Hacker News Reader

Comment by owenversteeg | Hacker News Reader

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.

View on HN

"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.

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.

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.

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 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

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

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/

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

spine/back/disk surgery is a huge one.

Reply on news.ycombinator.com