. focused on a cure including surgical attempts to do so, and b. fee for service model that encourages doctors to perform more surgeries for financial gain.

1) OK but I was showing the futility in some "level one" evidence for surgeries including ACL repair. You said it helped significantly (which is likely did) but according to researchers like Chou and Deyo that means NOTHING without level one evidence

2) I am showing that any procedural field can be put under the microscope by using the EBM credo. We have already talked about the IPM issues already and understand it thoroughly. The purpose of my argument is that once they put everyone else under the same "scrutiny", almost all of procedural medicine will be found lacking. BMJ has just now started up with Orthopedics.

Its kind've like first they came for IPM, then fusions, then Ortho, etc. If we don't stand together, we hang alone man.

3) The reason I used his article was really just his links to other articles on these surgeries. The BMJ article (most prestigious medicine journal in Britain, equivalent to NEJM) has basically said >80% of Ortho has no evidence and implied "useless". It seems like the PCP people have it out for procedural medicine and are becoming the "expert" on analyzing procedural medicine by showing they are "lacking in evidence"

4 I agree with that. I wouldn't mind everyone getting put on a salary schedule but patients will need to realize they will have to "ration" care and might have to wait long times for any treatment.

The problem also is the high level of debt that med students take on. Is it worth giving up your 20s with high debt for much lower salary potential after EBM/PCP guys say most of procedural medicine is "useless", which will collapse future salaries?

Rather get an MBA from a top school at that point.

 

[DrCommonSense]

1. I am an advocate of ACL repairs, from personal experience.

my knee would slip and pseudo-dislocate, unless I wore a cumbersome custom fit Donjoy knee brace. it was difficult even to ride a bicycle, or anything more strenuous. while playing baseball once, I couldn't make it to first base because it gave out on me.

I was never mistaken for an athlete, unless you consider competitive eating to be a real sport (not hot dogs, but I think I could have given Joey Chestnut a run for his money in Jiao xi).

2. if I were you, I might not look too hard at these studies. you might not like the results when the microscope is put on IPM...

3. and fyi, quoting an article from a site by a competing treatment, that has also generated questionable results, puts your judgement into question. read the original article, not Centeno's.

4. the blame for this overuse are not the procedures themselves - it is a fact that most of modern medicine is a. focused on a cure including surgical attempts to do so, and b. fee for service model that encourages doctors to perform more surgeries for financial gain.

Also, I'd like to know how a FAMILY PHYSICIAN such as Deyo who probably can't tie a suture, place an IV, know which side of a Tuoy needle is used to puncture the skin, etc becomes the "expert" arbiter of which treatments are "useless or useful"?

Awesome racket he has there. How much are they paying this clown compared to being a regular FP physician? Its a great racket if you can get it.

 

[VA Hopeful Dr]

Also, I'd like to know how a FAMILY PHYSICIAN such as Deyo who probably can't tie a suture, place an IV, know which side of a Tuoy needle is used to puncture the skin, etc becomes the "expert" arbiter of which treatments are "useless or useful"?

Awesome racket he has there. How much are they paying this clown compared to being a regular FP physician? Its a great racket if you can get it.

Reviewing published studies isn't that hard, and us FPs don't have a dog in any part of this fight - fusions v. injections, for example.

 

[DrCommonSense]

Reviewing published studies isn't that hard, and us FPs don't have a dog in any part of this fight - fusions v. injections, for example.

They have a "dog in the fight" if they are paid as "experts in EBM".

Largely, they can strawman any procedure/almost any medication they want to reject it or accept it based upon politics.

For instance, why not stop covering Opioids for the Medicaid population? That costs far more in terms of pharmacy costs/abuse costs in this population with no evidence for benefit?

Also, which "studies" in the metanalysis are considered powerful is often biased.

For instance, Lyrica has only show very marginal benefits over placebo for fibro or neuropathic pain but the studies were all done by drug company physicians using Pfizer statisticians.

Scrutiny of procedures/medications are very dependent on political winds/pay off concerns to help "sway' the evidence.

That is why Oxycontin at 600/month for Medicaid patients will always be covered for low back pain.

The Oregon/Washington State board can then use the analysis as justification to eliminate a procedure or ignore them/not ask them to do a metaanalysis on the medications/procedures they want to continue.

Really not that complicated actually.

 

[VA Hopeful Dr]

They have a "dog in the fight" if they are paid as "experts in EBM".

Largely, they can strawman any procedure/almost any medication they want to reject it or accept it based upon politics.

For instance, why not stop covering Opioids for the Medicaid population? That costs far more in terms of pharmacy costs/abuse costs in this population with no evidence for benefit?

Also, which "studies" in the metanalysis are considered powerful is often biased.

For instance, Lyrica has only show very marginal benefits over placebo for fibro or neuropathic pain but the studies were all done by drug company physicians using Pfizer statisticians.

Scrutiny of procedures/medications are very dependent on political winds/pay off concerns to help "sway' the evidence.

That is why Oxycontin at 600/month for Medicaid patients will always be covered for low back pain.

The Oregon/Washington State board can then use the analysis as justification to eliminate a procedure or ignore them/not ask them to do a metaanalysis on the medications/procedures they want to continue.

Really not that complicated actually.

In order:

You can say that about literally anyone though, at least non-procedural docs only have that one bias, instead of that bias AND getting paid to do the procedure

I'd love to not pay for chronic opioids in honestly any insured population - the damn things are dirt cheap as is.

Interestingly enough, it was this forum that got me to really stop paying attention to meta-analyses.

I've never had much luck with lyrica personally, I rarely ever write for it.

 

[DrCommonSense]

In order:

You can say that about literally anyone though, at least non-procedural docs only have that one bias, instead of that bias AND getting paid to do the procedure

I'd love to not pay for chronic opioids in honestly any insured population - the damn things are dirt cheap as is.

Interestingly enough, it was this forum that got me to really stop paying attention to meta-analyses.

I've never had much luck with lyrica personally, I rarely ever write for it.

Actually, most opioids really aren't cheap.

For instance, Oxycontin goes for approximately 600/month.

Butrans, Zohydro, Hysingla, etc are all in the 300s-600s/month.

Incidentally, these "medicaid" policies also pay huge amounts of "anti psych" and "anti depressant" medications that utterly fail to decrease suicide rates or even depression.

In fact, most independent analysis shows these medications are at best as good as placebo:

https://www.newscientist.com/articl...sants-dont-work-well-why-are-they-so-popular/

Actually, there is no evidence of the serotonin hypothesis in terms of depression at all. Yet, our biggest cost medications are "anti psych" medications that literally cost BILLIONs per year (far more than injections) for medicaid policies.

Yet I never see anyone looking to get rid of these medications despite zero evidence except for largely INCREASING suicide rates.

 

[bedrock]

So are you a naturopath or something?

You apparently believe than no modern scientific medical treatments have any value.

 

[DrCommonSense]

So are you a naturopath or something?

You apparently believe than no modern scientific medical treatments have any value.

Actually, the a few things have been proven beyond question:

1) Antibiotics
2) Vaccination
3) Sanitation

Outside of those, most of modern medicine really doesn't have any "level one" evidence by the standards of Chou and Deyo.

Give me 5 procedures used in modern medicine COMMONLY that meet these criteria of EBM.

 

[lobelsteve]

Breast augmentation.
Rhinoplasty.
Carpal tunnel release.
Chemo for myeloma.
Anticoagulation for a fib.

 

[DrCommonSense]

Breast augmentation.
Rhinoplasty.
Carpal tunnel release.
Chemo for myeloma.
Anticoagulation for a fib.

lol nice

 

[Ducttape]

"Procedures"...

Level 1 evidence:
Early defibrillation for cardiac arrest
High quality CPR for cardiac arrest

Regional anesthesia preoperatively for hip fracture.
Anesthesia itself for hip fracture.
Early surgical intervention for unstable intertrochanteric hip fractures

Early radiologic imaging for suspected intracranial hemorrhage
Evacuation of intracranial hemorrhage causing cerebellar compression and neurologic deterioration

Placement of cardiac pacemaker for 3rd degree AV block with periods of asystole
Placement of pacemaker for 2nd degree AV block with symptomatic bradicardia
Placement for AICD for recurrent sustained VT
Placement for AICD for cardiac arrest due to VF or VT not due to a reversible cause

okay im bored. let me know if there is a specialty you want looked at for Level 1 evidence, and ill post, when I get interested again

 

[DrCommonSense]

"Procedures"...

Level 1 evidence:
Early defibrillation for cardiac arrest
High quality CPR for cardiac arrest

Regional anesthesia preoperatively for hip fracture.
Anesthesia itself for hip fracture.
Early surgical intervention for unstable intertrochanteric hip fractures

Early radiologic imaging for suspected intracranial hemorrhage
Evacuation of intracranial hemorrhage causing cerebellar compression and neurologic deterioration

Placement of cardiac pacemaker for 3rd degree AV block with periods of asystole
Placement of pacemaker for 2nd degree AV block with symptomatic bradicardia
Placement for AICD for recurrent sustained VT
Placement for AICD for cardiac arrest due to VF or VT not due to a reversible cause

okay im bored. let me know if there is a specialty you want looked at for Level 1 evidence, and ill post, when I get interested again

I clearly said 5 PROCEDURES MOST COMMONLY done in medicine. You have listed things like CPR, Radiological Imaging, etc.

I agree that Trauma medicine and possibly pacemakers for very specific causes have level one evidence.

1) There is no level 1 evidence for CPR at all outside of Defibrillation for VF. There is actually no evidence for epinephrine or any of the routine drugs given in CPR. Here is the level of "evidence" listed for CPR: https://www.ncbi.nlm.nih.gov/books/NBK349834/ Not most of it is level 3.
2) Intracranial evacuation and trauma medicine have level one evidence I would argue. However, ICH surgeries are very uncommon compared to fusions, stents, CABGs, common ortho procedures, etc. I wouldn't really place that procedure even in the top 20 procedures that are MOST COMMONLY done in medicine.
3) AICD for the specific measures you listed is basically the only common procedure you have named. However, many are placed for conditions without evidence or at ages that have proven to not be cost effective, so it is far over utilized. http://www.modernhealthcare.com/article/20140128/news/301289915

You're "bored" because your reading comprehension skills are extremely poor and you have NOT proven your case.

My argument is thus: If level one evidence was applied to the vast majority of the MOST COMMON procedures implemented in America, there would be essentially no procedural medicine. Less than 5% of so of PROCEDURAL MEDICINE that is COMMONLY done could be justified by using level 1 evidence.

Also, even for procedures with "level one evidence", this is only for a very SPECIFIC reason, with many of the procedures being performed outside of this specified indication that is given for level one designation.

For instance, if a study shows that TKR has level one evidence for HEALTHY 60 year old active patients with few/no comorbidity but approximately 95% of these surgeries are performed on obese patients, smoking patients, >75 year old patients, immobile patients, etc that weren't studied, I consider that procedure to effectively be lacking in level one evidence for the VAST MAJORITY of cases the procedure is done.

 

[lonelobo]

Actually, the a few things have been proven beyond question:

1) Antibiotics
2) Vaccination
3) Sanitation

Outside of those, most of modern medicine really doesn't have any "level one" evidence by the standards of Chou and Deyo.

Give me 5 procedures used in modern medicine COMMONLY that meet these criteria of EBM.

You sure you believe in Vaccines , one of your trusted sources( Alex Jones) think they still cause Autism
http://www.infowars.com/trump-vaccine-made-one-of-my-employees-children-autistic/

 

[Stim4me]

Should I still floss my teeth?

The interesting thing about this conversation is that we can make arguements about EBM and guidelines and so forth, yet each insurance carrier has the right to interpret the data independently and can deny care based on biased reviewers and dierectors... that's rigged

 

[dpmd]

Relevant to this thread.

Conclusions

As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

 

[DrCommonSense]

Should I still floss my teeth?

The interesting thing about this conversation is that we can make arguements about EBM and guidelines and so forth, yet each insurance carrier has the right to interpret the data independently and can deny care based on biased reviewers and dierectors... that's rigged

Correct.

For instance, Oregon's Medicaid board controlled by Chou will crap over injections with increasing weight given to studies that are negative while downplaying positive ones compared but never touch opioid prescriptions that cost far more money/cause more morbidity/etc.

This is also common with big pharma/big device companies.

For instance, insurance companies will often use studies made by Pfizer that show Lyrica offers benefit over non Pfizer sponsored studies that don't show benefit. Which studies are you going to believe? There's where the politics/money behind the scenes comes in.

 

[DrCommonSense]

Should I still floss my teeth?

The interesting thing about this conversation is that we can make arguements about EBM and guidelines and so forth, yet each insurance carrier has the right to interpret the data independently and can deny care based on biased reviewers and dierectors... that's rigged

Also, who defines that there is "positive effect size but it isn't of clinical significance".

For instance, Statin medications have an NNT of approximately 100 for ANY benefit in the general population of patients (no evidence at all in women, only slight in men with CHF already), which basically means it has less than a 1/100 chance of benefit in a 5 year period. Yet somehow this is "clinically significant".

Lyrica at 600/month offers maybe 3-5% over plaebo (in Pfizer sponsored studies, in non Pfizer studies its zero) for Fibro pain/Neuropathic Pain states. Yet, you don't see Chou on a rampage against this as being "non significant clinically for pain control" compared to say an injection that offered 40% benefit (where 50% is the arbitrary pain benefit score of significance).

ESI for Medicare is about 250 while Lyrica is about 600/month. ESI will require 50% benefit for 3 months while Lyrica has no requirements for pain control besides "it seems to help" even if its 1%.

Lyrica has many side effects and costs far more than 3 or 4 ESIs per year. Yet the criteria for Lyrica is far lower in terms of standards needed to be "beneficial".

Its very shady this "EBM" stuff.

 

[VA Hopeful Dr]

Its very shady this "EBM" stuff.

And there's the take-away point about all of this.

My general personal approach is this: if decent evidence says it works, I'll do it. If evidence says its harmful, I won't. If evidence says it doesn't work (but isn't grossly harmful), then its up to my judgement.

 

[neutro]

problem is that the patient will go elsewhere and seek a doctor who is willing to operate and hold different criteria, thereby rendering use of EBM for that specific individual patient completely useless.
the surgeon will say "because the patient's QOL is being affected and he is on narcotics I am going to operate" despite the fact that weight loss is all what may be needed.

too many physicians. too many views. too many ways to practice.