Six useless treatments

 

The Australian Physiotherapy Association (APA) recently pronounced that six interventions commonly used by physiotherapists are useless and were no longer being supported (link).

As part of the Choosing Wisely initiative, the APA has decided that requesting imaging for certain instances of non-specific low back pain, cervical pain, and acute ankle trauma; plus the routine use incentive ­spirometry after upper abdominal and cardiac surgery, electrotherapy in cases of lower back pain, and manual therapy for ­patients with frozen shoulder, are all now discouraged.

There are some interesting aspects to this decision that warrant some more thought.

Firstly, there is the fact that pronouncements from professional bodies – no matter how well informed or well-intentioned – rarely make any difference to practitioner’s behaviour.  This point was made some years ago by Miles, Laughlin and Polychronis in an editorial in the Journal of Evaluation in Clinical Practice (pdf).  In the editorial, the authors made the striking statement that evidence based medicine had never been shown to improve patient outcomes; that the ‘refusal of the protagonists of EBM to engage in formal intellectual exchange’…’represents nothing more than the long maintenance of an unscientific and antiscientific posture’, and that this represented ‘a pragmatic mechanism designed to protect the cherished ideological convictions of the EBM community’.

Despite our best intentions, people don’t seem to care all that much whether professional organisations like the APA claim that physiotherapists shouldn’t be stretching frozen shoulders.  Physiotherapists will carry on doing it, the public will continue to expect it, a doctors will still refer patients for it.

Some have argued that the Choosing Wisely campaign, and its many EBM siblings, are primarily vehicles designed to reinforce the authority of the medicine to maintain dominion over health care; to promote a biomedical way of thinking about these problems, and minimise the importance of ‘other’ ways of thinking about health.  Increasingly these decisions are inflected with justifications based on the need for cost and time efficiency, and the need to focus on those treatments that really work.  But what other discourses are being lost along the way?

I worked for years on acute medical and surgical wards, and the routine use of incentive spirometry was something we’d stopped doing years ago.  That didn’t mean to say that we got rid of the devices from the department though, because there were always the odd patients who they worked for.  The skill was to know when to use them and when to try other things.

Proclamations from ‘experts’ are all well and good, but they tend to be seen by professionals as overly simplistic rules-based prescriptions that ignore the local context and the ability of the practitioner to think for themselves.  Added to this, and despite practitioners paying lip-service to EBM, most practitioners know that what is proven to be good for us today, will be frowned on someone tomorrow.  One only has to look at the history of massage to know that its popularity has nothing to do with evidence for its efficacy.

In one of those supreme ironies, there is actually little evidence that evidence actually changes anyone’s behaviour.  And because experts never acknowledge this, we play out a continuous game of truth in which we pretend that expert opinion matters, while all the time doing it the way that makes most sense to us in the context of our own daily lives.  And the bizarre rules of this game depend on experts being the ones to break the spell, but we don’t listen to what they say, and so it goes on.

Two recent book reviews in the excellent journal Nursing Philosophy recently tackled both of these problems from different directions.  The first looked at Martin Lipscomb’s latest book Exploring evidence-based practice: debates and challenges in nursing (link).  The other looked back on Patricia Benner’s seminal 1984 text From Novice to Expert and asked whether Benner’s expert nurses were ‘near extinction’ (link).  In both cases, the focus is on the role of the expert and their ongoing relevance as vehicles for reassurance and certainty in increasingly uncertain times.

Societies appear to want something more nuanced; more sophisticated from their experts than the kinds of crude proclamations being issued from professional bodies and well-intentioned expert committees.  Should we, as critical-minded practitioners, be doing more to provoke these groups to aim higher in future?

Reference

Mennell, J. (1943). Massage, movement and exercises in the treatment of nerve suture and repair. In W. B. Doherty & D. D. Runes (Eds.), Rehabilitation of the war injured, a symposium (pp. 470-482). New York, Philosophical Library.