Natural History vs Clinical Evidence

This is a topic that I have blogged about so many times, but it came up for me with a patient I looked at a few weeks ago. The previous posts included topics like: But…but…it worked for me!, Anecdotes are not evidence, and Why Ineffective Treatments Sometimes Work. I won’t be litigating all those issues again here.

I never cease to be amazed just how many people are more trusting of anonymous anecdotes from fellow sufferers of conditions than they are of evidence-based health professionals. From time to time I hang out in social media groups of people who have a particular condition (eg comments here on a plantar fasciitis support group). So many seem to be so accepting of this advice from well-meaning people who can not be held legally accountable for the advice if it goes wrong or does not work. Health professionals who are licensed/regulated can be held accountable.

Often you see advice that is just not plausible. There is no mechanical, physiological or whatever mechanism that the treatment or advice being given can actually work. Yet you see it recommended and you see people advocate for it and claim it cured them. Yet you know that there is no way that it could or would have worked.

The most recent patient that brought this to my attention in a big way was not initially a patient. I was actually treating her mother for an ingrown toenail. The 11 year old daughter came in with her as her heel was too painful for her to go to school that day. While treating the mother I enquired why she was not at school. Pretty obvious to me that it was calcaneal apophysitis (Severs disease). This was on a Thursday; I was too busy to look and assess her properly then or do anything, so made an appointment for her to come back Monday for a proper consultation. Monday came around, she was back to school and the pain was 70-80% better. I had done nothing. They had done nothing. The pain had just naturally improved as part of the natural history of the condition.

What would have happened if they had followed some really bad online advice on the Thursday? Or if I had actually treated them with an effective treatment (or even an ineffective treatment)? No matter what, they were going to get better. Whatever was done on the Thursday would have been credited as the reason no matter what. Imagine trying to convince them that it wasn’t the treatment, but was just the natural history. Thats not going to happen. They are going to turn into an advocate for that intervention when it may or may not be effective. Can you see where this is heading?

This is why proper clinical trials are needed, so that we know a particular intervention is better than doing nothing or better than a placebo or better than the natural history.

This is also why there needs to be a better teaching of critical thinking skills and science education so that the general public (and some health professionals) understand these issues (and do not send me hate mail for pointing out that a particular intervention for calcaneal apophysitis/severs disease does not work and can not work and the reason it appears to work is because of placebo or natural history!) and are more understanding of advice for interventions that have been shown to actually work.

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