Don't do this: 150 medical practices that all fail, especially acupuncture

This is ineffective - and cruel.

Why do people keep doing things to their bodies that don't work, and that even hurt them? This seemingly self-destructive behavior is what allows bad medicine to thrive. One problem is that people are easily fooled by self-interested con artists selling snake oil: homeopathy and acupuncture fall into this category. Another problem is that even doctors can be fooled, especially when a practice seems to make sense.

One great example of this is stenting: the use of a small, flexible tube to re-open and hold open clogged arteries. This seems like such a reasonable idea–if a pipe is clogged, unclog it and put something in there to keep it clear. And it does work, sometimes, but the evidence shows that for people with minor blockage, it usually does more harm than good. A new article in The Atlantic, "When Evidence Says No, but Doctors Say Yes", explains that in a recent 5-year period in the U.S., "about half of all stent placements in stable patients were either definitely or possibly inappropriate," as shown in a new study. The authors also point out that stenting remains the go-to procedure for any patient with clogged arteries, even among physicians who have read the studies. The problem here is that stenting just seems so darned logical.

At least stents work some of the time. What about procedures and medications that don't work at all, and that sometimes cause harm? Five years ago, a team of scientists in Australia conducted a massive review of evidence for thousands of medical practices, and found 156 that either don't work or actually cause harm. Their list of ineffective and harmful procedures should be required reading for anyone who is considering a medical procedure.

I can't go through all 156 bad practices, but one group of procedures stands out as particularly ridiculous (by which I mean the original sense of the word, "deserving of ridicule"). These are the various uses of acupuncture, all of them ineffective, none of them with even the slightest plausibility, but all of them promoted by quacks acupuncturists. Here they are–and remember, each of these has been tested scientifically and shown to be either useless or, even worse, harmful:

1. Acupuncture for women in labor. From the study: "In the absence of sufficient evidence that proves either effectiveness or harm, acupuncture as a method of induction is not recommended."
2. Acupuncture for uterine fibroids. "There is no reliable proof of effectiveness of acupuncture for uterine fibroids." (Aside: if a woman has fibroids, multiple options are available, many quite effective. The claim that acupuncture might treat them is patently ridiculous.)
3. Acupuncture for irritable bowel syndrome. Studies have found "no significant effect of acupuncture on IBS global symptoms, pain, and quality of life compared with placebo." 
4. Acupuncture for otitis media with effusion (fluid in the middle ear). This condition is common in children, and acupuncturists are only too happy to plunge their needles into unsuspecting kids. The study found no evidence that this works, and concluded that "acupuncture should not be used for the management of patients with OME."
5. Acupuncture for lower urinary tract symptoms in men. This too doesn't work. I wonder where they stick the needles?
6. Acupuncture to treat hyperbilirubinaemia. This condition, commonly known as jaundice, is often seen in very young infants. The suggest that we treating babies with acupuncture is, frankly, primitive and terribly cruel. The study concluded starkly that "there is no evidence to support the use of acupuncture to treat hyperbilirubinaemia–NICE recommends that this treatment not be used in this population." (NICE is the Australian National Institute for Health and Clinical Excellence.)
7. Laser acupuncture for carpal tunnel syndrome. Multiple studies found that acupuncture doesn't work for this either. One study concluded that "more rigorous studies are needed." Why waste more time on this hopeless pursuit?
8. Acupuncture for depression. Lots of studies, most with a "high risk of bias," and all of them finding that acupuncture doesn't work for depression. This is depressing.
9. Acupuncture for osteoarthritis. Not surprising, acupuncture for arthritis is no better than placebo.
10. Acupuncture for Bell's palsy. Eight trials, none of them showing any reliable benefits. Subject patients to more of these trials would be cruel and unethical.

So there you have it: 10 out of the 156 bad medical practices involved acupuncture. If you want to see the rest of the list, check out the full study. As for acupuncture, this is by no means a complete list of the claims that acupuncturists make. Indeed, just last week a new study claimed that acupuncture helps treat migraines, prompting a rebuttal from UC San Francisco's Amy Gelfand, in the same journal, saying no, it doesn't. (Dr. Gelfand explained a lot more than that, but I'm summarizing.) The pro-acupuncture study was done in China, where virtually all acupuncture studies report positive results, and the lead author works at the Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine.

We should all thank Drs. Elshaug, Watt, Mundy, and Willis for their tireless effort in reviewing thousands of studies, so that the rest of us don't have to. Acupuncture studies will keep appearing, but there's no reason to believe anything new will emerge. It's time for people to stop fooling themselves about this particular brand of pre-scientific pseudoscience.

Dr. House Was Right

I’m a big fan of the show House, which ran on the Fox TV network for 8 years and is now on Netflix. Gregory House, masterfully played by actor Hugh Laurie, is an brilliant doctor who diagnoses patients whose bewildering symptoms have stymied other doctors. He’s also unbelievably rude: he insults and harrasses his patients and his fellow doctors alike, but they tolerate him - usually - because he’s almost always right.

I doubt that any real doctor is as rude as House. But like any group of professionals, doctors vary widely in their people skills. Recently, though, Medicare has started using patient satisfaction as a component of how it pays hospitals. In response, some doctors now try harder to give patients what they want, rather than what they need, as described last year by Kai Falkenberg at Forbes.  On Medscape recently, William Sonnenberg wrote that “patient satisfaction is overrated” and said of Press Ganey, a company that runs patient satisfaction surveys:

“Press Ganey has become a bigger threat to the practice of good medicine than trial lawyers.”

You can find Medicare's hospital survey online. Dr. House would fail, big time.

What’s wrong with giving patients what they want? It turns out that patient satisfaction is tied to higher costs and, even worse, a higher death rate. A large survey covering 52,000 patients, published by a team led by Joshua Fenton at the University of California-Davis  found that the most satisfied patients not only spent about 9% more than average, but had a 26% higher death rate. From the study: “The most satisfied patients had statistically significantly greater mortality risk compared with the least satisfied patients.”

For patients who think a nice doctor is a good doctor, this might come as very disappointing news. Was the effect due to patients already in poor health, who might be more inclined to like their doctors? No: when the researchers excluded the sickest patients and looked only at the healthier ones, the risk of dying was even higher. (It’s important to note here that this is relative risk; only 3.8% of patients died during the six-year followup to the study.)

Over at The Daily Beast last week, Daniela Drake summarized this trend as “You can’t Yelp your doctor.” (Not that Yelp isn’t useful for finding a good pizza place.) And yet, as Scott Hensley reported on the NPR blog Shots, online ratings of doctors are becoming very popular, even though they don’t measure how good a doctor is at diagnosing and treating illness.

This study has implications for so-called “alternative medicine” as well. Patients who frequent alternative providers such as acupuncturists, homeopaths, and naturopaths often report high levels of satisfaction, as if satisfaction correlated with better care. Now we have a large study showing that this is simply not the case.

It makes sense that patient satisfaction is related to cost: patients often demand treatments that they don’t need, and “Patient requests have also been shown to have a powerful influence on physician prescribing behavior”, as Fenton and colleagues reported. It is less clear why the most satisfied patients died at higher rates.

Obviously, doctors don’t need to act like Dr. House to be effective. But doctors need to be able to tell patients things they don’t want to hear. Just because you want an antibiotic for your sore throat or your child’s ear ache doesn’t mean you should get one.  The UC Davis study demonstrates that using patient satisfaction surveys to adjust reimbursement rates, as Medicare is currently doing, is a recipe for higher costs and lower quality of care.

Given a choice between a friendly doctor who gives me what I want and a brilliant doctor who gives me what I need, I’ll take Dr. House.