Can we trust clinicians’ perceptions about the benefits and harms of surgical interventions? A new study out today suggests not.

A steady increase in the diagnosis of tongue-tie in babies continues.

A tongue is tied when the tissue (frenulum) connecting the underside of the tongue to the floor of the mouth compromises tongue mobility.

Some health care providers claim that as many as 50% of the babies they see have this congenital anomaly.

Surgery to restore optimal tongue movement involves either cutting with scissors or lasering the lingual frenulum or the upper lip frenulum (the tissue connecting the inside of the lip with the gum). These procedures are frequently performed with the intention of helping more babies to breastfeed successfully.

There is little reliable evidence surrounding the whole topic of tongue-tie, a lack of appropriate screening for the condition, no standardised approach to treatment procedures, and no credible analysis of the existing data.

Is surgical intervention always appropriate?

A new study published today raises doubts about whether we can trust clinicians’ perceptions about the benefits and harms of surgical interventions.¹

In a systematic review of 48 studies (13 011 clinicians) carried out in 17 countries, Australian Doctors Hoffman and Del Mar ask whether clinicians have accurate expectations of the benefits and harms of a wide variety of treatments, tests, and screening tests.

Using a comprehensive search strategy, the researchers systematically reviewed and independently evaluated all studies that had quantitatively assessed clinicians’ expectations of the benefits and/or harms of any treatment, test, or screening test.

They concluded that clinicians rarely had accurate expectations of either benefits or harms and that they more often underestimated harms and overestimated benefits. In fact, they discovered that doctors are pretty bad when it comes to making such estimations, and this is likely to result in their making suboptimal management choices.

• For studies comparing benefit expectations, 50% or more of clinicians provided a correct estimate for only three of 28 outcomes (11%).
• For studies that provided overestimation or underestimation data (22 outcomes), 50% or more of doctors overestimated benefit for seven outcomes (32%) and underestimated benefit for two outcomes (9%).
• For studies comparing expectations of harm, most doctors correctly estimated harm for only nine of 69 outcomes (13%). Most doctors underestimated harm for 20 (34%) and overestimated harm for three (5%) of the 58 outcomes.

Reporting on the study in today’s Guardian, Ranjana Srivastava refers to unnecessary and expensive treatment being at an all-time high, with the usual reasons given:

patient expectations, financial incentives, therapeutic uncertainty, medico-legal fears and the sustenance of hope.

Inaccurate clinician expectations of the benefits and harms of interventions can have a drastic influence on decision making by the clinician and the patient (or his guardian) and may be contributing to overuse of interventions which won’t help and may well do harm.

Hoffmann and Del Mar note:

The finding of more instances of clinicians underestimating harms and overestimating benefits than the opposite provides some support for the existence of therapeutic illusion (‘an unjustified enthusiasm for treatment on the part of both doctors and patients’), which is a proposed contributor to the inappropriate use of interventions. 

In their earlier research Hoffmann and Del Mar found that patients also have inaccurate expectations, and most people think that interventions will help more and harm less than they actually do.²

Following the latest review, Dr. Hoffmann said:

When both the clinician and patient bring inaccurate expectations into the consultation, then the potential for misguided, ill-informed decisions is very high.

I shall not speculate on when, whether, or to what degree, tongues need snipping. I observe that some health care workers regard the efficacy of certain tongue-tie procedures as doubtful.

I do not have the answer to the question posed in the title to this post, but I think it is a question that deserves consideration.

In the meantime, this is just another call for caution.

References

1. Hoffmann TC, Del Mar C. Clinicians’ expectations of the benefits and harms of treatments, screening and tests: A systematic review. JAMA Intern Med. 2017 Jan 9. doi:10.1001/jamainternmed.2016.8254.

2. Hoffmann TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests: A systematic review. JAMA Intern Med. 2015 Feb;175(2):274–286. doi: 10.1001/jamainternmed.2014.6016.

Braithwaite, J. (2014). The medical miracles delusion. Journal of the Royal Society of Medicine, 107(3), 92–93. doi:10.1177/0141076814523951

And see Tongue-Tie Politics of Breastfeeding 

Always Ask Questions: Don’t Let Your Tongue Be Tied

PHOTO: GrassRoots Photography by Janet Fotheringham

May 20, 2017: ‘Many operations more harmful than beneficial’ Too many surgeons are performing operations that are likely to do more harm than good, a leading surgeon says.