Critical Thinking in Healthcare - Why Does it Matter?

There are a wide variety of treatments for every condition known to humanity. Some treatments have a solid research evidence base which demonstrates their safety and effectiveness, others do not. Very often personal anecdotes and testimonies are also used to demonstrate the worth of a given intervention. Does it matter whether you choose to buy into a rigorous scientific methodology or prefer to believe in a more natural approach, and if so why?


At the risk of stating the obvious, when we fall victim to a disease our first and primary interest is: 'How quickly can I get rid of this and return to normal?'. It can obviously be difficult to maintain a detached analytical thought process whilst in the midst of extreme suffering. Before proceeding further and to avoid the charge of simply being a sententious egotist I have to admit I am also human and no different to any other person in pain.

Several years ago a good friend of mine upon hearing of my plans to get engaged gave me a hug. Unfortunately my friend is a very large, strong man and his judgement was impaired by alcohol. His hug broke a bone in my lower back which has intermittently given me quite a large amount of pain. I have in the past seen both a Chiropractor and a Doctor of Traditional Chinese medicine, on both occasions it was during a period of extreme discomfort.

The Chiropractor was very convinced of her own efficacy. She took quite a detailed history of the injury, my ongoing symptoms, my emotional state and my work/home life. She then showed me where my pain was by drawing it in red felt tip on a medical looking picture of the back and spine. Strangely enough I was already quite familiar with this information. When she discovered I was an Audiologist she proudly told me of the ‘origin story’ of Chiropractic in which D.D. Palmer ‘cured’ the Deafness of a friend by manipulating his spine.

D.D. Palmer

http://maximizedhealth.blogspot.com/2008/04/can-chiropractic-cure-deaf-man.html

In my defence at the time I was unaware of the background of Chiropractic and believed I was seeing a legitimate scientific practitioner. My B.S. sensor did go into the red when she told me this story but I was in pain and if she could sort it out I wasn’t going to argue, I think I said something like ‘That seems unlikely’ to which she just smiled. Besides, I had just paid over £200 for a course of treatment, I was committed.

The following treatment sessions were remarkable in a number of ways. Firstly I discovered that I was only one of three or four people being treated at the same time in the same room, confidentiality be damned! Secondly having laid down face first on the very comfy massage bench she proceeded to do almost nothing at all. Sometimes she would touch a point just above my buttocks, sometimes a point at the top of the spine but that was it. Probably this was a good thing in the long run. But perhaps the most incredible aspect of the treatment was her positively Jesuitical ability to change literally any statement I made into a positive sign. If the pain was just as intense but in a different spot she would say ‘oh good, something’s moving’. If the pain was worse she would say ‘that’s a sign that something’s happening’, and of course any reduction in my symptoms were her doing. This is a clear example of a logical fallacy known as confirmation bias, i.e. the ‘tendency to search for or interpret new information in a way that confirms one's preconceptions’.

Despite my increasing frustration and the derision of a Physiotherapist friend of mine I stayed out the course. The point at which I really began to understand just what bunkum this was came when I walked into her office and saw a sign in neat calligraphy on the desk stating ‘All healing is magical and spontaneous’. I felt sufficiently moved to ask why, if this was so had I just spent a small fortune on her in order to get better? I didn’t return for any further treatments.

Attending the Doctor of Traditional Chinese medicine was a more opportunistic occasion during an acute period of pain after a long drive. My partner had been seeing this chap for back pain throughout her pregnancy and assured me that she had really benefited from his ministrations. Unfortunately her usual Doctor was not available. The Doctor who saw me prescribed a massage, acupuncture and two different pots of tiny black pills along with some horse lineament. The massage really seemed wonderful. The acupuncture seemed to do little but bring back my symptoms due to the length of time I was required to lie in one position waiting for them to take effect. I've no idea what was in the pills, but the horse lineament gave some relief. Sadly, despite the excellent massage I walked away 110 pounds lighter and still in pain.

By telling you all this I hope to make several points. We tend to seek out help for illness only when it's at its worst. Some conditions such as lower back pain and to a degree Tinnitus are self-limiting, i.e. they can only remain as bad as they are for so long before there is some degree of easing, with or without treatment. This easing is sometimes termed regression to the mean and it is easy to see how a naive and yet sincere alternative therapist can fall foul of both a confirmation bias and this regression fallacy and persuade themselves that their particular intervention is unusually successful. When my partner was overdue with our baby she went to see a reflexologist who said she specialised in inducing labour. At the consultation she told us with absolute sincerity that she had a 100% success rate. She said this with no evidence of humour or self-deprecation, and yet given enough time that statement was ALWAYS going to be true, whether the treatment was reflexology or vanilla ice-cream.

Still, does it really matter? We know that roughly 30% of the population are susceptible to the placebo effect, and that the more dramatic an intervention is the stronger the effect becomes. So if your therapist believes it and you believe it, and you feel better afterwards where's the harm? Ben Goldacre in his excellent book Bad Science sites the economic theory of 'opportunity cost', i.e. irrespective of any financial outlay involved how much extra time do you spend experiencing your symptoms when they could have been more effectively be treated elsewhere, and what impact does this have on your ability to enjoy life, earn a living etc. I believe there is also a more serious repercussion of treating all claims of benefit, whatever their source as equal. That is the potential for someone who is experiencing a symptom such as Tinnitus to become locked into 'health seeking behaviour' and to identify themselves as a "Tinnitus Sufferer" long-term, going from treatment to treatment in search of the miracle cure with thoughts about Tinnitus taking up a disproportionate amount of their time, rather than learning to manage their condition effectively. This is often seen in people who naturally have a very external, rather than internal locus of control, i.e they feel change must be done to them rather than come from themselves.

By the application of critical appraisal and critical thinking skills we can begin to learn that all claims are not made equal and should not be given equal weight. This can make us less anxious that we are somehow missing out by not trying Ear Candles or laser therapy etc. and gradually empower us to become more confident in the decisions we make about our own healthcare.