Imagine a scenario where a patient comes into your clinic with a history of chronic ankle pain. This hypothetical patient has seen a handful of providers in her day, each with varying degrees of success — some relief here and there, but her ankle pain continues to return from time to time. You conduct your examination, identify a few concordant signs, rule out any serious pathology and begin discussing your plan of care.
The patient interrupts and says “Sure! That all sounds well and good, but in the past the thing that has made the biggest difference is when my PT threw a kitchen sink at my ankle. It really was a breakthrough for my pain”
What do you do? You are well aware of the body of evidence suggesting that throwing a kitchen sink at someone does not produce clinically significant effects over that of placebo. Further, you find the mechanistic rationale for the use of a kitchen sink to be wholly underwhelming and farfetched. But, your patient here expects the treatment and for whatever reason, attributes the success of previous episodes of care to the kitchen sink. Do you educate her that high quality literature has demonstrated that throwing a kitchen sink at someone does not actually help at all? Do you throw a kitchen sink at her ankle anyway, despite your understanding of current best evidence, under the guise of “leveraging placebo”? Would you provide honest informed consent before hand? I have a feeling that many who provide ineffective treatments in order to “leverage placebo” do not actually present a clear picture to what the treatment is actually doing.
This is obviously a far fetched example because no one (I hope) is throwing kitchen sinks at their patients, but imagine the same scenario with a kitchen sink replaced by ultrasound. Or a CPM after knee replacement. Or homeopathy. Or foot reflexology. Or perhaps a surgery that has been shown to be no better than placebo? Would that change how you intervened? At what point does it become acceptable to deliver a treatment that we have good reason to believe provides no benefit beyond placebo?
I think physical therapy has a unique problem with providing ineffective treatments and this is due to the lack of immediate consequence for our continued use of ineffective treatments. If a critical care physician is treating a patient in a hypotensive crisis and provides a vasopressor that has been shown to not raise blood pressure any better than placebo — this is a bad thing because the patient might die as a result and certainly would not be rationalized as leveraging placebo. If a surgeon performs a knee arthroscopy on a patient with nonspecific knee pain that has no demonstrable benefit over placebo because the patient expects it, this is a bad thing because the surgery is wildly expensive and puts the patient at an unnecessary risk for little benefit. But if a physical therapist performs ultrasound on a patient, we often shrug and say “Well? what’s the harm? At worst we get those lovely placebo effects” (which is a poor conceptualization of placebo, take a look at a few of Erik Meira’s posts for more on this — Placebo Fu, Treating Ghosts, It's Magic!)
The harm comes from the fact that ineffective care does not occur in a vacuum — in providing ineffective treatments we are perpetuating the myth that an ineffective treatment is a meaningful contributor to a plan of care, continuing to adopt poor clinical reasoning, adding to unnecessary healthcare costs (however small our contribution is) and potentially leading our patients to seek more expensive or invasive care, because the treatment did not exactly provide a meaningful benefit. When high quality evidence is available suggesting a particular treatment is ineffective it should be clear that it is not acceptable to have continued use in clinical practice — even if is safe, or cheap, or used because of its “placebo effects.” Patients deserve high quality care and the use of treatments that best evidence suggests to be ineffective beyond placebo is anything but that.
But what of the patient’s previous experience? Surely you can not blindly disregard their positive outcome with a kitchen sink thrown at her ankle which might have resulted in a changed concordant sign within-session or some transient pain relief — and we shouldn’t. But as well educated healthcare providers we must consider WHY that patient experienced a positive outcome and we must remember that outcome measures measure outcomes, not treatment effectiveness. In the face of evidence suggesting a kitchen sink (or ultrasound or homeopathy or… ) provides no benefit over placebo and the lack of reasonable plausibility for any therapeutic mechanism associated with the kitchen sink, is it more likely that this individual is a unique responder to kitchen sink therapy? Or was their positive experience more likely the result of the many other factors that can make an ineffective treatment seem helpful. The idea of immediate effects (in both research and in the clinical observation) as a strong indicator of a treatment’s benefit is a poor one. As Chad Cook points out in his editorial, immediate effects can be achieved with almost anything — examples include alternate nostril breathing improving spatial cognitive tasking, hamstring stretching improving active mouth opening, or simple touch improving someone’s mood and pain. These are a few of the reasons why we test treatments in a fair and controlled fashion — to better understand if what we are doing to patients actually matters. We simply can not accomplish this with our clinical observations and we owe it to our patients to know if what we are doing actually works.
Further, as I’ve quoted him before, Neil O’Connell raises important questions with regards to patient expectation when he writes “Why do patients choose acupuncture or manipulation or ultrasound etc? I guess they do because each treatment has passionate advocates who promote them, advertise them, spread the word about them, often with a willing media tagging along like an enthusiastic labrador. So the treatments help because patients expect them to, but patients only expect them to because the culture that delivers those treatments has propagated that belief! It’s a fabulous business model (it all costs) but I smell a conflict of interest. Patient choice is difficult in a world where good information is so elusive.”
We have an obligation as healthcare providers to provide the highest quality of care, accurate education and transparent informed consent to the best of our ability. Perpetuating the use of treatments known to be ineffective flies in the face of this and only feeds into the cycle of misinformed patients attributing success to bogus treatments. The use of ineffective treatments for any reason should not be considered and as Todd Davenport writes “the challenge of our profession is that [the use of ineffective treatments] is even a point of discussion” — Ineffective treatments are useless and this should not need to be debated.