Steve E Hartman
Chiropractic & Osteopathy 2009, 17:10

Abstract

After any therapy, when symptoms improve, healthcare providers (and patients) are tempted to award credit to treatment. Over time, a particular treatment can seem so undeniably helpful that scientific verification of efficacy is judged an inconvenient waste of time and resources. Unfortunately, practitioners’ accumulated, day-to-day, informal impressions of diagnostic reliability and clinical efficacy are of limited value. To help clarify why even treatments entirely lacking in direct effect can seem helpful, I will explain why real signs and symptoms often improve, independent of treatment. Then, I will detail quirks of human perception, interpretation, and memory that often make symptoms seem improved, when they are not. I conclude that healthcare will grow to full potential only when judgments of clinical efficacy routinely are based in properly scientific, placebo-controlled, outcome analysis.
Why do ineffective treatments seem helpful?: A brief review

“Much the greater part of medicine’s useful and practical knowledge… derives not from physicians’ observations of patients at the bedside but from the laboratories of the natural sciences, physics, and engineering”[1].

An average day at the office: A patient presents with symptoms of a common, nonchronic malady. In your practice, you have observed this problem respond to a particular treatment protocol, and you manage the case accordingly. When your patient returns for follow up, symptoms are improved. Again, it seems your treatment has been effective.

In this contrived account, awarding credit to treatment seems reasonable, but is it? All we have are your personal, clinical impressions of cause and effect. For any particular case, your bedside experience and knowledge of an individual patient may inform diagnostic and treatment decisions, but are they likely to be enough?

Often, practitioners are tempted to base clinical convictions in personal experience. Controlled (scientific) verification of apparent efficacy can seem a bothersome hurdle. In fact, science sometimes seems to offer only a period at the end of a confident therapeutic sentence, already written. Unfortunately for those judging efficacy, symptoms can improve for many reasons unrelated to treatment. Even less-well understood by patients or practitioners, there are many reasons that symptoms may seem improved, when they are not. This assortment of causal possibilities renders casual, uncontrolled appraisals of clinical efficacy unreliable. In material that follows, I will show why:

1) clinical merits of one or more of your favored therapies might be open to question;

2) outcome studies must be designed and interpreted with caution;

3) randomized, placebo-controlled trials are the foundation of modern healthcare [2];

4) many medical journals (including this one) publish few case reports;

5) demonstrably valueless “alternative” and “complementary” approaches to healthcare are so popular; and

6) many alternative regimes (e.g., acupuncture, reflexology, and cranial osteopathy) seem effective against a plethora of health problems (from constipation and autism to Down Syndrome [3]) with numerous different biological foundations [3-5].

As we will see, discomfort engendered by opinions at odds with one’s own can derail one’s best intentions of reaching the truth. Although nothing in this review is, to my knowledge, new or controversial, some ideas expressed may conflict with views you already hold. If you give this review a thorough reading, and judge it incomplete (or even mistaken, in some regards), please consider publishing a counterview.
Continued…..
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