Every year, hundreds of thousands of patients undergo unnecessary, unhelpful, and even painful procedures that may result in catastrophic complications.
Well, the clinical practice guidelines are at least sticking to the evidence this time—not only saying don’t do it, but also that the procedures shouldn’t even be offered to patients since they’re all harm without benefit. In that case, why are they still among the most common surgeries in the world? Because of a powerful logical fallacy on the part of surgeons and patients alike called post hoc ergo propter hoc, Latin for “after this, therefore because of this.” The fallacy assumes that, because one event followed another, the first caused the second. Imagine how pervasive this is in all of medicine. Imagine you go to a doctor, a surgeon, a chiropractor, a physical therapist, a witch doctor, or a crystal healer and get your pill or potion, or your chakras shocked, then, a month later, you’re cured. You can imagine thinking, “Wow! That co-pay was totally worth it. Thank goodness for modern medicine / that scalpel / the crystal healing!” Well, without science, placebos, or do-nothing control groups, you simply cannot know if something had a positive effect, a negative effect, or even no effect at all. You might have gotten better even faster without the treatment (or the charlatan). That’s why we have science. When it comes to these operations, the surgeons who keep performing them have an attitude of “science, schmience.” (That is, unless the science called for more surgeries, in which case they’d be totally on board.) It kills me that, deep down, they know this, too.
Think of that study investigating whether surgeons treat their patients like they’d treat themselves. It kills me that surgeons were significantly more likely to push rotator cuff surgery on others than they would do it on themselves. You can imagine that some surgeons may think that if they don’t do the surgery, another surgeon will, so they might as well perform the operation and make the money. They might arrogantly consider themselves to be more skilled and be convinced they’ll cause less harm. Maybe, but they’re still lying to patients and hurting them.
Let me repeat that quote from the editor in chief of an orthopedic surgery journal: “Every year, hundreds of thousands of patients undergo unnecessary, unhelpful, painful procedures. A subset of those patients will experience serious and sometimes catastrophic complications.”
We accept risk when there’s benefit, but all risk and no benefit? That’s assault. If all the treatments are bunk, then that makes it all the more important to prevent rotator cuff degeneration in the first place and treat at least part of the underlying cause, which brings us to some good news, in my next video.
You may be interested in my new book How Not to Hurt (https://nutritionfacts.org/book/how-not-to-hurt/), available now for preorders. (All proceeds received from book sales are donated directly to charity.)
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Video Summary
AI Generated
This video explores why unnecessary rotator cuff surgeries remain common despite clinical guidelines suggesting they offer no benefit over non-surgical treatments. It examines the psychological biases of surgeons, the expectations of patients, and the systemic financial incentives that prioritize surgical intervention over evidence-based care.
With clinical practice guidelines strongly recommending against
the most common rotator cuff surgery for shoulder pain,
saying it shouldn't even be offered to patients
because anyone in their right mind would choose against it
because it offers only harms, no benefit,
why does it still remain one of the most frequently performed
shoulder surgeries in the world?
Think about it from a surgeon's perspective.
They perform the surgery, and the patient gets better.
It seems logical to them that their surgery led to the improvement,
and most patients do tend to get better.
But the evidence showed that they would have gotten better
at about the same degree at about the same rate
had they not gotten the surgery and all the attendant risks.
But the surgeons simply see that their patients get better.
Surgeons may end up trusting their own distorted personal experiences
with a surgical procedure more than they trust nice trials.
Found among orthopedic surgeons is a pervasive overconfidence
bias, which is the conviction that one's skill
is greater than it actually is.
In fairness, overconfidence is not limited to surgeons.
Competence and confidence seem poorly correlated in physicians.
One study of the diagnostic accuracy
of radiologists found that those who did the
worst were more confident than those who did the best.
The greater the ignorance of the founding father of modern medicine,
the greater the dogmatism.
Now think about it from the patient's perspective.
Patients may perceive intervention as diligence
and inaction as negligence.
They may perceive uncertainty as ignorance
and certainty as reassurance.
Surgeons often rationalize that, look,
if they don't offer to perform the surgery,
they'll just miss out because some other surgeon will.
Of all the thought put into disentangling conflicts
of interest in surgery
from medical device companies and the like,
the most fundamental conflict is the one most seldom discussed.
Surgeons like surgery, and the more surgeries they do,
the more most get paid.
Surgical practice guidelines better align with the evidence
when recommendations don't adversely affect the bottom line,
like when they advise against procedures
that haven't been done for decades,
or ones the surgeons wouldn't get paid to do anyway,
like splinting after a carpal tunnel surgery.
U.S. surgeons tend to be all for evidence-based medicine
when it's in their financial interest.
When a randomized trial found that surgery was preferable
for a certain type of collarbone fracture,
most said they changed their practice
and began operating more on these kind of fractures.
But when the same level of evidence showed that non-surgical treatment
was preferable for Achilles tendon ruptures,
relatively few changed their minds.
In contrast, Canadian surgeons tended to follow the evidence
where it led in both cases.
This was chalked up to American surgeons being paid
nearly three times more to operate.
In Finland, after a landmark study showed
the most common shoulder surgery
to be effectively useless,
surgery rates dropped in non-profit hospitals
where surgeons were salaried,
but continued to rise in for-profit institutions
where income from both the surgeons and the hospital
depended on the number of procedures performed.
The psychologist Abraham Maslow famously wrote,
If the only tool you have is a hammer,
it's tempting to treat everything as if it were a nail.
My mom actually had Dr. Maslow as a professor
when she studied at Brandeis.
A little point of family pride.
Anyway, it's hard for surgeons to admit that there might not be
a surgical solution to a problem.
What's to harm in performing a safe, simple operation like SAD
that seems to make patients feel better?
The answer, wrote the head of the Finnish Center
for Evidence-Based Orthopedics,
is that it's dishonest to do so.
Sometimes, quoting Hippocrates, to do nothing is also a good remedy.
Rather than offer futile surgery, surgeons may have to revert
to the less lucrative tools of caring and empathy.
Consider the paper titled,
Do Surgeons Treat Their Patients Like They Would Treat Themselves?
Surveys of orthopedic surgeons found that under the same circumstances,
they would be significantly more likely
to recommend surgery for a patient
than they would choose that same surgery for themselves.
Among the scenarios presented,
the greatest do-as-I-say-not-as-I-would-do-for-myself
discrepancy was for rotator cuff surgery.
Seth Leopold is the editor-in-chief of the journal
The Association of Bone and Joint Surgeons.
He's been an outspoken advocate for evidence-based surgery.
What a concept.
Surgery is done with a knife, he wrote,
and so it necessarily involves strategic harm.
Therefore, we must be sure there is sufficient benefit
to outweigh the inevitable risk.
Yet, every year hundreds of thousands of patients undergo unnecessary,
unhelpful, painful procedures, he writes.
A subset of those patients will experience serious
and sometimes catastrophic complications.
When it comes to judgments with such serious consequences,
our beliefs should be hypotheses we test, not treasures we guard.
