Fake Surgery
Robert E. Horseman, DDS
The scene: A dental patient presents with complaint of “twinges,” periodic episodes of “discomfort” and a strong conviction that he has a “cavity.” The dentist, after a careful examination consisting of murmuring h-m-m-m-m and wearing a frowny expression, determines that as far as he is concerned there is nothing visually or radiographically wrong with any of the teeth. However, he elects not to disappoint the patient or get into an argument, so he activates the PE (placebo effect) sequence as outlined in Krautzmeyer, J., “The Dynamics of White Lies.” Psychiatric Odontology. New York: McGraw-Hill, 1989.
Medium shot: Doctor and assistant busy themselves with the necessary paraphernalia and armamentaria. The area is anesthetized, lights positioned and the volume of the tastefully annoying elevator music is adjusted to a level just slightly over that of the annoying handpiece whine of 120 decibels.
Closeup: Head of handpiece with bur in place is centered over target tooth and is activated at 350,000 RPM. Appropriate sounds emanate from it and from the assistant’s vacuum hose as the camera zooms in tight to reveal the shank of the bur running against a cusp of the tooth. Cutting blades do not engage tooth structure.
Medium closeup: After suitable period of standard cavity prep busyness involving much vibration and 4-handed activity, but no actual tooth reduction, the matrix is applied. Tooth is “restored” while a running commentary by doctor and assistant reading teleprompters just out of camera range convince the patient he is in better hands than All State.
Wide angle: Patient is dismissed with stern warning not to chew on that side for four hours and cautioned against shocking tooth with cold things for perhaps 8 or 9 years. A prescription for post-operative pain is given.
Closeup: Grateful patient offers endearing lopsided smile and congratulates dental team on a fine, painless job. Fade to black.
THE END (not quite)
As far as we know, the above scenario has never happened, but a report published recently in the New England Journal of Medicine gives rise to speculation that medicine is on the verge of another one of its periodic discoveries. And whither goeth medicine, so goeth dentistry, goeth the old saying.
This particular breakthrough involves the introduction of fake surgery, ostensibly to prove that the placebo effect is alive and well and not nearly so messy. Briefly, the situation is this: arthroscopic knee surgery as performed on some 300,000 Americans each year simply doesn’t work. Its popularity stems from the fact that it is minimally invasive and requires little or no recovery time.
How do we know that it doesn’t work? “Sham surgery,“ that’s how. Clever doctors, many of whom have knees of their own, ran through a rarely used, but extremely effective test. With straight faces that would serve to advantage in any high-stake poker game, they randomly assigned some patients to undergo regular arthroscopic surgery while others went through a scene as convincing as any episode of ER.
This latter group was sedated and given superficial incisions to mimic the real thing. To the accompaniment of authentic operating room noises and doctor/nurse chitchat, the patients were patched up and sent home.
Two years later, 35% of the total of the two groups reported that they experienced less pain and were definitely more ambulatory. This was whether they had had the surgery or not! It was the conclusion of the doctors that surgery worked no better and sometimes not even as good as the placebo, or sham surgery. Nelda Wray, chief of general medicine at Veterans Affairs Medical Center in Houston says, “This casts grave doubt on the procedure.”
You can say that again, Nelda. One can assume that the faux surgery group, particularly those who experienced no relief whatsoever, might have some grave doubts of their own. “Wait a minute,” they might say, “We have some grave doubts here. These incisions for example---fake?
“Yep.”
“And the scars?”
“No, they’re real.”
“My knee still hurts.”
“That’s real, too.”
“And the bill for $5,000?”
“Oh, that’s real as well. Tell you what, for not actually going into the knee joint, we’ll knock off $75.”
“Thanks. I did enjoy the drama. I’ll check in with you again when I think I need some brain surgery.”
For those whiny patients who just won’t let go of the knee pain thing, there’s one other recourse—total knee replacement. Doctors think the operation is up to 90% effective. Or maybe not. We shudder to imagine how this might be faked.
It is difficult to believe that such placebo shenanigans actually took place. Perhaps this is one instance where dentistry should not follow medicine. Think of what the National Enquirer could do with a “Sham Dentistry” story!
Originally published in the Journal of the California Dental Association, 07/02.