Petr Skrabanek, a Czech, was in Ireland when the Soviets invaded his country, so he stayed, publishing many criticisms of medical humbug while working with James McCormick in the Department of Community Health at Trinity College, Dublin, until his premature death in 1994. The book has been translated into six languages and is on the reading list of medical schools around the world, to encourage an appropriate scepticism about medical dogma.
For example, could strict adherence to evidence based practice be harmful to patients? This is the intriguing hypothesis suggested in the first section of this subversive book. It points out that although the placebo effect is very powerful, to work best it requires both the patient and the doctor to believe in it. As most of the common conditions that disturb our equanimity are self limiting, arguably the priority is for treatments that make us feel better, thereby boosting our activity (speeding recovery from musculoskeletal disorders) and immune response (hastening recovery from infectious disease). So the placebo effect is an important therapeutic weapon. Unfortunately, while it is invariably maximised by believers in complementary medicine (which Skrabanek and McCormick devastatingly rubbish in section 6), it is rendered impotent by those expressing doubt in treatments they know to be ineffective in double blind, randomised trials (where the differential effect of the placebo is neutralised). This may be honest but destroys the placebo effect, thereby denying its advantages to the patient. I find that encouraging patients with a bad cold to keep warm, rest, and dose themselves with honey, hot lemon, and paracetamol results in substantially greater customer satisfaction than saying, "Don’t worry, it will just get better by itself." Does it hasten recovery? Probably not, but it makes the patient feel better while recovery takes place. Is this being completely honest with the patient? No. Is it ethical? Read this book and then decide.
The second section is a humbling account of the many fallacies that beset medical practice—too many to enumerate here. As a longtime clinical teacher I am hugely irritated by those who confuse association with causation or assume that what a senior person tells you is correct, but to fight the underlying human desire for certainty is difficult. "Conviction politicians" may be popular, but conviction doctors are potentially dangerous. Our understanding of risk is universally poor. Allowing yourself to be disproportionately influenced by a single bad (or good) outcome can deny hundreds of patients appropriate treatment.
The third section is about diagnosis and the risk of false positives. Treating people who are not actually ill exposes them to interventions and side effects. Together with therapeutic errors, this fills 10% of all hospital beds in the United Kingdom. And in the fourth section Skrabanek and McCormick point out that the holy grail of medicine, prevention, is limited more by our failure to understand how to influence self damaging behaviour than by knowledge of pathology (think only of smoking, drinking, and obesity to understand this point). Section five points out that it is ethically questionable to promote expensive treatments that have not been shown to be substantially effective. Self delusion by practitioners of faith healing, homoeopathy, manipulation, occultism, and quack devices is roundly condemned. Section six points out that we all have a duty to consider the ethical content of our practice. It would probably be good for our ethical health if we all read this book at least once a year.
Philip Steer
BMJ 2008;336:673 (22 March), doi:10.1136/bmj.39520.545613.94
Follies and Fallacies in Medicine
By Petr Skrabanek and James McCormick
First published in 1989.
The book can be downloaded free of charge as a pdf file from the Skrabanek Foundation’s website at http://www.medicine.tcd.ie/public_health_primary_care/skrabanek/publications.php
Keine Kommentare:
Kommentar veröffentlichen