We have a duty to our patients to prove that our treatments are both safe and effective. However, trying to prove that a treatment is ‘effective’ is both complex and challenging and there are many ways smart intelligent people are fooled into thinking a treatment has worked when actually it hasn’t. As one of my heroes Richard Feynman said “no one can fool you as easily as you can fool yourself” and so it is essential to be aware of the alternative explanations of why treatments appear to work!
For many years, I have been trying to raise awareness about how certain treatments within physiotherapy, medicine, and surgery appear to work when in fact there are a host of other factors giving the illusion of effectiveness. Despite highlighting these the popularity of many low value, unreliable, costly, and ultimately ineffective interventions continues to grow as physios and patients believe they are working.
The question remains why do people think this? The answer, I believe, lies in a combination of vigorous marketing campaigns, strong claims by the so-called experts and gurus, but also due to poor levels of scientific knowledge and understanding, and finally the ‘will to believe’ is just really strong.
There are many reasons why many people incorrectly conclude that ineffective treatments work, and so I am going to discuss some of the most common ones in an effort to, yet again, highlight how you are being made a fool of…
Correlation does not imply causation
We have a tendency to assume that when things occur together, they must be connected. For example, there is a correlation between the drinking coffee and cancer. Most would conclude that drinking coffee, therefore, gives you a higher risk of developing cancer. But it doesn’t. There are many reasons why this coffee/cancer correlation exists, the primary one being that a lot of people who drink coffee also smoke?
When giving a treatment for anything many factors are occurring simultaneously making it extremely difficult to determine what is a cause and/or an effect. Without comparing a similar group of people treated identically except for the believed effective treatment being withheld and an inert sham treatment is given instead, we can never know whether they would have recovered just as well without it.
Many health conditions are self-limiting. Natural history is medicines, surgery’s and physiotherapy’s dirty little-unspoken secret. Providing the condition is not fatal, the body’s own self-regulating, self-healing processes often restore the body back to homeostasis and the sufferer back to health. Thus, before a treatment can be acknowledged as effective, its advocates must show that the number of patients listed as improved exceeds the number expected to recover without any treatment, or that they have recovered significantly faster than if left untreated
Arthritis, multiple sclerosis, gastrointestinal complaints, and many musculoskeletal conditions are examples of conditions that have ups and downs. Naturally, sufferers tend to seek treatment when symptoms are at their worst during a period of deterioration. In these conditions, many treatments will have repeated opportunities to coincide with natural downturns and remissions that would have happened anyway, giving an illusion of effectiveness. In the absence of appropriate control groups, patients and clinicians are prone to misinterpret improvements due to normal cyclical variations in a conditions history as a treatment being effective.
Even with serious diseases such as cancer, spontaneous remissions can occur. The exact mechanisms responsible for this are not well understood, but the immune system and psychological variables no doubt play a role. Thoughts, emotions, desires, beliefs, etc, are physical states of the brain, and these neural processes affect glandular, immune, and other cellular processes throughout the body that will, in turn, affect healing processes. Psychological variables can and do have widespread physiological effects that can have positive or negative impacts upon health. While some research has confirmed that such effects exist, it must be remembered that they only account for a few percent of a disease variance.
However, many treatments and therapies often receive unearned acclaim for spontaneous remissions because many desperate patients turn to them when they feel that they have nothing left to lose. When there is an occasional positive response the treatment advocates assert that they have snatched many hopeless individuals from a life of misery and even death’s door. However, rarely do these “miracle workers” reveal what percentage of their clientele these successful cases represent.
The placebo effect
Another major reason why treatments are incorrectly credited with improvements is the ubiquitous placebo effect that I have discussed many times. The history of healthcare is strewn with examples of what, with hindsight, seem like crackpot procedures that were once enthusiastically endorsed by rationale clinicians and patients alike. Through a combination of suggestion, belief, expectancy, and diversion of attention, patients who are given biologically inert treatments can experience measurable relief. Some placebo responses produce actual changes in physical conditions; others create subjective changes that make patients feel better.
It is therefore paramount that randomised placebo-controlled trials are conducted on all our treatments, but because of the power of expectancy and compliance effects are so strong, clinicians must also be blinded which unfortunately is often not done. Such precautions are required because barely perceptible cues unintentionally conveyed by treatment providers, can bias treatment results. Likewise, those who assess the effects of the treatments must also be blinded due to experimenter bias that can affect even the most honest and well-trained professionals to unconsciously “read in” the outcomes they expect.
Interaction not intervention
A constant difficulty in trying to measure a treatment’s effectiveness is that many physical complaints arise from psychosocial distress and can be alleviated by support and reassurance alone. Many clinicians cater to the “worried well” who are mistakenly convinced that they are ill, often expressing psychological concerns as physiological symptoms. With the aid of pseudoscientific diagnostic devices, some practitioners will reinforce the conviction of these worried well that the cold-hearted, narrow-minded medical establishment, which can find nothing amiss, is both incompetent and unfair in refusing to acknowledge their very real organic condition.
Through the rituals of ‘delivering treatment’ these therapists supply the reassurance and support their worried clients seek, and there is no doubt this can be worthwhile. But the downside is that catering to the desire for medical diagnosis for psychological complaints promotes pseudo-scientific thinking while unduly inflating the success rates of the charlatans and quacks. Saddest of all, however, is it perpetuates the archaic myth that there is something shameful or illegitimate about psychological problems.
Symptom relief versus treatment
There is no doubt that alleviating pain and discomfort is what patients value most, and many treatments we offer make the symptoms more bearable without actually “treating” the underlying condition. Pain is an emotional sensation and by successfully reducing the emotional component it can leave the sensory portion surprisingly tolerable. Thus, suffering can often be reduced, even if the underlying pathology is untouched. Anything that can allay anxiety, redirect attention, reduce arousal, foster a sense of control, or lead to the cognitive reinterpretation of symptoms can alleviate pain. Whenever patients suffer less, this is good, however, we must be careful that we are not constantly removing pain unnecessarily or diverting time or attention away from proven active treatments for their underlying conditions.
In this era of obsession with health and fitness, many people are induced into thinking they have conditions they do not have. When these “healthy folk” receive what should be the good and reassuring news from rational, evidence-based clinicians that they have nothing to worry about, they often gravitate to “alternative practitioners” who can and almost always do find some kind of imbalance or issue.
When recovery of their mild malaise follows after interventions then another convert to the weird and whacky world of pseudo treatments is born adding strength to the quacks reputation and dubious interventions. Of course, evidence-based clinicians are not infallible and do miss conditions that can be inadvertently “treated” by others.
Many “alternative practitioners” have charming, charismatic personalities. If an enthusiastic, upbeat practitioner manages to elevate a patient’s mood and expectations, this can lead to greater compliance with, and effectiveness of, the orthodox treatments he or she may also be receiving. This expectant attitude can also motivate people to eat and sleep better, exercise and socialise more. These things, by themselves, could help speed natural recovery. Again this is far from being a bad thing, unless it diverts the patient away from more effective treatments, or if the charges and costs are exorbitant.
The will to believe
Even when they derive no objective improvements, devotees who have a strong psychological investment in alternative treatments can convince themselves they have been helped. Cognitive dissonance often occurs when experiences contradict existing attitudes, feelings, or knowledge. We tend to alleviate this uncomfortable feeling by reinterpreting the offending information.
For example, rather than admitting to ourselves or to others that we have received no relief after committing time, money, and “face” to a treatment, many will find and inflate some redeeming value in the treatment. Clinicians and patients are often prone to misinterpret and remember things as they wish had happened. Similarly, they may be selective in what they recall, overestimating the apparent success while ignoring, downplaying, or explaining away the failures.
Finally, there exists the “norm of reciprocity” which unless you are a complete arsehole is an implicit rule that obliges people to respond in kind when someone does them a good turn. Therapists, for the most part, sincerely believe they are helping their patients and it is only natural that patients would want to please them in return by saying they feel better. Without necessarily realising it, such obligations are sufficient to inflate patients perception of how much benefit they have received with an intervention.
So as you can see there are a host of ways a treatment can appear to work via a different mechanism. For patients who are unwell, disabled, and in pain, the promise of a cure, a fix, or some help is beguiling. As a result, false hope easily supplants common sense, and desperate patients can and do make clinicians do desperate things. In this vulnerable state, the need for hard-nosed, critical, sceptical thinking by honest, open, rationale clinicians is all the more necessary.
Recently there has been an eagerness to soften or even abandon the scientific processes of the investigation into our treatments. Claims have been made that science cannot explain everything we do and that we need to look more at what treatments work for individuals. As much as I understand this thinking, it concerns me that I am seeing this argument being used as an excuse to allow the woo and quackery of costly, ineffective, alternative treatments to creep into physio often at the expense of our more effective ones.
I will leave you with the father of evidence-based healthcare the late great Archie Cochrane’s most famous quote which I think is fitting here…
“Altering the natural course of any clinical condition is a difficult and complex challenge and one should be delightfully surprised when any treatment is effective, but always assume that the treatment is ineffective unless there is evidence to the contrary”
As always, thanks for reading