These are the kinds of stories I love. A study published in the New England Journal of Medicine examined the relative outcomes of arthroscopic surgery for a partial tear of the meniscus (cartilage under the kneecap) versus a fake surgery for the condition. (NEJM Article) The procedure is used to reduce the pain associated with this condition, which may reduce mobility. Over 700,000 are performed annually in the United States, at a cost of $4 billion. Prevalence has increased 50% in the last 15 years. The study was conducted at five clinics in Finland among patients 35 to 65 years old. All had a diagnostic arthroscopic procedure and during that procedure the surgeon was randomly told whether or not to do the surgery. For patients having the sham surgery, the physician went through all the usual procedures but did not actually remove torn tissue and repair damage. The patient was not told whether or not they had surgery, although they had consented either way. Follow-up care was identical in the two groups. Outcomes were knee pain and use of the Lysholm knee score and WOMET quality-of-life instrument, which evaluate knee functionality. Followup continued for 12 months. Both groups showed significant improvement, but there was no difference between the two groups. On questioning, patients did not show an ability to recognize whether or not they had real or sham surgery.
There are several lessons from this kind of research. One, the mind is a powerful tool in health care. If you believe something can help, it is more likely to do so. That may partly account for the results of this study, because many patients might have believed they had surgery who didn’t. Two, doctors, particularly surgeons, will persist in doing procedures despite skepticism about benefit, because frankly, like the rest of us, they are economic creatures and consciously or sub-consciously, they will engage in activities that raise their financial well-being. Finally, patients need to be patient. They need to be engaged in understanding their treatment options and they need to be encouraged to understand that often it is best and less risky to take the conservative option. The body does have an extensive and impressive ability to heal itself. And while our headline is intended to be ironic, at best, don’t be surprised if some surgeons suggest that fake surgery is a beneficial treatment and should be used and paid for.