A new sandpit for long side discussions, idees fixes and so on. Unless directly responding to the OP, all discussions of nuclear power, MMT and conspiracy theories should be directed to sandpits (or, if none is open, message boards).
-
Follow
Following
Already have a WordPress.com account? Log in now.
John Quiggin 
Having acquired a recent a “tennis elbow” (lateral epicondylitis or tendonitis) injury I have had cause to think about the phrase “evidence based practice”.
I went to a physiotherapy practice (for the first time in my life) and was given various treatments and exercises. These seemed to be either useless or to even exacerbate the injury. At the same time, I cannot rule out the possibility that I made mistakes in carrying out the exercises and/or in not fully resting the elbow at other times.
A short visit to the Harvard Medical site reveals an opinion as follows about tennis elbow;
“Treatments abound, but what works?
Studies haven’t come to any firm conclusions about the management of tennis elbow. Many treatments relieve the pain, but in most cases only temporarily.. Sometimes the best approach is to simply give the elbow a rest.
A trial published in the British Medical Journal (Nov. 4, 2006) randomly assigned 128 patients with tennis elbow to receive six weeks of physical therapy, two corticosteroid injections, or a “wait and see” approach in which participants were told to modify their daily activities and use heat, cold, pain-relieving drugs, and braces as needed. At the end of the one-year follow-up, improvements in pain-free grip strength and overall pain were roughly equivalent in the physical therapy and “wait and see” groups, while the corticosteroid group was worse off — possibly because the rapid early reduction of pain led to increased activity and overuse.
Australian researchers examined 28 randomized clinical trials involving various nonsurgical interventions, including physical therapy, bandaging, steroid injections, ultrasound, and acupuncture. They found that the studies were either too brief or too poorly designed to shed any light on long-term outcomes — or even to support the short-term use of most treatments.”
To make a long story short. There doesn’t appear to be any reliable evidence that any treatment works for tennis elbow (other than resting it, not doing anything that hurts and waiting for it – possibly for a long time – to heal).
This raises the issue of how many claims for “evidence based practice”, even in the “trusted professions” with some scientific basis, are supportable? The next question is, how can the layperson possibly know? Physiotherapy would seem to have a scientific basis in anatomy, physiology and so on. This sets it in contradistinction to practices like chiropractic and homeopathy which are very clearly complete quackery with no scientific basis.
However, possessing an overall scientific basis for a discipline is no guarantee that every practice and treatment under that broad umbrella is evidence based. This would indicate that the layperson, whilst accepting the general validity of professions with a scientific basis must retain a kind of selective or provisional scepticism to apply in every practical instance of seeking and accepting treatment (all the while wondering whether he has the competence to judge anyway).
Then, if we apply the “evidence based practice” principle to economics, we would have to ask in the first case: Is economics a properly scientific or empirical discipline? The answer must clearly be NO. The layperson can see any number of conflicting opinions in economics (even orthodox economics) at any one time. The clear question is this. Why would the inquiring layperson place any trust whatsoever in economics and economists? The question of “evidence based practice” is tricky enough to resolve in relation to disciplines with a scientific basis. It would seem to be insuperable in relation to “disciplines” like economics.
Why would I not place economics with other quack disciplines like homeopathy? It might be excessive of me to couch the question this strongly. I wonder what others think.
That reminds me of a work friend who had a birthday party.
When asked how his birthday was, he replied: “It was OK, I got pool balls.”
I said: “Oh, is that like tennis elbow?”
Speaking of health issues and economics, RN has some good stuff and there is some of a transcript of Iona Heath’s talk.
“Iona Heath is a retired GP and immediate past president of the Royal College of General Practitioners in the UK. This is an edited extract of her speech, Too Much Medicine: Exploiting Fear for the Pursuit of Profit, delivered as part of the Sydney Ideas program.”
She says: “The systematic medicalisation of ordinary human distress has turned into an epidemic of disease-mongering, which actively inflates fear and plays on the resulting insecurity deliberately for financial gain.
“Fear also sells newspapers and so many journalists, and almost all editors, play their parts willingly. Benign symptoms are portrayed as serious disease, as in irritable bowel syndrome; personal or social problems are recast as medical ones, as in much mild depression; and risks are conceptualised as diseases, as in reduced bone density or raised blood pressure.
http://www.abc.net.au/radionational/programs/bigideas/too-much-medicine-exploiting-fear-for-the-pursuit-of-profit/6709098
The article that Julie links to mentions the difficulties of “any endeavour that takes general truths derived from large numbers of people and tries to apply them to a succession of unique individuals.”
Certainly, economics could plead a similar difficulty as in “any endeavour that takes general truths derived from large numbers of cases and tries to apply them to a new succession of unique cases.”
My question in my original post might seem disrespectful. “Why would I not place economics with other quack disciplines like homeopathy?”
But J.Q. himself posted a piece on this blog. “The state of macroeconomics: it all went wrong in 1958”.
In this light, my question perhaps does not look quite so impertinent. Now macroeconomics is not identical to economics. But there are also seems to be a lot of debate around the ridges about the validity of microeconomics. One could probably say that skepticism about orthodox economics is a lot more supportable that skepticism about Climate Change.
@Julie Thomas
That speech is something of a jeremiad, but how true is it? After all, it does start with the admission that people actually are living longer, healthier lives. Are people really more anxious about their health than they were in the past? And if they are, is the medico-pharma industry entirely, or mostly to blame? Dr Health makes those claims, but doesn’t provide any evidence to back them up.
In my (admittedly) anecdotal experience, skepticism about big pharma and conventional medicine doesn’t appear to do too much to relieve health-related fear; on the contrary, skeptics of conventional medicine often have a range of even more poorly founded fears about their health (such as an exaggerated concern about household chemicals and non-organically farmed foods, for example).
I could be wrong of course 😉 , but I think Dr Heath is rather overstating the case. I do agree with her, though, that media alarmism is responsible for a lot of unwarranted fear about health.
@Julie Thomas
Aargh. Dr Heath, obviously.
@Ikonoclast
I had ultrasound therapy on my tennis elbow and I am still dubious about whether it did anything. I was also given a forearm strap to prevent aggravation of the inflamed tissue when I unavoidably used my hand and arm. That did seem to work. No idea if it’s been peer-reviewed, but the biomechanical logic behind it seemed sound.
I remember reading somewhere in an article about evidence-based medicine that no-one had ever done a double-blind study on the practice of setting a broken bone. I guess randomised trials are more important when the basis for the treatment is not so immediately obvious. All treatments should have critical evaluation, of course, even the ones that seem obviously useful.
@Tim Macknay
That was the only criticism that I heard during the discussion following the speech; that she overstated the case somewhat. So?
But yeah, I don’t see high levels of fear in people about their health, it’s more of a low level anxiety about things that could happen to them and a resignation or acceptance that whatever is wrong with needs to be fixed by drugs and a misplaced confidence in the ability of doctors to ‘care’ for therm and to be able to diagnose accurately and in the efficacy of drugs they are prescribed.
I have not experienced the people that you describe in your anecdote though.
I live in a small town in a broad acre farming area. I am pretty much the only greenie in the village so I have very few neighbours who are worried about pestcides or chemicals or even climate change.
Do you fear and worry about the ‘far-out’ left who have these so totally exaggerated fears about chemicals in their food?
Most of the people I know, including my right wing red neck neighbours – who are currently posting fear filled warnings about Halal labelling – and my far-out hippie lefties friends are more worried about the lack of nutrients in the food that is available. Broad acre farmers cannot grow their vegetables or fruit! just wheat and sorghum.
As for organic farming, I think some of the younger farmers maybe turning slightly green and are actually looking at the benefits that could come from this revolutionary thinking in agriculture. The number of solar panel arrays beside the dams just this last year is impressive and would suggest that there is a lessening of the hysteria against re-newables.
@Ikonoclast
I developed tennis elbow soon after transferring from squash to tennis and an older lady told me to use an elastic support band around my upper fore-arm. This seemed odd to me as the pain was over the elbow itself but after a few weeks of using it the pain went away.
@Julie Thomas
Not really. It’s tragic, of course, when someone with cancer decides to eschew conventional treatment in favour of an alternative that’s essentially imaginary, and loses their life as a result. But the only real concern I have about skeptics of conventional medicine is the increased risk to children caused by undervaccination. I live in an inner-city suburb with one of the lowest vaccination rates in the country – so low that it’s dropped below herd immunity for conditions like whooping cough, which can be fatal to young children. In order to try to address this issue there’s a campaign around my neighbourhood with posters carrying slogans like “I breastfeed, I grow organic vegetables, and I immunise”, and so forth.
I’ve never thought of an anti conventional medicine stance as being a particularly left wing thing, although most of the ‘far-out hippie’ people in my neighbourhood (including me) could probably be described as centre left or left (I don’t generally think of myself as being a ‘far out hippie’ BTW, but I have been described that way by others on occasion).
I prefer to buy organic produce for the most part, because in my opinion it (mostly) has a lesser environmental impact than conventional produce. I generally buy plant-based household cleaning products for the same reason. There’s no real evidence that organic food is healthier or safer than conventionally produced food, though. Both kinds are generally OK.
@Salient Green
Sounds very similar to the strap that the physio gave me.
I believe so Tim. Your post prompted me to add my experience which was also backed up by the experience of the older lady who told me about it. Mine was a simple elasticised tube around 100 mm long and I only wore it while using a racquet.
Tim and Salient Green, I take your points but so far as I can find out from reputable sources there is no firm evidence that any treatments work for lateral epicondylitis.
It’s interesting to me that the practice I went to makes an explicit claim to be an evidence based practice. Yet they offered me treatments which have no evidence to support them. This I only discovered afterwards as I began to check after wondering why my injury was only feeling worse.
It seems now there is no evidence to support icing injuries either. This from the guy who virtually institutionalized icing in the RICE method.
http://drmirkin.com/fitness/why-ice-delays-recovery.html
@Tim Macknay
Very good, but I am still wondering why you needed to point out to me that the accurate and insightful talk by the UK doctor was a jeremiad.
The distress and poor health suffered by my neighbours is more a function of the appalling food ‘choices’ they make than any problems coming from over servicing by doctors and other health professionals.
These people are not living longer and if they do the last years of their lives are not what I would want for my final years.
“The food system isn’t just broken. It’s killing us.” – Australian Food Sovereignty Alliance.
Not sure why they have word “sovereignty” in there. I hope it isn’t nationalistic or jingoistic. But they are right. Our over-industrialised world food system is broken and it is killing us. Gains in medicine and other areas are being lost to food-induced diseases.
@Julie Thomas
Well, that’s the thing, Julie. What’s the basis for saying that her talk was insightful and accurate? How do we know it’s accurate? It seems to me that if it isn’t accurate, it isn’t particularly insightful either (or at least considerably less insightful).
You mentioned before that one response to Dr Heath’s speech was that she overstated her case. My remark to that effect was a deliberate understatement – I don’t think she made her case at all. She just made assertions, but didn’t provide any evidence to back it up.
Now I’m perfectly prepared to accept that it’s entirely possible she’s right, and that people are experiencing increased and unnecessary anxiety about their health, due to overdiagnosis, ultimately driven by commercial considerations. But her speech didn’t give me any reason to suppose that she’s right. There are alternative hypotheses, which could also be true, such as that people are no more or less anxious about their health than they used to be, or that people are more anxious, but they have reason to be, because of the increase in obesity-related health problems at Ikon alludes to, for example. I guess I’m just a little bit allergic to sweeping statements made without evidence. That’s just me, though.
@Tim Macknay
Not so much these days, but it certainly was 40-odd years ago. (Speaking as one who, at the time, drank the hippie kool-aid.)
@Ikonoclast
Yeah, I’ve read that ice treatment has been more-or-less shown not to work, as well. It’s a murky world out there.
@David Irving (no relation)
I wasn’t around then, but I get the impression that back in the ’60s medicine was a lot more high-handed than it is today. In the wake of things like the thalidomide scandal, a strong reaction against conventional medicine was understandable I think, even if ultimately misguided. Suspicion of vaccines has been around for a long time, but again, it was understandable, to a degree, after Andrew Wakefield’s research was published. Of course, that work has been entirely discredited.
@Tim Macknay
Are you sure you listened to the same speech that I did? And the discussion after? I did only listen to it once and I’m by no means an expert on the physical aspects of medicine but I was impressed by what she said and usually when I find my self impressed with what someone says, it is because what they say fits with my experience of the world as I conceptualise it.
So you have your equally valid experience of the world in which you think nothing she said was worth noting. The point that I wanted to be sure you were not making was that I was over excited and a bit fluffy perhaps in linking to the woman and her speech.
It must be the case that all the evidence I thought she presented to support her ‘sweeping statements’ was not evidence at all. I will try and be as understated as possible in future so as not to cause your allergies to flare up.
I fear that to do that, I might have to go the doctor to get more anti-anxiety medication to be able to restrain my tendencies to link to silly articles.
@David Irving (no relation)
I don’t remember it as being anti-medicine so much as an attitude and a belief that we could do better than the medical fraternity. Several of my earliest hippie friends in the late 60’s were med students – a couple of whom made LSD in the labs at UQ or so they claimed.
But there were many many different types of hippie cool-aid; the ones to avoid I found were the ones who insisted that they were better people than the straights. It was so frustrating to hear these people railing against the awful people who wanted to make everyone live by their rules and then they would have and create increasingly strict rules about how people in their community were allowed to live.
@Julie Thomas
No, I only read the abridged version of the speech online. If there was a lot of evidence presented in the full version that was not mentioned in the online abridged transcript, then my interpretation of the speech would be mistaken and require revision. I’ll endeavour to listen to the full speech when I get the chance.
That also happens to me, and in fact I did find Dr Heath’s speech (at least the abridged version I read) to have a lot of intuitive appeal. I guess I don’t entirely trust my own intuition when it comes to general claims about the society and the world at large, so I prefer a claim to be supported by some kind of data before I’ll accept it, even if I find it intuitively appealing.
Julie, that’s not an accurate characterisation of what I think, and I don’t believe it’s a fair one, based on what I wrote. I think she didn’t make her case because the foundational claim, that people are experiencing increased health anxiety, wasn’t supported by evidence. That’s not the same thing as saying that nothing she said was worth noting.
I certainly hope you don’t think that is a point I was trying to make, because it was not. If you could point out what I wrote that gave you that impression, I’ll consider it (sincerely), because if what I wrote did give you that impression, it was a fault in expression on my part.
To clarify, what I meant by evidence was a reference to studies, or data, showing that anxiety over health was on the rise or had risen. There was nothing like that in the abridged transcript, although it’s of course possible that there was evidence presented in the full version of the speech, in which case my statement about it doesn’t stand.
I’m sorry if I offended you. It was genuinely not my intention.
@Julie Thomas
Heh. Back in the day, I had a friend who, I can attest, was a very gifted chemist. Unfortunately, the last time I heard of him he was addicted to skag. I doubt if he’s still alive.
@Tim Macknay
Whatever.
You mistake me for someone who does get offended. I’m not allergic to much either.
Probably the scent of a patronising man is my biggest problem these days and I realise I should be over that because these days men are all re-constructed feminists, So I should apologise to you but only if apologising is something I can do that will not raise your allergy levels.
If it is not appropriate to apologise and/or if I have offended you by suggesting that you might have been patronising me then I will be sorry – very sorry – if that helps.
Have you been tested to find out the range of allergies from which you suffer?
I can imagine that it is not a pleasant experience to be so sensitive to “sweeping statements made without evidence”. I can recommend mindfulness if you want to help yourself fit in with those of us who can’t tell a sweeping statement from an interesting talk.
@David Irving (no relation)
There was a neuroscientist on RN today who has written a book in which he describes the way he understands addiction from his “personal experience of insatiable drug taking, and a controversial yet compassionate perspective from a physician suggesting that the main source of addiction is not to be found in genes – but in the childhood environment.”
I got to know quite a few heroin addicts during the years I lived an alternative life and of course other drugs and drug takers and what he says seems to me to be very insightful and accurate.
Should I put a possible sweeping statement alert out for this talk? Or shall we get over it and move on or possibly people could just ignore me if I offend with my lack of precision? So many alternatives available to avoid unnecessary conflict or is conflict, like war, a good thing?
@Julie Thomas
That sounds interesting. I’ll seek it out.
@Julie Thomas
I interpreted the snark in your last comment as an indication of offence. But it’s hard to tell in a text-only medium, and you are particularly adroit in your use of snark, so I wasn’t sure.
The apology is accepted, but was not necessary. I have many allergies (of the psychological kind), but I fear, like Ikon and his tennis elbow, that the methods for testing them may not be reliable. I agree that mindfulness can help, although I find that with mental allergies it’s more of a management technique than a cure. I also do sometimes wonder about the evidence…
@Julie Thomas
I agree we should get over it. But are you sure you’re ready? 😉
@Julie Thomas
But seriously, that does sound interesting.
@Tim Macknay
Snark? Please, context is everything.
If you went to the social events that I have to go to among my neighbours who make jokes about those sad arse men who have thumbprints on top of their heads and – I didn’t even get that joke – you might understand that my readiness and ability to get over stuff men do is fcking awesome.
OK. So why the snark, then?
@Tim Macknay
You keep seeing snark and I think I keep telling you this conceptualisation of what I do – the way I respond to certain stimuli in my environment – is to ‘not’ take offence or snark.
You seem to have come to the conclusion that I do snark so well it doesn’t look like snark but it must be snark, even though you are not sure it is snark.
Now I’m confused, but as I freely admit to anyone who cares, I am often and always have been confused about why people including myself do the things that they do.
If you want an explanation of why I sometimes respond in a way that looks to you like snark, I can’t self-analyse on demand. I’ll think about it but I usually never manage to come to any definite conclusion when I think about things that I do and wonder why I do them.
I tend to become even more confused and I feel like I am the stupid person in that old joke – often it is an Irishman – who is put in a barrel and told to piss in the corner.
Do you have any hypotheses?
Is China going to blow our house down? The Chinese government cut interest rates, and is encouraging/coercing more lending activity. There is a big bubble of air in their stock markets, if the economic commentators are to be believed, so are we looking at some real economic disruption ahead, or is it something the Chinese government can essentially correct through systematic intervention? It sure looks wobbly from here.
At least one writer has made the comparison with the October jitters in 1929’s Wall Street Crash, the harbinger of the Great Depression. Any economists here care to expound and explain what they think might shake out?
@Julie Thomas
The comments that came across to me as snark were the ones about not wanting to raise my ‘allergy levels’, my ‘sensitivity to sweeping statements’ and assisting me to ‘fit in’ with people who ‘can’t tell a sweeping statement from an interesting talk’. They don’t seem snarky to you? When I said I wasn’t sure, I meant I wasn’t sure if you were offended, not that I wasn’t sure if it was snark.
Anyway, one thing this exchange has illustrated pretty clearly to me is that we can’t control how other people interpret what we say or write. You can make statements, not intending them to be snark, which others may nonetheless interpret as snarky. I can consciously try to avoid saying or writing things that are patronising, sexist or which make unwarranted assumptions about people, but others may nonetheless take statements I make to be patronising, sexist and casting aspersions on them.
You asked for a hypothesis. To be honest, I’m a little hesitant to speculate about what motivates other people to say or do things, particularly when they’re people I’ve never met. But since you asked, here goes. My guess is that the snark is part of a toolkit you’ve developed to respond to being patronised and underestimated because you’re a woman. It’s pretty effective – I recall not that long ago on this blog some clown undergoing a spectacular meltdown with a sort of seventies, gold medallion flavour to it after an exchange with you. I could practically see the guy’s forearms lengthen, his forehead recede and his knuckles press into the ground before my eyes.
However, evidently, my comment about the Dr Heath speech was close enough in resemblance to some kind of half-witted attempt at intellectual dominance to have the aroma of patronising man to you. Looking back I can see I used words like ‘evidence’ and ‘intuition’ in a couple of places- enough, maybe, to raise the spectre of the old stuff about men being rational and women emoting etcetera blah de blah, if you’re sensitised to it. Hence your suspicion that I was accusing you of being ‘over excited and fluffy’. Sorry if this is all terribly obvious, it takes time for me to work through these things.
But the relative persuasiveness of the Dr Heath speech is something I sincerely believe that reasonable people can disagree about!
Some of those sentences may not quite make sense – typing on an iPad; hard to edit.
@Donald Oats
I’m not an economist, but I strongly recommend looking at “the automatic earth” generally, and this post in particular.
They seem to me (having lurked there for years) to “get it” and have a lot of thoughts about where this spectacular bubble-pop may end up.
IMHO their opinions are at least, and probably far more, as worthy of consideration as anything from our “establishment”.
Ooooops!!
Forgot the eternal no-free-speech-but-please-link-to-dodgy-Turkish-websites-moderation.
Reply to Donald at #34:
I’m not an economist, but I strongly recommend looking at “the automatic earth” generally, and this post in particular.
They seem to me (having lurked there for years) to “get it” and have a lot of thoughts about where this spectacular bubble-pop may end up.
IMHO their opinions are at least, and probably far more, as worthy of consideration as anything from our “establishment”.
@Tim Macknay
“However, evidently, my comment about the Dr Heath speech was close enough in resemblance to some kind of half-witted attempt at intellectual dominance to have the aroma of patronising man to you. ”
Yes, there is new evidence that supports the obvious, that women who have lived most of their lives around unreconstructed and violent men, verbal or physical can suffer from ptsd.
It was not any specific words you used, though or perhaps the jerimiah one was significant, it seems to me that it was the fact that you responded negatively that was unexpected, appeared unfair and not a response to me as an individual but as a member of a class of people who are flaky and might need to be set back on the right path to rationality.
Perhaps my ‘latest’ defence mechanism – in my search to find a way to live with dignity among the patriarchs – is to put any person who responds to me as a flaky woman in this category and the most functional way of interacting with both old fashioned patriarchs and the libertarian patriarchs, for me and them, is to adopt a “tragically flip”? attitude that puts the onus or responsibility on the patriarch to examine their own words and behaviour in a different context.
There is no doubt that we could disagree about Dr Heath and her macro view of what is wrong with medicine. I suspect or know that I come from a very rare perspective on the benefits of medicine; that of someone who has never had any physical health problems. My mother is mid eighties and still lives alone in her own house, plants her own trees, mows her own grass and won’t go to the pensioner’s groups because she hates old people.
We all have very good genes for physical health in my family and my belief in the wrongness of modern medicine is of course founded in this context.
@Julie Thomas
Very fortunate about the good genes. I don’t have any significant physical health problems, although I am a bit prone to chest infections. I’ve noticed that insurance companies tend to focus in on that. Epilepsy and breast cancer both run in my family, although fortunately for me I am not personally afflicted by either of them.
@Donald Oats
Donald and Megan: The Grauniad has an interesting graphic that shows estimates of the costs to various countries of the Chinese downturn. Australia is estimated to cop 1.4% of GDP.
http://www.theguardian.com/world/ng-interactive/2015/aug/26/china-economic-slowdown-world-imports
@Donald Oats
Trying again sans link…
Donald and Megan: The Grauniad has an interesting graphic that shows estimates of the costs to various countries of the Chinese downturn. Australia is estimated to cop 1.4% of GDP. I won’t link to it ‘cos automod.
Alex Kidman has an article on the NBN difficulties, especially the question as to what they have bought with respect to choosing the copper network for the last leg. My personal experience, and that of a few other people I know, is that getting broadband speed on copper is like betting on a recently injured marathoner: perhaps they’ll make the distance, or perhaps they’ll fade in and out, eventually pulling out of the race altogether.
Australia spent $40 million dollars to ensure that 4 refugees didn’t come to Australia.
Actually, it’s much more than that because that was just the bribe to Cambodia. We are also paying for all their costs there and we spent billions to create the system that spat out those 4.
This is stupid and cruel.
And, in any case, Cambodia says there won’t be any more.