Why Treatments Work!

We have a responsibility 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 very smart intelligent people are often fooled into thinking a treatment has worked when actually it hasn’t.

One of my personal heroes Richard Feynman once said: “no one can fool you as easily as you can fool yourself”. So it is essential for all healthcare professionals to be aware of other alternative explanations of why treatments appear to work!

There are many reasons why clinicians and patients alike think ineffective treatments work, I am just going to discuss the 10 most common ones in an effort to ensure you are not fooling yourself.

No1: Correlation ≠ Causation

Humans have a tendency to assume that when things occur together they are connected. For example, there is a correlation between drinking coffee and cancer, and so many conclude that drinking coffee gives you a higher risk of developing cancer. But there are many other reasons why this coffee and cancer correlation exists, the most obvious one being that a lot of people who drink coffee also smoke?

When giving treatments for anything many factors are occurring simultaneously making it extremely difficult to determine what is a cause and what is 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.

No2: Natural History

Many health conditions are self-limiting. Natural history is medicines, surgery’s and physiotherapy’s dirty little-unspoken secret. Providing a condition is not fatal, the body’s own self-regulating, self-healing processes often restore it back to homeostasis and the sufferer back to health.

Thus, before a treatment can be acknowledged as effective, its advocates must demonstrate 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

No3: Cyclical Conditions

Multiple sclerosis, gastrointestinal complaints, arthritis, tendinopathy and many other conditions are examples of diagnoses that have natural ups and downs in their symptoms. Naturally, sufferers tend to seek treatment when symptoms are at their worst and many treatments have repeated opportunities to coincide with natural remissions and downturns giving an illusion of effectiveness.

In the absence of appropriate control groups, patients and clinicians are prone to misinterpret improvements seen due to normal cyclical variations as a treatment being effective.

No4: Spontaneous Remission

Even with serious terminal diseases such as cancer, spontaneous remissions can occur. The exact mechanisms responsible for these are not well understood, but the immune system and psychological variables no doubt play a large 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 have widespread physiological effects that can have positive or negative impacts on health. While some research has confirmed such effects exist, it must be remembered that they only account for a few percentages of a diseases variance.

However, many alternative treatments and therapies have received 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 a positive response the treatment advocates assert that they have snatched the hopeless individual from death’s door, but rarely do these “miracle workers” reveal what percentage of their clientele these successful cases represent.

No5: Placebo Effect

Another reason why treatments are incorrectly credited with improvements is the ubiquitous placebo effect that I have discussed many times before.

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 essential that randomised placebo-controlled trials are conducted on all treatments, but because of the power of expectancy and compliance effects are so strong, clinicians and patients must be blinded which unfortunately is often not done well. Blinding is essential in research because of barely perceptible cues can unintentionally convey bias that can and do affect treatment results.

No 6: Interaction NOT Intervention

A constant difficulty in trying to measure a treatment’s effectiveness is that many physical complaints arise from psychological 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 standard, cold-hearted, narrow-minded medical establishment, which can find nothing wrong or amiss, is both incompetent and unfair in refusing to acknowledge their very real condition.

Through the ritual of ‘delivering treatment’ these therapists supply the reassurance and support their worried clients seek, and there is no doubt this can be helpful and worthwhile.

However, the downside to this is that catering to the desire for medical diagnosis of psychological complaints promotes pseudo-scientific thinking which inflates the success rates of charlatans and quacks.

Saddest of all, however, is it continues to perpetuate the myth that there is something shameful or illegitimate about diagnosing patients physical pains and disabilities as manifestations of their psychological problems such as anxiety or hypervigilance.

No7: Symptom Relief ≠ Treatment

There is no doubt that alleviating pain and discomfort is what patients value a lot, but many treatments make symptoms more bearable without actually “treating” the underlying condition.

Pain is a multifactorial sensation and by successfully reducing the emotional component it can leave the sensory portion surprisingly tolerable. Thus, the suffering of pain 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. When 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.

No8: Misdiagnosis

In this era of modern medicine and the obsession with perfect health and fitness, many people are induced into thinking they have conditions they do not have.

When these “healthy folk” receive what should be good and reassuring news from rational, evidence-based clinicians that they have nothing to worry about, they often reject this and gravitate to “alternative practitioners” who can and almost always do find some kind of problem, imbalance, misalignment, or issue with a tissue.

When recovery of their non-issues follow another convert to the weird and wacky world of pseudo treatments is born adding strength to the quacks reputation and dubious interventions.

No9: Derivative Benefits

Many “alternative practitioners” have charming, charismatic personalities, and very strong ‘bedside manners’. 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 improve the natural recovery which 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.

No10: The Will to Believe

Even when they derive no objective improvements, devotees who have a strong emotional and psychological investment in alternative treatments can convince themselves they have been helped.

Cognitive dissonance often occurs when experiences contradict existing attitudes, feelings, or knowledge. So 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 rather than admit it did nothing.

Clinicians and patients are often prone to misinterpret and remember things happing 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 phenomenon of 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.

Many clinicians genuinely try to help patients so its only natural that patients want to please them by saying they feel better. Without realising it, these obligations are sufficient to grossly inflate our perceptions of how effective our treatments are.

Summary

As you can see there are a host of ways treatments can appear to work. For patients who are unwell, disabled, and in pain, the promise of a cure, a fix, or some help is appealing and beguiling. As a result, false hope can easily supplant common sense, and desperate patients can and do make clinicians do desperate things.

I will leave you with the late, great, Godfather of evidence-based healthcare Archie Cochrane’s 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 seen to do this, but one should always assume that any treatment is ineffective unless there is strong, robust, reproducable evidence to the contrary”

As always, thanks for reading

Adam