Surgery, the Ultimate Placebo | Hacker News Reader

Surgery, the Ultimate Placebo

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261 pointscpncrunch198 comments

One of my favourite stories along these lines (this is from Ben Goldacre's great book Bad Science, and may be slightly misremembered in parts) is about Archie Cochrane, who gave his name to the Cochrane Collaboration, an organisation who rigorously analyse the evidence for medical treatments, even "obvious" ones. He set it up after being a Japanese prisoner of war, where he had to make decisions about medical treatment in the face of extremely callous treatment by the Japanese officers. They were often decisions you only hear about in philosophical games - e.g. do you save one person's life or the sight of ten people - and he realised that much of his medical training was not based on proper evidence.

In the UK in the 1970s, hospitals started equipping expensive cardiac units, specifically designed for the treatment of heart attacks, full of expensive medical equipment (and if HN doesn't mind a good-natured tease, cardiac surgeons don't exactly shun the heroic mode of medicine). Part-way through a Cochrane study of their effectiveness, the data was pointing to survival rates being slightly higher when people were treated at home rather than in the cardiac units, but the results were not statistically significant. He decided to play a trick and annouced at an interim meeting that the data were pointing the opposite way - that treatment in cardiac units showed slightly higher survival rates, but were still not statistically significant. The doctors in the meeting were extremely angry that he insisted that the study should go on because the results were not statistically significant and therefore no conclusions could be drawn from the data. It wasn't until later in the meeting that he came clean, and told them that the data were pointing in the other direction. Funnily enough, none of the doctors still called for the study to be halted early in the face of identical evidence, just pointing to a different conclusion.

This kind of thinking is so common I often wonder how the hell we manage to progress as a species. People seem to only ever look at the evidence that supports positions they originally adopted for bad reasons. I can't remember the last time I talked to anyone who could recall to me a single time they changed their mind based on seriously weighing evidence for & against their positions. People Google to find out why they're right and that's the end of it.

Maybe because we are not really made to adapt as individuals, only as a specie?

And that we reached this level of collaboration and specialization, while usual at a cellular level is unknown at the individual level?

I think thats going into the right direction. Rationalism is a dead end on the individual level. Some thoughts in this direction: https://alexkaschuta.substack.com/p/trad-the-final-frontier

The issue with the trad philosophy is that these cute blog posts never clarify what to do when the “haha quirky” traditions passed down have real life victims. It’s one thing to stick to “let the cassava rest” or “don’t eat shellfish” but I’ll be damned before I go along with “stone the rape victims” or “enslave anyone with skin darker than a manilla folder”

This is more about a change in perspective. Its about giving a voice to the generations that existed before us, and what they have to tell us about how societies function and how to optimize for human happiness. The alternative is making up the rules of how civilisation works from first principles using a rationalist blank slate, which went horribly wrong when the communists did it, and goes completely off the rails right now [0].

The idea that we are rational decision-making machines, where all you have to do is to allow maximum freedom of decision making on an individual level, and you will automatically arrive at a happiness maximum, turns out not to be true. Communities are important, (shared) values are important, the right norms are important. There is much of value to be learned. It is not about accepting all the old ideas, because norms are evolving for good reasons, but instead take a hard look and evaluate which ones actually made a lot of sense.

[0] https://twitter.com/swipewright/status/1340199529891549184?s...

So, not much better than insects?

All of our fitness is due to memetic evolution, that is supposed to run on a time not comparable to genetic one. If it takes a generation to clean the memetic noise, that doesn't work at all.

Given that we are a quite successful species, I doubt those observations generalize well.

> Given that we are a quite successful species

I'm given to think we're 'successful' mostly by blind luck

COVID gave us a reality check and I doubt most people recognised it as such. If it had Ebola mortality rate, any delusions of progress would be washed away with exacting precision. We are here by grace it seems, unscientific as that sounds, and have been resting on our heels giving generous valuations to meaningless companies.

Heres a quote: The people of old knew and drew maps with 'here be the dragon', now they don't. Doesnt mean the dragons aren't there.

If the virus had ebola mortality rates I genuinely think it would have done less damage than covid has. When people are genuinely afraid for their lives they're more likely to follow lockdowns.

Yes: Much human progress is faster than generational speed. We didn’t have to wait for Oppenheimer’s kids to start believing neutrons existed. This points to some memetic evolution, which can be behind important changes.

Still: average people seem to change their minds very slowly and reluctantly, if at all.

I remember exactly one big change. A couple years ago I was convinced [1] to move from being vaguely libertarian to being vaguely liberal. I used to be either against welfare, or mixed on it, to now firmly supporting it.

I also gave up on hating web apps.

[1] By reading blogs I found interesting, and talking to a friend who was not especially trying to convince me but does hold my current position.

welfare is kinda a broad description for a lot of ideas but in general I would say if someone has extreme views on this is most probably due to a lack of understanding the effect it has. I cant imagine that someone who would serious dig into this topic to come out of it on either extreme side. Kinda sounds like the middle ground fallacy but its really just accepting that both extreme sides are utopic.

'as a species' is the key phrase. luckily, societal change needn't depend on individuals ever changing their minds.

What's fascinating is that I believe it's this exact trait that has allowed us to advance as a species.

Humans are excellent copycats, we follow traditions and practices often without question. Call this "culture". Culture can change, but often only slowly. Successful survival strategies are passed down via culture. Since culture is mostly preserved, but may change gradually, it experiences evolution in exactly the same way species do.

The result is that we are empowered with cultural knowledge that is far greater than we could ever devise in a single lifetime. It's allowed humans to inhabit almost everywhere on earth. A human without local, cultural knowledge would not survive, regardless of where on earth you place them.

These aren't my thoughts. Joseph Henrich first made this argument in his book The Secret of Our Success (https://press.princeton.edu/books/paperback/9780691178431/th...) though I haven't read it.

I was about to post about the cassava example which is often used to explain the role of blind faith in cultural evolution, but then I found this fascinating article that argues against it: http://cognitionandculture.net/blogs/hugo-mercier/a-matter-o...

The reason for that is because most insightful people do not have an externally visible firm position on most things. There is bias in your experience because the people you see with these highly visible entrenched beliefs are a subset of all people.

A separate subset of people focus more often on the interesting and unique aspects of the issue. They tend to outwardly express their insights about the situation as opposed to their opinions.

It is hard enough for me to remember where I read something. Never mind keeping a full history of my beliefs if they change. There are some exceptions though.

That's not how I handle things.

As just one example: I used to think video games would rot your brains. I've done an about face on that position.

It's not something I talk that much about in part because everyone just insists that no one operates that way, in part because it encourages abusive behavior from closed minded bullies and in part because it just doesn't typically come up in a natural way.

> This kind of thinking is so common I often wonder how the hell we manage to progress as a species.

Well, your universe is an experiment with a sample-size of n=1. Sure, taking risks might help other humans or other species' civilizations, but...

After thinking about this, I am in fact happy that we leave in a world where there is enough "slack": even if we make grave judgement errors, this will only lead to slightly worse outcomes, not to extinction. It is not good that we make so many mistakes, but it is good that there is room for error.

Until nuclear weapons. Now one mistake ends humanity forever.

I haven't seen any support for the argument that nuclear mistakes would cause extinction of the human species outside of fiction.

Arguably, we've already had at least two mistakes of the nuclear weapons kind in history already.

> I can't remember the last time I talked to anyone who could recall to me a single time they changed their mind

If I gave you an example, would you change your mind or still be of the same impression that no one changes their mind the next time this discussion comes up? ;)

Probablty thats the point, even if you give evidence to the person who asked, they would soon forget about it and move on with their convictions.

As the famous saying goes "It is difficult to get a man to understand something, when his salary depends on his not understanding it." People look out for thier own interests, and will work to craft narratives that support themselves until they compeletly fall apart. Thats the bad news.

The good news is that many people don't have vested interests in any given subject (or have crafted an outsider narrative for themselves). Outsiders get to compete with the vested players in both the marketplace and marketplace of ideas. Competition ensures progress.

I've noticed that in myself, it's really hard to change my way of living with facts, Like I know I should exercise more, and eat more healthy, and create habits, etc. What I found works: emotions. Reading a good book will change the way you think deeply, watching a good documentary or movie can motive you for months, and so on.

BTW I recommend The Minimalist on Netflix.

* Progress within a generation is not mandatory for progress across generations. We progress as a species across generations. You don't need to find people changing opinions within your circle. Our sample set is far, far bigger.

* Data/Evidence itself is a living thing. It changes, new data comes in, old data is discarded, or scientific consensus on the "interpretation" changes and evolves like an organism. Whether you like it or not, entities who interpret and report the data operate on and are influenced by political, social, financial and many other factors. Sometimes they believe they are "doing the right thing" while changing the interpretation. To give you some examples:

* For more than 40 years, there was super strong evidence and scientific consensus that neutering dogs early reduces cancer risk. Now, it has already come to light that this consensus was largely driven by moral dilemma to prevent the stray litters epidemic. Last 5 years, the opposite scientific consensus is building up: Neutering dogs early increases cancer and health risk [1]

* The complete international goof up on wearing masks, where everyone including WHO and CDC unanimously publicised consensus that masks do not help wearers — was driven by unquantified fears of masks running out of supply for frontline workers, and not by data. There were many ways they could have tackled that fear, e.g. by recommending governments to split retail and emergency stocks. But no, they decided to tackle it by changing the consensus instead, huge confusion and endless debates followed (like how do masks work for workers but does not work for regular people), lives were lost. Now that interpretation consensus has taken a U turn, except it's not new data, data was already scientifically present in the SARS and various other past epidemics. Just new consensus.

In many cases, you see that data was politicised not by politicians, but by the scientific community itself — because they are still learning how to cope with moral, social and practical dilemmas when interpreting data, and they do not have accountability for their interpretations. Their interpretations are just recommendations and the final decision making falls on authorities who are only held accountable.

Within one generation, you can have one huge mess up with the data or consensus, and have the whole species die off. It could have very well happened already, had COVID not been less fatal to younger population. It's too early to root for within generation progress, but we definitely do progress as a species. That's how it's intended to work.

1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6070019/

I started out believing that COVID is blown way out of proportion for the first couple of weeks, seeking evidence that mortality rates are lower than people thought, etc (not that it's a conspiracy or whatever, just that we're overreacting).

But reading papers about it looking for data to support this, then hearing accounts of medical staff, and discussing it with friends made me do a 180 pretty quickly. It could also be the social atmosphere around me, I'm not sure, but I do remember totally flipping my position and understanding what an idiot I was, it wasn't a very gradual process.

Sometimes it only gets difficult when you materialize your belief and are passionate about it.

Say we believed officials and advocated for not wearing masks in the beginning and called out everyone who wore masks anti-science. Then, officials turned out to be completely wrong.

With that, we would have a very hard time reverse our position.

Where is the puzzle? We have a lot of obvious inefficiencies that are there just because of politics. We still make progress, because evidence does make one’s political agenda slightly stronger.

I used to think homeopathy was unethical fraudulent quackery to get rich off the sick. Now that I learn about the efficacy of placebo, I start thinking homeopathy is fraudulent quackery to help the sick (and get rich in the process?).

Not sure if this counts as changing my mind.

A lot of the practitioners seem to believe in the stuff and I guess if it makes them and their patients feel better that's OK? I mean we all peg out in the end so if it helps you feel better during the process that's something. Of course it's a problem if you then skip chemo or some such to do it.

Perhaps beliefs are evolving over time, and how one navigates information and contemplation (or lack thereof) determines the direction and magnitude of changes in those beliefs.

I mean Ben Goldacre's book itself is a pretty good example of people being irrational. He's mostly just covering the same ground as Marcia Angell's earlier book The Truth About Drug Companies, which "skeptics" hated. But when Goldacre published his book the same folks decided they loved it, presumably because it was written by a man.

I mean don't get me wrong, there's enough difference between them that it's absolutely worth reading both of them, but the difference in reception between them was shocking.

It’s toxic to just assume/accuse sexism out of thin air.

I mean ... parent was talking about Bad Science, Ben's first book in 2008.

You seem to be comparing his second book, Bad Pharma (2012) with Marcia Angell's 'Truth About the Drug Companies' (2005), and assuming some claimed disparity in popularity is down to author gender.

It may be that new readers will pick a more recent publication, assuming it to be more contemporary. Or that they're (more) familiar with someone that had generated a large online following. (I think that's why I picked up his book, but had not heard of Marcia Angell.)

OTOH I'm not sure what '"skeptics" hated' refers to. Looking now on Amazon (I am not happy about visiting this site) both are showing 4.6 / 5.0 ratings.

On Goodreads Bad Pharma is showing 4.1 compared to Truth with 3.95 (but that's a pretty tight race).

The Cochrane Collaboration is a noble effort but its impact is limited in practice. There is a huge incentive to produce papers in the modern medical system, and I'm in a good place to know that you can make the data say whatever you want with techniques such as meta analysis, which incidentally is a big part of Cochrane studies. Meta analysis as a field has grown trendemously because who doesn't want to publish high impact papers without having to gather any new data, right? Publication of end-to-end single-command build reproducible research should be the only one allowed at this point, with everything accessible to the reader, including data. I've been doing shit medical science for ten years already because of hierarchical pressure, and I'd love a change of course.

As far as I can tell the Cochrane meta-analyses are usually of above average quality, pretty honest, don't have particular reason or evidence for bias in any direction and are conducted fairly well. Do you have any specific examples of problems in their meta-analyses?

Firstly, I have a problem with meta analysis in general and the sheer volume of meta papers tends to drown the Cochrane papers.

Additionally, I challenge the judgment calls about honesty of authors, be it the source trial authors or the meta authors. There is a _really_ large interpretation gap between what is written and what really happened depending on how you encode the data into the dataset and the analysis model.

I am a clinical researcher. And TBH, I think it's not really possible to conduct truthful and fundamentally believable clinical research given the current social and technological environments of academic research. I'm far from the only one slaving for professors who don't know what they're doing. If I did not have a family to feed, I would not accept doing the work I am doing right now.

Meta-analysis is still very valuable though because you would have a hard time finding significant disagreements between studies otherwise. Of course it comes with the benefit of not having to produce novel data but IMO that does not absolve such studies from merit and impact.

> that does not absolve such studies from merit and impact

Not completely, but is it justified that meta analysis papers are among the highest-impact things you can produce when it is known that the chance of type I error is particularly high? Really, I think we should strive to improve data retrieval capabilities in our healthcare systems to conduct trials based on hard data as extensively as possible instead of bickering over the dubious scientific interpretation of clinical facts gathered, analyzed and interpreted by people having little to no scientific education.

I don't follow your anecdote. Why would the surgeons want a non-significant study to stop when they were coming out on top, and want it to continue when they were coming out on the bottom?

In either case it's non-significant, so continuing it will likely

1) continue to be negative, or

2) develop large enough n that the trend becomes signifant.

If it's 2, then the incentives are exactly the opposite of what you outlined, if I'm understanding what you wrote.

Nitpick: Cochrane was British then did not fight against the Japanese, and he was prisoner of war in a German camp.

Here is his story about the prisoners' camp[1] and there is no mention of blinding people, “just” German soldiers shooting or throwing grenades at random on prisoners.

[1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1444794/?page=1

Fair nitpick - as I said, I was recalling the book from memory having read it quite a while ago, and couldn't remember what the exact tradeoffs were. Thanks for linking to an original source.

Does anyone have any examples of surgeries that are done today in modern medicine that are basically placebo? I'm surprised the article didn't give a single example.

https://www.nytimes.com/2016/08/04/upshot/the-right-to-know-...

https://www.mdalert.com/article/surgery-for-torn-meniscus-in...

https://www.health.harvard.edu/blog/knee-arthroscopy-should-...

The first thing that occurred to me when I read the title: Tonsillectomies used to be very common when I was growing up, and eventually that stopped. See eg:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883156/

Circumcision is another big one which used to be widely purported to have some positive health effects.

I'm against circumcision because foreskin can be used to make a vagina, if your baby boy turns 18 and decides to be a woman instead.

It's part of my "Weird hills to die on Grand Tour"

https://en.wikipedia.org/wiki/Sex_reassignment_surgery_(male...

Not because genital mutilation of children is just barbaric?

The US CDC (Center for Disease Control) currently recommends male circumcision for positive health effects.

Yes, but almost all of the studies referenced in the guidelines took place in Africa, where proper genital hygiene and sex-ed is not taught. If you teach your kids to properly clean under the foreskin, circumcision largely loses its advantages.

That's kinda the point - the healthcare bureaucracy is up to its ears in precisely this kind of bullshit. The "studies" demonstrating the beneficial properties of circumcision are often backed by groups with obvious biases (eg, Jewish or Islamic religious groups) and almost never mention the possibility (and likely correct explanation) that the causality behind the improved health correlation goes the other way: healthy people are simply more likely to be circumcised (more likely to be from or join a religion that values cleanliness, restricted sexual behavior, etc.), rather than circumcision itself causing improved health.

How surprising that in a country where cutting off parts of baby infants is culturally acceptable, the national associations recommend it. Its just shocking to me that anyone can defend the practice, health benefits or not.

I've read that one of the positive sides of it is hygiene.

If you cut off your arms will you no longer have to wash your armpits?

Someone did a great short story of a society where everyone got their fingernails removed for this reason (as an analogy to circumcision).

Apparently, in the UK many people used to have their teeth removed when marrying.

Not just UK , and not just when marrying. If you could afford it, removing all your teeth before 30 was a great idea, since a rotting tooth and the subsequent infection would most likely kill you. So it just increased your chances.

Washing regularly also helps hygiene. As a bonus it doesn't require cutting off a body part according to the suggestions of a fairy tale.

Circumcision for hygiene is a bit like shaving your whole head so you don't need to use shampoo(Edit: with the difference that hair can actually grow back and doesn't have countless sensitive nerve endings).

But are they placebo based health effects?

Placebo does not just mean an effect that is questionable or might not be present.

Placebo is a name for procedures and drugs that have no direct effect. They might have indirect effects, such as alleviating anxiety by convincing the patient that you are taking care of them. Or, it might just be indirect effects where people try to be helpful and report some improvement in their conditions, even if none has occurred. Or, it might just be reporters fudging the data to support the medicine's effectiveness. They may also change patient behavior through effects such as 'sunk cost' or more complex ones, like circumcision possibly reducing sexual pleasure, therefore decreasing the chance of risky sexual behavior.

But there is 0 evidence of placebos having actual positive effects aprt from the first one about subjective symptoms.

That’s why the "effect" of placebos is highest in every study about pain (which is highly subjective).

A placebo never stops a virus infection, although you might feel like it helps a bit.

WHO and the UN agree it does have positive health effects -

https://www.who.int/teams/global-hiv-programme/hiv-preventio...

My tonsils get seriously inflamed once a year and I wish i had had them removed. Yes, i tried various gargles. I've been given antibiotics, and all sorts of stuff. Nowadays my doctor just gives me Vicodin when i complain that my tonsils are inflamed. I then subside a week on nothing but warm soup. (I cannot take vicodin - makes me feel like i am thinking through a fog. i hate the feeling).

Sadly, tonsillectomies on adults are actually quite complex and dangerous, but as a chronic tonsil sufferer, i assure you, removing them would not be a placebo. And every year, i have a week when i check hourly whether Laser tonsil ablation is available and approved in USA yet.

I relate to this story. However, after several years, I figured the inflamed tonsils were just a side-effect of other issues. Check if you have postnasal drip, a deviated septum, or a nasal polyp. Several related chronic issues may also cause it.

Look into Orthotropics and Mewing. Oral posture does wonders. The jaws should grow forward, not be retracted by braces and extractions. There should be enough airway space. Look for airway-focused dentists for treatment.

A friend's child had snoring problems before the age of 5, possible obstructive sleep apnea. There can be serious developmental consequences to this, some of which were showing early signs.

The specialist diagnosed his tonsil enlargement as grade 3 (4 maximum) and recommended tonsillectomy and adenoidectomy. This is recommended in grade 3s with his symptoms; strongly advised in grade 4s. But the specialist gave them thorough context that led them to go against his advice. Children go through 2 growth spurts of the neck around ages 5-7 and ages 10-12. After these growth spurts the ratio of tonsil mass to neck cavity decreases, giving even large tonsils more room -- possibly enough to no longer require surgery.

They pursued simpler treatments like saline sprays before bed to make nose breathing easier, which greatly reduced snoring. Developmental delays were caught up, and now at 6 years old they are glad they avoided the surgery, though admit it wasn't necessarily bad advice and were prepared to reconsider it if no progress was shown in 6 or so months.

jpmattia says >"Tonsillectomies used to be very common when I was growing up, and eventually that stopped"<

Luckily, as a child I had my tonsils removed. It was just something almost everyone did. After that I had only an occasional sore throat. In contrast friends who still had their tonsils had serious illness, visits to the hospital, weeks out of school and parents who constantly worried.

So as far as tonsils are concerned my feeling are "Good riddance!"

Knee surgery [0] is the one I've heard about before. Placebo (and nocebo) are really interesting effects, but also conflated with regression to the mean. There's a nice discussion of this in the very entertaining Math of Life and Death by Kit Yates [1], a fun book for people not normally interested in math especially (but I also found it informative and a good read).

[0] https://www.scientificamerican.com/article/study-suggests-co...

[1] https://kityates.com/

My dad just had a similar surgery in the shoulder; I'm not sure whether to send him this! There's no sense making the placebo effect less effective, or even reducing the efficacy of a useful surgery with the nocebo effect.

In his case, there was a golf-ball-sized "something" that they had to cut up into pieces to remove. So hopefully that's a real improvement, along with the debridement that they went in there to do.

If he's feeling better and doing well, why mess with a good thing! There's definitely a range of issues people have, and probably an over prescribing of treatment generally, which can make some of these broader studies harder to interpret (as pointed out in the article). If I had something that big basically anywhere it's not supposed to be, I think I'd be happier with it gone. In any event, hope your dad keeps feeling better!

The reason for sharing recovery could be largely placebo driven is because it empowers the patient by revealing a previously unknown skill they can develop.

Studies are showing that "open placebos," which is when the patient knows it's a placebo, can work even better than when the patient doesn't know.

Choosing one's own beliefs with deep intention and choosing to pick them up or put them down quickly are skills for improving both learning and healing. Withholding opportunities to develop these skills from people denies their need for autonomy and efficacy in their healing.

I would ask him if he wants to know of anything simple that can boost his recovery. I would also propose he prepare to mourn many losses immediately after, since there's possibly a lot of opportunity for regret when someone learns so much of the things they've done in their lives may have been unnecessary and within their power to heal from. Some people can get stuck in grieving/regret and this slows the healing process down, so I consider it important to learn to grieve efficiently for quick healing.

>Studies are showing that "open placebos," which is when the patient knows it's a placebo, can work even better than when the patient doesn't know.

Yeah, but are those studies RCTs?

A cursory search on google for "RCT open placebo" suggests some of them are. Here's one: https://pubmed.ncbi.nlm.nih.gov/29513699/

What I find fun is that it's something I can simply experiment on myself with to find out for myself. After all, by the time I learned about open placebos, I'd already spent years healing without knowing about the effect. As a result, I'm already my own blind study. It may not bring certainty, but if I really wanted certainty, I'd be working on a device to transport myself to the parallel universe where everything operates purely on certainty, rather than this one that's more likely built on uncertainty. I'm choosing to embrace uncertainty and subjectivity, instead of chasing certainty and objectivity. Science without subjectivity is science denial of the subjective nature of the observers, anyway. I choose to meet all needs while denying none.

Also, RCTs aren't the only tool for studying the subjective and sometimes aren't even available due to the subjective nature of placebos. With regard to psychedelic healing, for instance, it's impossible to keep from learning who's taken the placebo. This will likely be the case until people develop the skills related to tripping without drugs, assuming that's a skill available to us, which I think is worth choosing to believe in. I'm saying this because I've noticed a culture of RCT dependency growing, where someone will choose to withhold believing in something if there isn't what they deem to be sufficient RCT-based evidence available to them. This is a type of bias that distracts from the power of placebos, which is we can choose to believe in anything simply because it is useful to us and allows us to see more potential paths forward to consider.

This article [1] was interesting to me and applies directly to your situation. Essentially, knowing that something is a placebo doesn't necessarily decrease the effects of the treatment.

[1] https://www.health.harvard.edu/blog/placebo-can-work-even-kn...

Routine wisdom teeth removal, male genital mutilation, dentists giving fillings far before they are required, causing toothaches and sensitivity...

But these all turn out to be easy money for someone, for some odd reason.

I imagine that this gray area is where a lot of "unnecessary surgery" comes from. The vast majority of people have no medical need for circumcision (but some do). A lot of people don't need their wisdom teeth removed (but many probably should). You might need a filling eventually (just not now). Where do you draw the line, in a world where setting up studies to find conclusive evidence for binary medical decision-making ("Should this ever be done in the presence of x, or should it never be done?") is hard enough?

I had two surgeries in 2019; in both cases the consulting doctor told me that it was 50/50 if I actually needed them or if they'd actually fix the issues that might have been associated with them. One was a pretty smashing success, the other (ironically more expensive) one was a 4-figure wash that had the surgeon dodging my inquiries as to what went wrong.

Unfortunately, it turns out that medical decision-making entails taking a holistic view of the situation and giving advice that the doctor then has to take responsibility for. Good luck achieving that on a systemic level within the ever-dysfunctional structure of American healthcare.

I've assisted on numerous third molar extractions, on patients up to sixty years old. None of those people were glad they had neglected to get the work done in their twenties.

If you're not sure about a recommended dental filling, just go to a different dentist for a second opinion. By the time a cavity causes you pain you'll need a root canal and possibly a crown.

I got all mine out at ~18 for no discernable reason.

Earlier in the year, got a filling despite visible substantial enamel. Was fine before, but I could barely handle drinks colder than body temperature for about 6 months. I think it could've waited.

> If you're not sure about a recommended dental filling, just go to a different dentist for a second opinion.

This happened to me, probably twice. The first time I got rushed through the fillings and had them the same appointment as a cleaning because they were minor (they were). I still felt abused by it. A few years later, the same dentist found something else. I got a second opinion this time. It was basically that an aggressive dentist might reasonably want to fill it, but the second opinion was "don't bother." Five years and on a new dentist and it hasn't been so much as mentioned by the new dentist.

Unless something is obviously wrong or you have a known history of cavities, I'd always get a second opinion.

In my early twenties, I was scheduled to get my wisdom teeth removed. It was going to cost me the equivalent of about a couple week's wages at the time. If I did it without general anesthetic it would be significantly cheaper. The oral surgeon to whom I was referred said I could do it either way, it was my choice. He did mention that, on a scale of 1-10, he would estimate the difficulty of removing my teeth at a 9. In x-rays, a couple looked like they were coming in upside-down.

After calculating the number of hours of work the anesthetic would cost me, I decided to bite the bullet of go with a local anesthetic. (My dad was also tough-guying me to skip the general anesthetic.) So I called the surgeon's office to make an appointment. When I mentioned that I would be opting opt of general anesthetic, the receptionist paused and asked me to hold. When she came back, she said that the doctor specified that general anesthetic would be necessary. I mentioned the conversation I had already had with him. She again asked me to hold. When she returned, she said it was no longer an option.

I put off the appointment. Miffed, I decided to take a closer look at the practice. This was pre-internet so I went to my local public library. I tracked down a British NHS study that suggested extraction was over-prescribed in the US in part due to the private insurance system. (I guess you can insert your tired joke about British teeth here.) One NHS study coupled with my incipient suspicion of the American medical system was enough for me. Plus all the money I was going to save. I decided to forego the surgery.

Almost 30 years on and I can say I have no regrets. (Yet?) My third molars are still buried in my gums. A few years ago, the bottom right one partially broke through the gum. It was irritating at times but never really painful. I take care to floss and brush it with my other teeth. It seems to have come to rest. If I remember correctly, the study stated that after age 30 or 40, most people's wisdom teeth will have settled.

One internet commenter's tale backed by one study for which I no longer have the reference.

> When I mentioned that I would be opting opt of general anesthetic, the receptionist paused and asked me to hold. When she came back, she said that the doctor specified that general anesthetic would be necessary. I mentioned the conversation I had already had with him. She again asked me to hold. When she returned, she said it was no longer an option.

That's a very strange outcome indeed, I wonder if you could have pushed for it anyway. My wisdom teeth were also impacted (nearly buried in gums, horizontally aligned), and I also opted for a local anesthetic.

The worst part of the procedure was seeing the size of the syringe. They really didn't spare any anesthetic for it. I felt numb all the way to my neck and ears. To my surprise the whole procedure took less than 40 minutes from start to finish, including cutting the gums, sawing the impacted teeth in half (the noise and smell is not for the faint of heart), and then putting sutures in.

Personally, I don't regret getting rid of them either. Made hygiene slightly easier and no risk of inflammation where the wisdom teeth were breaking through the skin.

...the noise and smell is not for the faint of heart...

Working in a dentist's office, I have seen a wide range of tolerances for discomfort (not pain: we always anesthetize). The people who need ativan or nitrous for a simple filling are probably going to need general for impacted third molars. Those need to be sectioned if they're going to come out without breaking the jaw. In USA, relatively few dentists would offer general anesthesia in a non-hospital setting.

Everyone I know was knocked out for their wisdom teeth removal, is that not general anesthesia?

It depends on many factors (teeth being devitalised, expected complications during the surgery, and other non-teeth related factors as well). Some people do get a local anesthesia (not knocked out), others have no choice.

Where I live (NYC), everyone I know has been knocked out for routine wisdom teeth surgery.

I chose local anesthetic when I got my impacted wisdom teeth removed in NYC. This was in 2006 at a dental school though.

What, you can get general anesthesia for wisdom teeth removal? Is that a thing?

What exactly makes dentists so apprehensive about performing this procedure? I've heard of practices that insist on general anesthesia myself and I've also seen some who will only offer a referral.

it makes less money than the full monty

local anesthetic to the jaw or maxilla is just incredibly effective

Lots of general dentists refer these extractions because they can't physically do them in a way that is safe for the patient. (It is an open question whether state board exams should exclude such practitioners from the profession entirely.) Introducing general anesthesia to the situation makes the procedure more, not less, dangerous. Especially in larger cities, there would be numerous dentists capable of safely performing an impacted third molar extraction under general anesthesia. Such dentists will charge for their expertise. Poor and rural patients will get local anesthesia.

Yeah getting my wisdom teeth removed in my 40s seemed like 20 years later than optimal. They always seemed to take up too much space in my mouth, were hard to brush (which led to them eventually needing removal), and contributed to canker sores and other routine pain and irritation. After they were removed, my mouth felt so much healthier, easier to keep clean, and free of miscellaneous pain.

The entire point of this discussion is that you are biased. What you need is scientific evidence to back it up. Finding water for your patients is not a good way to view the world.

This is exactly what I thought 3 years ago when a dentist told me that it was very important for me to get rid of my wisdom teeth, because loss of enamel meant that they were very likely to decay quickly even with proper hygiene. Other dentists told me that it was not necessary, and could be done later if the teeth ended up decaying too much.

Now the teeth are completely decayed, I've started to feel severe pain, and since I've developed severe thrombopenia (<20 G/L), I can't get them extracted easily (couldn't find any dentist willing to take that risk), so since six months, I have to take anti inflammatory drugs for the pain and antiobiotics to limit the infections, as well as the folic acid and corticosteroids needed for ITP, and I have no idea when will this end.

It's very difficult to differentiate important advice from "easy money" advices, especially when this advice stems for a principle of precaution. Most peoples don't develop severe ITP, but if they do, getting wisdom teeth removed before they can cause problems can be very important.

This is a long shot but some claim that vitamin K-2 can regenerate teeth to some degree. It might get your teeth in good enough condition to remove.

I had started taking K-2 (Jarrow MK-7 menaquinone-7 FWIW) for other reasons but when my semiannual dental checkup came due, both the technician and dentist kept marveling about how pristine and healthy my teeth were. They credited it to my brushing and flossing habits, which had not changed. I took the praise but was puzzled until I remembered that the K-2 might be helping my teeth.

> Routine wisdom teeth removal

That one is new to me. My dentist took X-rays at that point in puberty where it would become obvious if the wisdom teeth were obviously and majorly deviating (thus requiring removal).

The X-ray came back somewhere between "inconclusive" and "too early to tell", so I still have my wisdom teeth.

"Does anyone have any examples of surgeries that are done today in modern medicine that are basically placebo?"

Spinal fusions for injuries not sustained in car accidents or horse throws or ... other literally back-breaking trauma.

People with plain old uninteresting everyone-gets-it back pain get spinal fusions - a major, invasive surgery. There is a complicated nexus of obesity, refusal to do PT exercises, and huge economic incentives for surgeons that lead to these procedures.

This critical review even mentions a Cochrane review[1]:

"... and often does not even result in the spine being fused. That last one is not a big deal, because the results of the surgery are not well correlated with whether or not the spine fuses."[2]

[1] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD...

[1] http://doctorskeptic.blogspot.com/2012/08/is-lumbar-spine-fu...

Here's a New Yorker article that I bookmarked years ago that also questions the efficacy of back surgery for chronic pain:

https://www.newyorker.com/magazine/2002/04/08/a-knife-in-the...

From the opening:

Last year, approximately a hundred and fifty thousand lower-lumbar spinal fusions were performed in the United States. The operation, which involves removing lumbar disks and mechanically bracing the vertebrae, is of tremendous benefit to patients with fractured spines or spinal cancers; more frequently, however, it is performed to alleviate chronic lower-back pain. But how effective is it? That’s a question that many of the doctors who perform the fusions, and the insurers who pay for them, appear reluctant to ask.

In addition to the nexus you point to, it's worth mentioning that for a lot of back pain, we have no idea what causes it, or why it goes away (if it does). I suspect a lot of it is pressure from individuals wanting their doctor to do something to help them with their debilitating and mysterious problem.

Source: I talked my dad out of a spinal fusion. I'm still not sure it was the right choice.

Start at 2min08sec:

https://www.youtube.com/watch?v=NyugCJ40IIw

“You’re using a clothesline as a flagpole”.

Is what you are claiming still accurate today? That Cochrane review is 15 years old, a lot has changed.

Spondylosis (vertebrae wear) has a primary cause, which is more often than not a herniated disc above or below that vertebra.

Unless there is some extreme space constraint most Orthopedists or Neurosurgeons would attempt an artificial disc replacement prosthesis instead of vertrebra fusion.

Unnecessary/ineffective fusions are still happening all the time. My Gf is a PT and unfortunately had to work for one of the surgeons for a time, as recent as 2 years ago. So perhaps this is a regional issue, but there's still not much pushback from payers in hundreds of cases yearly. Perhaps 2020 may be different due to COVID reducing procedures in general.

Not really a placebo, but broken collarbones are an example of this. The most common injuries can be healed with just a sling and rest. With surgery it makes sense with compound fractures or bones that are overlapping significantly or not where they need to be as it might not heal at all with a sling. Compared to just healing with a sling, surgery has increased risks from complications, the metal plate that can cause discomfort and a noticeable scar. With surgery the healing time is usually faster too

I don't know if it is a placebo, but many births by cesarean section are medically unnecessary, and can cause harm.

There are questions about the efficacy of some meniscus surgeries performed for knee pain. Outcomes are rehab are often similar to outcomes after surgery + rehab.

https://pubmed.ncbi.nlm.nih.gov/28522452/

The pathology for clavicle fractures is still changing today, with evidence suggesting that there is no need to operate on types of fractures they would previously operate on.

I shattered my clavicle on my bike, many pieces, bits were floating in the middle of nowhere, it was pointing in all the wrong directions. It would have typically been suggested for surgery, but my hospital is a research hospital and so my case was cause for heated debate and I was eventually recommended not to get the surgery.

During the process I met with many doctors for checkins and most of them were extremely surprised it wasn't operated on, but by the end of the healing process the surgeons said that if they had gotten that result from surgery they would be elated. So it all worked out and I've healed just fine without surgery, plates or follow up operations.

There is a difference in time though, I was in a sling for nearly 8 weeks, whereas my friend who had surgery and plates put in was using his arm again in much less time.

spine/back/disk surgery is a huge one.

The article links to a YouTube video of a lecture by the author[0]. One of the top comments contains a list of timestamps in the video where he discusses specific surgeries:

    7:55 Angina example
    10:05 Parkinson’s disease example
    13:10 Multiple sclerosis example
    14:52 emphysema example
    18:47 knee pain
    20:40 spine surgery
    21:52 Injection therapy for pain
    24:59 Explain perceived effectiveness 
    26:29 correlation vs causation
    29:33 Improvement not due surgery
    30:33 Natural history
    34:01 regression to the mean
    35:43 concomitant treatment
    39:16 perceived improvement: patient vs clinician
    41:50 therapeutic envelope
    42:38 Intervention: the placebo pill
    44:02 Building the ideal placebo
    47:02 “Why do we still operated?”
    52:00 Determining effectiveness
    52:55 Reducing error in estimating the truth
    54:55 Why we need blinded randomized trials
    55:12 Ethics and Placebo
    59:50 One possible solution
    1:00:20 Current status of placebo RCT in orthopedics
    1:00:44 Summary, questions, and comments

[0]: https://www.youtube.com/watch?v=IzueFu1cq5U

Without specifics this article is not helpful.

I've had 5 orthopedic surgeries and they were transformative -- and this article is written by an orthopedist!

There's some data [1] against these operations:

- Arthoscopic knee surgery

- Subacromial shoulder decompression

- Acromioplasty for rotator cuffs

- Vertebroplasty for the spine

That's 4 techniques out of...how many exactly?

It's just an n=1 anecdote but my surgeries absolutely changed my life for the better. I don't want to get into the gory details but I feel incredibly grateful to have had such talented surgeons.

You can argue placebo but my years of ineffective physical therapy suggest otherwise.

Instead of saying "Surgery, the Ultimate Placebo" this article should say "A handful of specific surgeries shown to be no better than a placebo" -- generically describing all surgeries as a placebo is clickbait, in my non-medical-professional opinion.

[1] https://www.realclearscience.com/blog/2020/11/07/some_surger...

> It's just an n=1 anecdote but my surgeries absolutely changed my life for the better. [...] You can argue placebo but my years of ineffective physical therapy suggest otherwise.

They don't though, do they. You can't disprove placebo with N=1.

If the placebo is the act of surgery then anything not surgery not working doesn't mean that the surgery worked by not placebo means.

But who cares how, it worked!

So cynical. I hope you're never in debilitating physical pain, only to have other people dismiss the effect of surgical intervention as a figment of your imagination.

It's not just about the sample size, I could get into the anatomy of my injuries but I don't want to divulge more of my medical privacy than I already have.

Suffice to say that when certain things are torn or detached surgical intervention is often the only way to re-attach or restore function to the affected joints. No mount of wishing it way mentally is going to change that.

I think you're misunderstanding what "placebo effect" means. Colloquially it's applied to things that "do nothing," or have only a psychological impact but in reality the placebo effect continues to work even when people are fully aware that what they are taking is a placebo:

1. https://onlinelibrary.wiley.com/doi/full/10.1111/jebm.12251 2. https://www.sciencedirect.com/science/article/pii/S152659001...

So the situation is more complicated than "figment of your imagination" or "wishing it away" (this doesn't work and isn't what placebo is referring to by they way - you have to actually receive a treatment even if that treatment has no direct effect) - it's clearly a real biological effect. Just the mechanisms are more obscure.

There's obviously a limit to what placebo effects can accomplish even if they can be positive, and I think the goal & point made is that because surgery is inherently risky, there should be an expectation of benefit over and above what can be accomplished with risk-free methods; ie., that surgeries which are shown to be only as effective as placebo should probably not be performed.

I find those studies problematic. In the ones I read from your links, the doctor says something along the lines of "this pill is a placebo. It means it has no active ingredients. However, the 'placebo effect' is known to be powerful and if you take these pills as instructed they can still help you..."

As I understand it, a big part of the placebo effect is setting the expectation that the treatment will help. And it is only known to help in subjective conditions, such as pain.

I expect we might see different results if the doctor said something more like "This pill has no active ingredients and does nothing. We are giving it to you to see if you will imagine that it worked anyway."

Kissing a child's scraped knee is not a treatment but, it along with a reassuring "there, all better!" works wonders for the child anyway. They are comforted and relived.

There is as yet no reason to think placebo is a 'real' effect, except for cases of subjective symptoms or body functions under conscious control (directly like breathing rhythm or indirectly like pulse).

For all other cases, like infections or tumors, the placebo effect seems to only be a measure of poorly understood differences in natural processes, which can cause spontaneous remissions at unpredictable rates.

The act of giving fake medicine to the control group has no direct effect on the people taking it - the idealized study results would almost certainly be the same if the control group received no medication at all. However, the reported data would be much harder to trust, as it would be obvious for the data collectors and pacients which group they are part of, making it trivial for them to misreport data and symptoms to influence the result in the direction they desire (whether consciously or not).

That is the real reason for the double blind study design in most tteatments - fear of fake data, not any mysterious healing/detrimental effects from the act of taking sugar pills.

Regarding something like your rotator cup issue: it's not simply a question of doing no treatment (you just having a painful shoulder) vs. having your surgery. It is more does having your rotator cup surgery and associated post-op rehab statistically work better than having a "sham" placebo surgery and doing the associated post-op rehab. People can begin to feel better after having placebo surgeries where nothing was actually repaired.

Below is a study seeking to measure the efficacy of rotator cuff surgeries. The point is that even this surgery, which I think you had performed and were happy with, does not necessarily have clear, proven efficacy vs. a placebo surgery.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6530362/

The improvements from okeechobee Placebo are demonstrably real. We don't always understand why/how, but... the sugar pill, for example, in combination with your body and mind are very literally resulting in improvement. Placebo does not mean fake nor tricked. The efficacy is absolutely fascinating, though.

That is only true for subjective symptoms like pain or anxiety, or for objective symptoms where there is some measure of conscious control, like blood pressure or pulse.

But there is no proof whatsoever of any kind of real placebo effect for body functions with no direct conscious control, such as immune function improvements from placebos.

I’ve seen debilitating physical pain gone by “meditation.” I myself have had pain in my chest and throat out of anxiety. Pain is ultimately a perception the brain makes, not a physical attribute.

Please allow me to reiterate: who cares how, it worked!

If I ever suffer debilitating physical pain, as I'm sorry you did and I hope I do not, the only thing I shall care about is that it stops.

Please understand that I'm not advocating for an end to the surgery that spared you that, whatever the means by which it did so.

So the surgeon found water for you. Good for you, I'd rather listen to the data.

You and Sam's mum have the best health care ever.

Orthopedic surgery is, IMHO, one the most "controversial" medical fields. Ask an orthopedic surgeon, and the answer will be in most cases surgery. Ask a non-surgeon orthopedic, and the answer will be therapy. Source: Having gone through some consultations, and having family that spent their professional career in orthopedic rehab.

Thing is, for every case one of the above might wrong there are two cases they might be right. Sometimes both are right.

Personally, I choose to forgo surgery. I have no intention to become a professional athlete or compete again, so I stick with my original parts, so to say. I did stop snowboarding and kickboxing, so. My knees really don't like these sports anymore. And I don't like them enough to go through surgery. I switched to boxing and skiing. I am rather sure that I would chosen surgery like 10 years or so ago.

It's really interesting how people with theoretical knowledge of what the placebo effect is can still refuse to believe in it in practice. From my experience, I think a lot of doctors don't really believe in these effects.

If a surgery’s effectiveness has not been evaluated vs a placebo, you cannot assume it to be effective based on anecdotes. Obviously there are many surgeries that are effective (repeating broken limbs, emergency surgeries, etc). Those surgeries having to do with pain relief are more nebulous.

My partner is a physical therapist, and in cases where it’s ineffective, it’s often because the patient is noncompliant or is doing it just to check off that “attempt” prior to surgery. A relative, as an example, goes to PT for all sorts of issues, but her real problems are psychological/neurological (due to brain damage); no amount of PT will ever heal her mind or change her excessive perception of pain.

> Question: Is physical therapy noninferior to early surgery with arthroscopic partial meniscectomy for improving knee function among patients with nonobstructive meniscal tears?

> Findings: In this noninferiority randomized clinical trial that included 321 patients, knee function that was measured by a self-administered questionnaire improved by 20.4 points in the physical therapy group vs 26.2 points in the early surgery group over a follow-up period of 24 months. The difference between the 2 treatment groups did not exceed the noninferiority margin of 8 points.

> Meaning: These results demonstrate noninferiority of physical therapy compared with early surgery with arthroscopic partial meniscectomy for improving self-reported knee function in patients with nonobstructive meniscal tears.

https://jamanetwork.com/journals/jama/fullarticle/2705186

That doesn't really sound like non-inferiority to me as a layman. That's a difference of over 25%.

Reading further in their additional conclusions, the surgery group also did better in both pain and general health.

Look at the graph in figure 2 - the massive overlap in the interquartlie ranges suggests that any differene in the median values can be attributed to random variation within the samples, rather than a true difference in the populations.

Also its better to quote an absolute rather than relative reduction, so the difference is really 3.6%

"Question: Is physical therapy noninferior to early surgery with arthroscopic partial meniscectomy for improving knee function among patients with nonobstructive meniscal tears?"

Vertical (deep, interior) meniscal tears can actually heal, since they have a blood supply, and the surgery for them is basically a coin flip - the results of which you only learn after a nine month recovery period.

You should absolutely be pursuing a rigorous course of PT to heal such a vertical meniscal tear. You should specifically look into whether your adductors (inner leg) are weaker than, and being overpowered by, your abductors (outer leg) resulting in knee valgus.

I had a meniscectomy a couple of years ago. When I looked at the monitor during the procedure, my meniscus was looking as if someone just threw an egg in boiling water, spread all around in thin strands.

Kind of hard to say you'll just do PT when a night of dancing leads to locking the knee at certain points.

At the way it was looking on the display, there is no way I did not have mechanical issues because of it.

“Statistically not effective” doesn’t necessarily mean no patient ever gains from the treatment.

It could be that we just cannot discriminate well enough between those for whom it would be a gain in health and those for whom it would be a loss.

An example is the yearly checkup with a GP. It might save your life, but definitely costs time, and also may lead to somewhat risky tests for many. Better selection of those to be tested can make that much more effective.

Same here, same experience with my meniscus looking like loose egg white (though I was under general for the procedure, I saw pics afterward).

I did PT before (didn't help, I had mechanical locking) and after (did help).

PT doesn't help some physical issues, but I had shoulder problems that PT fixed 100% and they've stayed fixed for years. IMO, it's important for a physician to treat each case as unique, and start with conservative therapy and move to more invasive measures.

Now I'm doing PT yet again because I have an onset of carpal tunnel syndrome, but it looks like I'll probably be going under the knife for it...

Anecdotal evidence, but I tore my meniscus playing football when I was 14. I thought I would have to have surgery but the doctor just told me to use crutches and a knee brace for a while.

It healed up really well, didn't have any issues afterwards.

Anecdote.

I had undiagnosed Familial Mediterranean Fever for years in my early 20s. Terrible, sickening abdominal inflammation attacks every few weeks.

After about 5 years I was desperate and one doctor said my gallbladder did show signs of low functioning, and recommended taking it out.

I did go into “remission” for about 8 months after. It eventually came back, but then faded soon after. It wasn’t until a few years later with a DNA test that I found the cause.

But I did always wonder if the surgery, along with my desperate hope to be better / not be wrong, had such a strong placebo effect that it actually did help me out.

> Familial Mediterranean fever (FMF) is a hereditary inflammatory disorder... an autoinflammatory disease caused by mutations in Mediterranean fever gene, which encodes a 781–amino acid protein called pyrin.

https://en.wikipedia.org/wiki/Familial_Mediterranean_fever

I'm halfway through the talk right now (shoutout to Youtube 2x speed). This is fascinating and brilliant, but so frustrating, because there is no way for us to ethically use placebos for human benefit. I would love if every doctor I ever saw first treated me with placebo, and only tried something else once placebo treatment was ineffective, but can that ethically be done without me knowing? And if I know, the placebo won't work.

Well, there's always the DIY approach: positive thinking. (But it only works if you believe it will.)

Placebo effect works even if you know it's a placebo.

https://www.health.harvard.edu/blog/placebo-can-work-even-kn...

There was a pretty serious-sounding contingent of commenters here in a recent thread about RSI. To them, the main cause of RSI was some sort of unconscious tension they were holding in the affected areas, and they needed to relax to make the pain go away. I wonder if that was placebo too

> And if I know, the placebo won't work.

This is not a given:

https://www.health.harvard.edu/blog/placebo-can-work-even-kn...

https://www.npr.org/sections/health-shots/2016/10/27/4994752...

Well, this is life changing information. Thanks for it.

I have knee pain when running with no physical explanation (MRI found nothing) I'm sure a placebic treatment would be helpful, but can I treat myself with a placebo? I wonder if an authority figure giving you an open placebo is more effective than me just telling myself that I'm cured, but I'm going to start with the latter.

I recall reading that the placebo effect tends to be proportional to the perceived degree of intervention. So getting a shot would have more of an effect than taking a pill, and a surgery would have more effect than a shot. Presumably getting something from an authority figure would also do more than whatever you can do yourself, but that doesn't mean the latter would be useless. If you can find some kind of physio exercise that's claimed to potentially help, maybe that would have a decent placebo effect, if nothing else?

Of course it's likely there is some kind of physical explanation for your pain, just not a known one (or even knowable, with current medicine). I'm in much the same situation with hip pain.

Just pick an "alternative" treatment that is (a) harmless and (b) you consider "could possibly work"

For running pain in a knee someone I know had a course of laser accupuncture [1] with really good success. There's nothing scientific about the treatement, no studies, no data. But it is at worst harmless so, we probably don't need to care.

I can see "I'm aware it might be just a placebo" as working better than "This /is/ just a placebo"

[1] My undertanding of this was that a general practioner (Doctor) shined a low power laser at close quarters on various parts of the knee. Zero chance of burning, completely harmless at worst.

Perhaps instead of a placebo, try a healing ritual or some form of alternative medicine. You can easily have someone else administer the treatment, and you can even choose something like acupuncture where there is potentially some evidence that it actually works (I don't believe it but if you can convince yourself, all the better for the placebo effect).

MRI isn't necessarily going to reveal reasons you'd have knee pain while running. For example, I know for a fact that if I don't routinely roll out my IT band, it gets too tight and that then results in pressure on the outer portion of the patella. It's rather unlikely that'd show up on an MRI, except perhaps for someone noticing "Hey, maybe your IT band is tight". Even then, probably not, since it tightens as I begin running.

So, there's probably something real going on, and something real you can do to fix it. Consistent stretching, rolling, and low-weight exercises to build strength in muscles like your hip abductors makes a world of difference.

If you're not doing those things, start there. Really do get a roller. The IT band cannot be stretched - since you can't exactly flex your femur.

> I have knee pain when running with no physical explanation (MRI found nothing)

That MRI found nothing only means there isn't clear damage no? Would it find e.g. short or tight tendons, or unbalanced muscle mass?

> can I treat myself with a placebo?

Nothing stops your from trying. You can just get some inactive pills (I don't know if it's possible to find excipients-only pills which would be the ideal but homeopathic crap or some innocuous supplements would do the trick) and take that on the regular as "treatment".

Dr. Ted J. Kaptchuk is has been at this a long time. His agenda is pushing so-called alternative medicine. When you dig in just a little and do some research on him you will find a lot of reasons to question his assertions.

In his studies, it is true that he tells people he is giving them a placebo. He also tells them that it can still help them. This is not really an "open label" placebo as people still have the expectation that it is some kind of treatment and will help.

I also find it interesting that the placebo effect only helps with subjective conditions, such as pain and nausea. No placebo will set a broken bone or seal a laceration.

I believe the placebo effect can also work just by telling someone about it (and then giving them the sugar pill or whatever). However, the whole placebo effect may just be (poor understanding of) statistics, namely regression to the mean. Here's an article [0] (found via Wikipedia on placebo [1])

[0] https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2796....

[1] https://en.wikipedia.org/wiki/Placebo#Confounding_factors

I thought placebos work even with open labels?

A lot of placebo effects still show up when the patient knows they're getting placebos. It probably has some ritualistic advantage in helping them mentally.

I have direct experience in the "doctor's know that under their care it works".

In an earlier startup we developed a particular dissolving mesh that could be placed in situ in a surgical site to prevent adhesions. E.g. if you tear your rotator cuff, the healing of sewn up region will adhere not only to the cuff but other parts of your shoulder, preventing it from moving. The only fix is to (painfully) move the shoulder as it heals to tear those adhesions and form some scar tissue.

Experiments in animals showed that they would recover full motion in their joints with no apparent discomfort.

But when we interviewed doctors we discovered that they knew this was a terrible problem but blamed it on the techniques of other doctors. "When it's my turn on call I get these calls from patients, some in terrible pain. I am very careful and my patients never have this problem. This sounds like a great idea though I'd never use it myself." Of course we sometimes talked to multiple doctors in the same physician's group and they would say this about each other.

We ended up using the technology in a different (medical) application.

my brother had never water sky(ed) before, so after a month of vacation doing it, he felt his knees. he talk about it with two doctors and they both wanted to perform surgery on his knees. he went and got a third evaluation and the third doctor told him the truth: that he didn't needed surgery and the doctors were after his money. the doctor proceeded by putting my brother in physical therapy, which healed both of his knees.

this is a real history. but there are plenty of other medical shows about the same subject - surgeons trying to force surgery on people that don't actually need it.

This is dangerous thinking. For example when it comes to chronic pain, there is that belief being pushed that opioids are actually a placebo and they don't help. Then people are being sentenced to a talking therapies instead. These therapies try to implant the thought that all the pain people experience is in their heads and it is not real. If only they could just stop thinking about pain, then they wouldn't need to take any pills. This is one of the reasons why people turn to dealers, if doctors start to believe this and are made afraid of prescribing anything. Also organisations who get involved in such "therapies" promote them, because that is, let's be honest, rather easy money from the public health organisations. It fits the western perception of suffering, that it is noble and virtuous. I wish this topic was explored more by investigative journalists.

I don't think there are any doctors, except perhaps a handful of cranks, who believe that opioids are "a placebo". Perhaps you mean something else? There are definitely doctors who underprescribe pain medications to certain groups of people - as I understand it, women are notably underprescribed pain medications for example - but that doesn't mean that those people think opioids are a "placebo".

And what if suffering does actually promote noble and virtuous thoughts? You left the most influential thought in the western tradition unexamined.

From experience suffering, in any form, certainly enhances the idea of the golden rule, that is ‘Treat others as you would like others to treat you’.

What does it mean for pain to be "real" vs experienced in one's head? I don't think this is an easy question, which is why our medical system struggles to deal with chronic pain.

I think there is evidence that people's attitudes toward pain can affect both the amount of pain that they feel and how much they suffer from it, and more generally that there are mental skills related to pain management and experience that are genuinely useful. (Also, there are cases where classic psychotherapy or psychoanalysis methods led to an alleviation or complete disappearance of somatic pain symptoms, even without focusing at all on the symptoms or pain themselves... although it doesn't seem ethically appropriate to somehow assume that that would be the best treatment for everyone.)

I agree with the concern that this should not be seen as a substitute for helping reduce people's suffering with pain medication. But I think we also still have lots to learn about the mental component of pain and potentially identifying psychological interventions that make a difference in this area.

I also agree that the "all the pain people experience is in their heads" angle isn't a constructive one, both because of its proximity to accusing people of lying or malingering, and because it doesn't seem like a helpful summary of any apparently-beneficial psychological techniques.

> "all the pain people experience is in their heads"

The funny thing about this one is that it is literally true, and not easily actionable.

I remember reading during my neuroscience MSc that there are two distinct areas in the brain activated during pain, one which is to do with the feeling of pain, and the other which is to do with the mental anguish caused by that pain. It makes sense to me that there are non-medical ways of diminishing the anguish aspect of pain (although of course whether something "makes sense" doesn't automatically mean it's true). It also matches the different psychological responses to pain of soldiers in battle, where the pain is not as intrusive, vs a sportsperson who's injured during a game and who's in an otherwise safe space where they can ruminate about what the injury means for their career.

The easiest "psychological technique" in this case is to simply understand the pain is likely not caused by any obvious identifiable physical cause. Just have people go through all the information. Pain usually signals something's wrong. Once you truly understand there's no basis for that pain, you will process it in a different way.

Many reports of chronic pain completely going away just by reading. Psychotherapy sounds like a much less efficient way with potential to create new problems.

There’s an enormous mental aspect to pain. As an extreme example, soldiers being shot may be happy getting a ticket home, even if their injury is severe.

https://theconversation.com/emotions-affect-how-pain-feels-a...:

“In 1943 and 1944, Beecher, who was described by friends as a street fighter in the field of medicine, travelled to the Venafro and Cassino fronts in Italy, where he questioned 215 seriously wounded men who were waiting on the beachfront to be evacuated by boat to hospital. He concluded that the anecdotal evidence was correct: there was no necessary correlation between the seriousness of any wound and men’s expressions of suffering. In fact, three-quarters of wounded soldiers claimed that they weren’t experiencing significant pain and didn’t ask for pain relief, even when offered it.

[…]

In contrast, suffering a similar kind of injury in civilian contexts (a car crash, for example) was excruciatingly painful because it heralded “the beginning of disaster”. Beecher confirmed anecdotal evidence that being wounded was viewed as good luck: wounds enabled men to escape “this hell with nothing more perhaps than the loss of half a foot”, as one World War I soldier put it. Emotions and expectations affected physiological sensations.“

Also, I think we should educate people that, if an expert says “we can’t find anything physical, so I think it’s in your head” doesn’t mean you put it there, or that you should be able to take it out without any help and, hence you’re to be blamed for it.

(I also think we should educate doctors to tell patients that “we can’t find” doesn’t mean “there isn’t”)

You don't need to go to war and study soldiers to observe this very human phenomenon. You just have to be around young children for a short while.

Kids will run and tumble and bonk their heads and get up laughing. Then they'll catch their finger and look at it: if it looks fine, they carry on but of they see a drop of blood, suddenly they're in mortal pain and the end times are nigh as they scream in agony.

I don't think people grow out of that. The stakes just change as they get older.

Good example, but I think the military example better shows how enormous the mental aspect is.

For kids, one could argue that they still have to learn what pain is, just as they have to learn what it is to be physically tired (go on a walk with them until they say they’re too tired to make another step. At that moment, point out there’s an ice cream vendor or a playground a kilometer away, and be amazed).

Kids sometimes also (consciously or unconsciously) play the tired/injured card just to get attention (that probably applies to some grown ups, too)

There are actually many many people who have overcome chronic pain through mindbody methods when nothing else worked. Look up Dr. John Sarno.

Also, all pain even acute is literally 'in your head'

I dealt with a case of chronic patellar tendonitis for years between ages 23 and 26. Debilitating to the point where I could not go anywhere that would require me to stand in line. The book Healing Back Pain by John Sarno, which is basically the talking therapy you mentioned, was hugely transformative for me. I was able to stop fixating on the pain and focus on strength training knowing that flare up were no big deal. I'm recovered now and regularly skateboarding and standing in line again.

Edit: I should mention I spent upwards of an hour each day for those years doing physical therapy rehab. I turned down recommendations of surgery during that time as well.

This is a baffling mischaracterisation of the arguments.

People don't say that opioids are a placebo. They say that people taking opioids develop tolerance for them and the meds lose effectiveness over time. This means that people are still in pain, but are now also taking dangerous and debilitating amounts of opioid meds. Their function is worse because of the opioids.

Providing talking therapy to these people isn't saying that the pain is not real. You saying this causes harm and you need to stop saying it, because you clearly do not understand what's happening.

When people have long term pain they lose function. They stop doing activities they used to enjoy. Their quality of life plummets. This makes their pain worse. (We know this, there's plenty of research.) Talking therapy aims to get people their life back by helping them regain function. They start to learn to live with pain. They get back to doing activities they enjoy. This doesn't eliminate pain, but it does lessen the pain and it improves quality of life.

You seem to think that "pain free but on opioids" is possible. For most[1] people in long term pain that's not possible, because opioids don't work like that.

[1] most, not all.

I've always heard the problem with opioids are when you get too many or too few.

> They say that people taking opioids develop tolerance for them and the meds lose effectiveness over time.

And this is the root of those claims. Some people even started to believe that patients fake chronic pain just to get those sweet sweet opioids. I've been taking them for over five years and I have not noticed that they lose effectiveness, nor I had to increase the dose. You do still feel pain, but the difference is between being able to function in the society and thinking about killing yourself. I've been through many of those therapies and I have seen disbelief on people faces. You can't get your life back just by thinking there is no pain or that the pain will not take it away. What they do is they get people to learn some basic thought patterns that any CBT therapy do and then sprinkle it here and there with theories about pain. This is not bad in itself, but when you marry it with the thought that opioids are unnecessary, you sentence people for unimaginable suffering, while patting yourself on the back, that you are "helping".

6:30 in this radio programme: https://www.bbc.co.uk/sounds/play/b04wv052

From 9:00 they interview someone who was on huge amounts of opioids and who managed to get off them.

This really isn't true. (Source: I'm a psychiatrist who treats some forms of chronic pain, while also treating people with opioid use disorder who started with prescription pills).

Good psychotherapy for chronic pain explicitly acknowledges that pain is real and not just in the patient's head. Chronic pain is thought (at a grossly oversimplified level) to be due to nerve sensitization rather than acute trauma, but experience, co-morbid health problems, and life stressors all interact to influence this.

Psychotherapy for chronic pain helps people identify maladaptive behaviors that could be worsening chronic pain, and then help to set goals and learn skills to improve their overall function. On average, it's only modestly effective, but it's better than many alternatives.

Some people might say that opioids are a placebo. A more nuanced statement would be that most trials can't distinguish between opioids and placebo for chronic pain. That doesn't necessarily mean they don't work for an individual, it just means that it's an intervention based upon low-quality evidence. On the other hand, opioids come with significant (and occasionally catastrophic) risks, and so the decision to pursue a high-risk/low-benefit treatment is discouraged. There are always exceptions, but I've been really pleased with the results I've seen as we've moved further away from opioids for chronic non-cancer pain.

This doesn't contain the details that would interest me.

My understanding is modern surgery routinely involves significant antibiotics to prevent serious infection during the operation. If that's followed with both "sham" surgeries and real surgeries, then it points to the possibility that the strong antibiotics are more important in some cases than the procedure.

There may be other medically significant details of sham surgeries that we overlook as not therapeutic. Many diagnostic exams involve not eating for x hours beforehand. Surgeries also can involve restrictions on diet during recovery or exposure to drugs like anesthesia that are given without intent to be therapeutic per se.

You can't really rule out the possibility that those types of things are therapeutically significant but overlooked because they are done to be curative.

Yeah it's always seemed bizarre to me that surgical procedures aren't held to the same standard of evidence as drugs and surgeons are allowed to pretty much make things up and do whatever they want as long as they don't engage in clear malpractice.

"The same standard" as in double-blind studies would clearly present issues when it comes to surgery. I can see the argument for a higher standard than is currently held to, but "the same" seems impossible to do in an ethical way, or even just practically.

Many double blind surgical procedures have been tested. Unless it’s limb removal you go in and either do the procedure or go in and don’t do the final setup. The ethics is interesting as surgical procedures can become common without any actual testing of effectiveness.

Overall about 1/2 of surgical procedures have had double blind tests and of those about 1/2 passed the test. Which suggests something like 1/4 to 1/2 of surgery’s are ineffective.

It doesn’t seem that unreasonable to me — bad drugs can harm people at a much larger scale than a bad doctor.

They're the same when abstracted to the level of "the practice of doing knee surgery."

Doctors are free to use drugs off label also, so that is consistent.

The constraints around producers (drugs, devices) are tight, but the clinicians can do what they think is worthwhile from there.

There is an absolutely fantastic quote relevant to this in An Astronaut's Guide to Life by Chris Hadfield (a fantastic book). Unfortunately, I don't have the book handy and cannot do it proper justice, but the part I refer to involves dozens of years after a childhood appendectomy when Hadfield was beginning his "real" astronaut career.

After experiencing severe abdominal pain at the surgical site, he was sent to a panel of surgeons for guidance. Going into surgery at this time would've been catastrophic to his career, as after a surgery one cannot fly into space for some extended period of time. At this point in his career Hadfield was relatively green, and there was a plethora of new astronauts as talented as he was just waiting to take his spot. Going into surgery at this point would have relegated him to a successful career at mission control, but not in space.

To the best of my recollection, his physician's opinion was he didn't need a full surgery to investigate this abdominal pain. However, the panel of surgeons universally, unequivocally recommended the gastrointestinal surgery. He states infinitely more eloquently than I can how applicable "uf you only have a hammer, everything looks like a nail" in regards to the surgical panel.

I recall he decided against the recommendations of the surgeon panel, and decided his abdominals wouldn't suddenly tear apart with potentially fatal results while orbiting earth in the ISS. It turns out he guessed right, and had one of the most prolific careers of any astronaut of the last few decades.

While this anecdote may make it seem like I am some anti-surgeon, anti-surgery person, let me state that I have had one surgery (besides wisdom teeth, which "doesn't count" as it's so common). It was an orthopedic reconstructive ulnar collateral (thumb) surgery, and my repaired thumb is honestly almost indistinguishable from my left thumb. And in this case it was clear surgery was needed, but after reading Hadfield's book and the parent article here it was astounding how the surgeons were literally unable to see any mode of treatment which didn't involve surgery. I think just like overprescription of antibiotics, we as a society should look at the overprescription of surgeries for medical issues which can be treated without surgical intervention.

> it was astounding how the surgeons were literally unable to see any mode of treatment which didn't involve surgery.

Current medical practice is the definition of "when all you have is a hammer, everything looks like a nail", so no surprise here. This a result of hyperspecialization which most of the time is good (capable hands) but sometimes not so good (rigid mind).

The problem with that anecdote is that its all with the benefit of hindsight. Certainly, in this instance, non-operative management was appropriate. But the more important question is what on average happens to the entire 'population' of people presenting with Hadfield's symptoms and signs if they're managed operatively and non-operatively.

If we imagine a disease where non-operative management leads to a 50% mortality rate within a year. If we take 100 people with this disease and manage them non-operatively, at the end of a year we'll have 50 people saying how pleased they are to have avoided surgery and complaining about the aggressiveness of surgeons, and we'll have 50 dead people.

That's why the diagnosis and management of disease must be informed by high quality clinical studies, rather than anecdotes.

While your general point about anecdoes makes sense, your point about the 100 people and 50 dead is completely incorrect. and ironically that example is a made up anecdote, at least Hadfield is a real example. It's well documented across many studies that a staggering number of surgeries are unnecessary.

https://www.usatoday.com/story/news/nation/2013/06/18/unnece...

key highlights:

"About 10% of all spinal fusions paid for by Medicare in 2011 were not necessary, either because there was no medical basis for them or because doctors did not follow standards of care by exploring non-surgical treatments"

"An estimated 7.5 million unnecessary medical and surgical procedures are performed annually with the number of unnecessary hospital stays around 8.9 million a year. One study determined that almost 29% were not necessary (Health In The 21st Century by Fransisco Contreras MD, page 212)"

"A 2011 study in the Journal of the American Medical Association reviewed records for 112,000 patients who had an implantable cardioverter-defibrillator (ICD), a pacemaker-like device that corrects heartbeat irregularities. In 22.5% of the cases, researchers found no medical evidence to support installing the devices"

Anecdotes are great for illustrating a point and making an emotional connection which is why I brought up the story from Astronaut's Guide. But there's absolutely no doubt that a significant and unacceptable number of surgeries are unnecessary.

The column is fudging the facts to justify its bombast title.

Example:

> A systematic review found that placebo was just as effective as surgery in over half of the cases studied, and all of the recent trials comparing surgery to placebo have found that surgery was no better than placebo.

We note that that the text doesn't tell us...:

1. which kind of operation is supposedly not very helpful.

2. which kind of medical condition(s) were studied.

3. whether the relevant medical condition is transitory/accute or chronic;

4. whether the condition is known to be amenable to non-surgical treatment;

5. what review this was, exactly, and where one can read the details.

6. what, exactly, the review reviewed.

7. what happened in the less-than-half the cases.

8. what chances of success the surgery purports to have. i.e. it might be a surgery which proponents suggest solves the problem in 45% of cases and has little effect (but no significant negative effect) in 55% percent of cases - in which case you "get what it says on the label".

Also, I would assume are almost no, or no trials comparing surgery to placebo where surgery is known, or reasonably assumed, to be efficacious. So those "recent trials" probably considered surgical procedures which are apriori under suspicion of not being efficacious. etc.

I've been told by more than one doctor (for chronic pain I had been having) to avoid seeing a surgeon unless absolutely necessary because they were worried the surgeon would recommend surgery even if it wasn't needed. I found it interesting. Seemed like they didn't trust their colleagues (or even they didn't trust me to make my own decision if I got the recommendation to undergo surgery).

There's also the perverse incentives in the american medico-legal system: surgeons get sued for not performing surgery, or performing surgery badly, but they rarely get sued for performing 'unnecessary' surgery unless its completely egregious. If the patient has a history/examination which could indicate a need for surgery, and the patient has given informed consent, the surgeon is very unlikely to be succcessfully sued for operating. I'm not implying this is a consious decision on their part, rather a subconscious influence of their training, anecdotes from other surgeons etc.

Different, but a related topic that I've come to be fascinated by are athletic tools and techniques that are held as canon that turn out to have no scientific support.

The author talks about reactions of physicians dismissing convincing data — the befuddlement and dismissals — and it's the same reaction athletes and coaches give when they're part of some of a controlled trial.

This topic reminds me of a subthread of the last time we discussed Alzheimer's research. And more specifically about the great public tragedy caused by overconfidence on the part of medical researchers. The details are different, but the fundamental pattern is the same.

https://news.ycombinator.com/item?id=24906758 was the discussion, and https://news.ycombinator.com/item?id=24910211 has the at times heated discussion that I am referring to.

Sometimes animals are in abdominal pain, supplementary exams leave us clueless and we resort to surgery to see whats happening, nothing looks wrong inside, we stitch them back and the patient gets better nonetheless.

Had scoliosis-kyphosis fusion surgery when I was 14 and it was rapidly-progressing. All it did was cosmetic and bought me time until Functional Patterns was invented. Today I am 70% cured. It's basically strength training according to the body's myofascial slings (gait). Flat feet, knee valgus, scoliosis, jaw growth, forward head – it's all connected.

Still, no surgeon in the world would undo (as in chip away the bone grafts limiting my spinal mobility) my fusion.

Sloan-Kettering publishes a set of online predictive tools [1] patients can use to make statistical estimates of the outcomes of surgery and other treatments. They're based on data from thousands of patients.

[1] https://www.mskcc.org/nomograms

Microdiscectomy for treatment of sciatica, numbness and foot drop from a herniated disc is highly effective (most people see a 90-100% reduction in symptoms) and minimally invasive. However, the longer term outcomes are mixed because many patients dont stick to the required long term PT (maintaining excellent core strength and avoiding risky activities like lifting heavy objects) and end up reinjuring themselves. Many people dont need the procedure and can releive symptoms through conservative therapy, but some cannot and will benefit from surgery, especially if the condition is causing extreme pain, weakness or loss of function that make physical therapy almost impossible. Its misleading for him to say that surgery “doesn’t work” when there are so many complicating factors impacting the population-wide, long term efficacy of a treatment. Surgery is just one step of many that you would take in order to recover and stay better. Talk to multiple surgeons as well as other patients to understand if surgery is the best option for your particular situation.

Maybe the categorization of the surgeries is too broad? Surgery is naturally an exploratory act and I would assume that what you find once someone is "opened" can vary massively. Maybe one should take that into account?

I think that an article like this that doesn't emphasize the fact that a placebo is still treatment is remiss. The naive reading is that surgery is useless, but that is not at all the conclusion if compared to a placebo.

The neuroscience of placebo effect(s) are super cool and quite difficult to study. Pain-related ones which involve release of endogenous opioid receptor agonists are fairly well mapped out, and similar circuits for blood pressure and other physiological functions controlled by the brain can be imagined. I've read about placebo antibiotics, though, which presumably involve the immune system in cool ways. There have been big investments by NIH into the idea that we should be treating a lot more disease with neurostimulation, but I think so far this has not paid off...

Sure but if it's just a placebo, there are probably cheaper and safer ways of achieving that affect. Even a routine surgery can be really risk.

To a man with a scalpel, everything looks like a surgery ;)

This is one of the best presentations I have seen in a long time.

This is one trial I won't be volunteering for.

Surgery --> stem cells

I know a surgeon, he says that he thinks it’s the enforced rest post surgery that is what really does the healing in some cases such as for example Surgery for back pain.

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