Sunday, April 3, 2016

Does Appendicitis Need Surgery?

Some issues do not need to be studied.   For example, would we expect the National Institutes of Health to fund a study to determine if drivers wearing blindfolds have better outcomes?   In the past few weeks, the National Football League (NFL) has conceded that head trauma is linked to chronic traumatic encephalopathy (CTE), a fancy term that means brain damage.  Of course, there have been multiple studies that have examined this question.  And, in a nod to the tobacco companies, the NFL for too long failed to admit what any school child could have deduced.  Smashing your head several hundreds of times against the ground or another helmeted gladiator does not promote good brain health. 

Sometimes industries will cite their own ‘studies’ that astonishingly contradict what our intuition and common sense tell us should be true.  Would we accept the results, for example, of a movie industry  ‘study’ that extolled the health benefits of popcorn?

Sometimes, in medicine, we need a study to derail a standard treatment that is based on habit, rather than on medical evidence.  For decades, appendicitis has been treated with appendectomy, surgical removal of this finger-like structure at the uppermost portion of the large bowel.  Diverticulitis, a presumed infection of the colon, has been treated with antibiotics long before I became a doctor 30 years ago.  In the past few months, I have read expert opinions that challenge the embedded dogma of the treatment of these two diseases.

There is evidence and belief that appendicitis can be successfully treated with antibiotics, rather than surgery.  And, some authorities have suggested that diverticulitis may resolve on its own without antibiotic treatment. 

Appendix at bottom right

These were fascinating and refreshing new observations on old diseases.  So much of what we do in medicine is based on scant data and evidence.  Despite these lapses, these practices become the standard of care, leading patients and physicians to believe that there is firm underlying scientific support for them.  When my kids were small, most case of otitis, an ear infection, were treated with antibiotics.  Why?  Because that was how it was done.  Over time, this practice has changed.

Medical practice is an ocean liner whose direction cannot be easily or quickly changed.  Of course, we would not want a truly effective treatment to be abandoned on the basis of one study whose results may not be sound.  Conversely, it is difficult to cull the profession of established treatments that should have never become established in the first place.

Finally, just because there is no persuasive evidence that a treatment works, doesn’t make it quackery.  There’s plenty of stuff in medicine and in life that works well despite the absence of supportive data.  Sure, medicine is a science.  But it’s also an art.

If a sport requires that an athelete wears body armor and a helmet, then do we need a study to conclude that this head-smashing and bone-breaking activity isn't the best strategy to stay well?  

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