If it doesn't work, stop it
Authors: Caroline White
Journal: BMJ (2004)

Editor—Most of the 50 or so correspondents agreed that doctors are guilty of using treatments that don't work.1-3 Some thought that patients respond very differently to the same treatment, so what works in one might not work in another. And sometimes useless, but harmless, treatment bought much needed time for patients to heal themselves, suggested others.

But many simply felt that culture and training and peer pressure and patient expectations often got in the way of change, even when patients stand to benefit. Financial imperatives, some of which are not always obvious, also favour using treatments that don't work, suggested an ethicist in Qatar. The lack of published negative trial results didn't help much either, volunteered a professor of psychiatry from India.

Just because everyone is doing it, doesn't mean it's right, it was acknowledged. But deviating from accepted practice or long held traditions, for which a great deal of time and effort had often been invested, took considerable courage, to say nothing of persistence, suggested some correspondents. This risked not only the wrath of the profession but also the threat of litigation, which, with its propulsion towards defensive medicine and standardisation, left little room for manoeuvre.

But the risks are worth it, and must be taken in the light of proof of ineffectiveness, to avoid potential harm, warned a senior lecturer from the University of New South Wales, Australia. His examples included the failure to research polio in the early decades of the last century and the over reliance of prison smoking cessation programmes on drug treatments in this one.

A French doctor wondered if medicine is not also about “killing the patient quicker than nature would do it?” This vein of cynicism was echoed in a saying attributed to Moliere: “Medicine is only for those who are fit enough to survive the treatment as well as the illness.”

A few writers questioned some of the criteria for evidence based practice, which, they felt, ignored whether an effective treatment might also be a harmful one. But one retired physician pointed out that measuring harm is even more difficult than measuring benefit. And in any case, should doctors be the only judges of what is or isn't harmful for patients, she asks?

Patients' views are all too often ignored, and their expectations rarely sought, which makes doing nothing all the harder. Not least because this tactic relies on advanced communication skills to present it in a positive light—skills which many doctors simply don't possess, opined an associate director of postgraduate general practice education.

One correspondent cautioned that medicine jumped to conclusions on the basis of statistical associations. These could be both spurious and misleading, which researchers from the health think tank the King's Fund had proved. They found an association between a country's ranking for health system performance, as judged by the World Health Organization, and its international football ranking.

Several correspondents continued the theme begun by US defence secretary Donald Rumsfeld's somewhat infamous mouthful of knowns and unknowns. One suggested that true knowledge was humbling, rather than a source of pride, and a spur to extend the frontiers of knowledge. Another pointed out that 25 years of medicine had convinced him that there were far more “unknown unknowns” than “known knowns.” Very few of the “facts” he had been taught at medical school had retained their factual status.

But one correspondent pointed out one of the essential difficulties of admitting to unknowns. Doctors “are trained to `know.' In medical training and practice, ignorance is so often equated with failure.”