Tag Archives: EBM

Higher Expectations from Patients than Doctors

Study Reveals Presurgical Expectations of Foot and Ankle Patients Exceed Those of Their Surgeons – by Hospital for Special Surgery – June 2020

In the first-ever study to compare surgeon and patient expectations in foot and ankle surgery, research performed at Hospital for Special Surgery (HSS) in New York City has determined that two-thirds of patients have higher presurgical expectations than their surgeons.

That’s probably because they’re desperate for relief – especially nowadays when effective pain relievers are so hard to get. Plus, these surgeries and so profitable there may be some bias on the surgeon’s side.

Somehow, I can’t imagine a surgeon asking a patient what they expect the result to be; they’re too busy *telling* patients what the results will be.  And they do the “telling” in vague language that doesn’t convey the full impact of this brutal assault on their body.

Patients aren’t informed how little or short-lived the improvements might be, or that surgery can often leave not just visible scars, but invisible internal scars that become the source of chronic pain later.

I can’t imagine a doctor telling a patient, in a way that really gets through to them, the critical message: “it will never be as good as the original“.

The paper, titled “Comparison of Patients’ and Surgeons’ Expectations in Foot and Ankle Surgery,” is available online as part of the AAOS 2020 Virtual Education Experience.

Patient expectations of orthopaedic procedures have been demonstrated to be strongly associated with clinical outcomes and postoperative satisfaction.

If patients have high expectations shouldn’t this create the placebo effect? Just like negative expectations (sometimes called catastrophizing) are alleged to worsen chronic pain and lessen functionality, shouldn’t positive expectations lead to less pain and more functionality?

If “patient expectations” determine the outcome of treatment, this would apply to all treatments; the placebo effect either is or isn’t a factor. A placebo can’t have different effects for different treatments like surgery where a placebo doesn’t work and chronic pain where a placebo supposedly does work.

If higher expectations don’t lead to better results, the placebo effect is not.

In reviewing the operative schedules of seven foot and ankle surgeons at HSS, Dr. Ellis and his colleagues hypothesized

  • that patients would have greater expectations for their outcomes than their surgeons,
  • that there would be greater differences in preoperative expectations between patients and surgeons in major versus minor foot or ankle surgery, and
  • that greater differences between patient and surgeon expectations would be associated with worse preoperative physical and mental health.

“Although most surgeons do their best to engage in open conversations with their patients about what they can expect from surgery, many find it difficult to tell patients that they are not going be as good as new postoperatively,

…patients completed Patient-Rated Outcomes Measurement Information System (PROMIS) computer adaptive tests in Physical Function, Pain Interference, Pain Intensity, Depression and Global Health prior to their procedures.

“We determined that

  • 66.3% of patients had higher expectations than their surgeons,
  • 21.3% had concordant expectations, and
  • 12.4% had lower expectations,” said Dr. Ellis.

“In addition, the study showed that the majority of patients who had worse preoperative PROMIS scores had higher postoperative expectations.

That makes sense because people who are worse off are more desperate for surgery and also more likely to see at least some improvement from it.

We also found that depressed and anxious individuals had greater expectations than their surgeons, as did patients with a higher body mass index.”

Again, these are the desperate ones, not the ones who can still tolerate their pain. Because their condition is so bad, there’s a lot of room for improvement so their high expectations seem logical.

Going forward, said Dr. Ellis, future research should delve into other potential factors such as medical literacy and patients’ knowledge of their condition, as well as the bond between surgeon and patient.

What “bonds” can there be within standardized Evidece-Based Medicine? Can a guideline be written to standardize the doctor-patient bond?

Would such a guideline be ike the scripts they give to flight attendants, the ones they are required to recite at the start of every flight?

I went with my mother to an appointment with her PCP at Kaiser which was unnecessary but required because she takes 2 Vicodin a day.

The doctor had to speed read to us over a dozen questions from her screen and quickly type in or select the answers (a click and a delay meant she was scrolling through a drop-down menu).

She wasn’t talking to us, she was reading. Everything my mother said was met with an utterly ineffective and obvious suggestion.

  • Pain? take more Tylenol.
  • Fatigue? You’re just old.
  • Hips so painful can’t walk? Do more walking exercise (!)
  • Piriformis pain? Here’s some Voltaren Gel. (I looked it up and there’s no way it can penetrate deep into a buttock where that muscle is but, hey, at least it’s not an opioid!)

I feel sorry for the doctors that are forced to “practice” like this because it’s clear they can be replaced by data entry clerks (and eventually robots). No medical knowledge or treatment is required, literally only the ability to read questions and transcribe answers.

In the meantime, we suggest that a preoperative educational class for foot and ankle patients would go a long way towards a rapprochement between patients and surgeons when it comes to expectations.

Rethinking bias and truth in evidence‐based health care

Rethinking bias and truth in evidence‐based health care –  free full-text /PMC6175413/Oct 2019

This article points out that bias cannot be removed from human thinking because we all have different internal mental maps, assumptions, and concepts that guide our behavior.

It’s hard to see how “evidence‐based health care” can operate on individuals that are not the “average patients” that the evidence is built upon.

In modern philosophy, the concept of truth has been problematized from different angles, yet in evidence‐based health care (EBHC), it continues to operate hidden and almost undisputed through the linked concept of “bias.”   Continue reading

More on the Science of Health Care

More on the Science of Health CareTex Heart Inst J. – Jun 2017

Mark Scheid skillfully reviews a provocative book that challenges the theory and practice of population medicine (PM).

The book’s author—Michel Accad, is a practicing cardiologist.

Accad attributes the healthcare community’s widespread embrace of PM to 3 factors:

  • the economics,
  • the science, and
  • the ethics of health care.

This editorial focuses on the science of health care, highlighting the intimate ties between PM and evidence-based medicine (EBM).  Continue reading

The importance of values in evidence-based medicine

The importance of values in evidence-based medicine – free full-text  /PMC4603687/ – Oct 2015

This is a long well-thought-out article about the current model of evidence-based medical care that we have to live with. I think the meat of the matter is in these two paragraphs:

The world as we think it ought to be is the world of values. Different people will have different values, and it is very hard to resolve value-based disagreements on the basis of scientific evidence. But values are ever present.

Despite the caricature of the passionless objective (often male) scientist in a white coat, the questions scientists decide to ask, the methods they select, and the way they interpret results are chosen through a filter of often unacknowledged and subconscious values.   Continue reading

Benefits of doctors practicing without EBM

How I learned to stop worrying and love practicing without EBM | Alert & Oriented – by Michel Accad – Sept 2016

My aim is to show you practical ways you can safely and effectively exercise clinical judgment without recourse to “evidence-based” knowledge, provided you follow simple but fundamental principles of clinical care: circumspection, parsimony, and due respect to patient autonomy.

What’s more, I will make my case against RCTs using examples that EBM apologists have precisely identified as paradigmatic of this “single greatest medical advance.”

Dr. Acacd then works through four population-wide cases when RCTs overturned “common knowledge” and EBM and changed medical practice.  Continue reading

EBM only works for the mythical “average patient”

Evidence-Based Medicine (EBM) figures prominently in these efforts and is vigorously pursued and implemented by corporate healthcare (whose prime directive is to create profit for shareholders).

‘Population Health’ Versus ‘Person-Centered’ Healthcare

Population health: At odds with person-centered healthcare | Accad2017

This is an open-access PDF article making the case that the trend towards population health is leading to more guidelines and standardization and less individual care.

This is exactly what I’ve been seeing as a huge flaw in pain management these days: it’s not tailored to the individual but determined by various government agencies now interfering with our treatment.

To conclude, the population health movement is an ambitious attempt to determine and improve the health of large groups of individuals “top down,” by identifying and modifying socioeconomic contexts and global health outcomes. 

The framework of population health, however, necessarily diminishes or subverts the traditional concept of health, rooted in the integrity of the person.   Continue reading

Evidence-informed Person-Centered Healthcare

Evidence-informed Person-Centered Healthcare Part I: Do ‘Cognitive Biases Plus’ at Organizational Levels Influence Quality of Evidence? – PubMed – Dec 2014

As our medical system tries to implement Evidence-Based Medicine, it’s becoming more and more clear that the “evidence” isn’t the factual unbiased truth we expect.

Introduction: There is increasing concern about the unreliability of much of health care evidence, especially in its application to individuals.

  • Cognitive biases,
  • financial and non-financial conflicts of interest, and
  • ethical violations

at the levels of individuals and organizations involved in health care undermine the evidence that informs person-centred care.   Continue reading

Evidence-Based Medicine and Bioethics

Evidence-Based Medicine and Bioethics: Implications for Health Care Organizations, Clinicians, and Patients – free full-text /PMC6207438/ – Erin G Stone, MD, MA, FACP – Oct 2018

This article discusses the deontologic and utilitarian aspects of EBM and assesses EBM according to 4 bioethical principles:

  1. Respect for autonomy,
  2. beneficence,
  3. nonmaleficence, and
  4. justice.

Strong ethical arguments support EBM as the best approach to patient care. However, practitioners and health care organizations must be aware that each principle involves complex issues that challenge EBM’s ethical values.   Continue reading

How Western medicine lost its soul

How Western medicine lost its soul – free full-text /PMC5102204/ – by Michel Accad – May 2016

Today, someone who needs attention for a health matter can seek conventional “Western” medicine or opt to receive a “holistic” treatment from the realm of so-called alternative medicine.

For most people, there is a clear distinction between the two. Why does conventional medicine seem so unable to attend to the complete welfare of the patient?

I think this is largely due to the “medicine by guideline” model of conventional medicine.  Continue reading