Tonsillectomy Confidential

I wrote a piece for Boing Boing about tonsillectomies that has just been posted. It stemmed from a comment on this blog by a woman named Rachael. A doctor said her son should have a tonsillectomy. When Rachael did her own research, however, it seemed to her that the risks outweighed the benefits. I looked further into tonsillectomies and found that the risks were routinely greatly understated, even by advocates of evidence-based medicine.

More Here is a page on a doctor-run website called MedicineNet that grossly understates the risks of tonsillectomies. Compare their list of possible bad effects to mine.

23 Responses to “Tonsillectomy Confidential”

  1. threepipeproblem Says:

    Link is broken. Should be

    http://boingboing.net/2012/01/10/tonsillectomy-confidential-do.html

  2. Seth Roberts Says:

    Thanks, link fixed.

  3. ck Says:

    Are there analogous risks/benefits to be found for appendectomy?

  4. ck Says:

    I’d like to expand a little on my comment above “Are there analogous risks/benefits to be found for appendectomy?”:

    WIkipedia mentions that the appendix could play a role in immune function, in particular in maintaining the gut flora.

    Like tonsillectomy, appendectomy also has been a routine operation (I have been told that many doctors used to remove the appendix of their own children per laparoscopy at an early age). Unlike tonsillectomy, appendectomy can be strongly indicated, that is in case of acute appendicitis.

    It would be interesting to know if people who had their appendix removed show signs of lowered immune function or have an increased risk of gut diseases.

  5. jeff borsato Says:

    enjoy the blog on a daily basis, but Seth, please note the response from the folks at my other fav blog Science Based Medicine, they pose some reasonable questions that would be interesting as a f/u piece..

    http://www.sciencebasedmedicine.org/index.php/tonsillectomy-indications-and-complications/#more-18655

  6. SB Says:

    Great article – thank you for writing it.

  7. Tuck Says:

    The blog “Science-Based Medicine” posts a rebuttal to this post here:

    http://www.sciencebasedmedicine.org/index.php/tonsillectomy-indications-and-complications/

    I find their rebuttal less than convincing, but judge for yourself.

    Science-based medicine purports to be more scientific than evidence-based medicine, but is still not quite scientific medicine, sadly.

  8. Jim Purdy Says:

    Your Boing Boing article is fascinating, especially the many correlations between tonsillectomies and various health problems.

    Here’s a correlation that I’ve noticed: The more doctors I see, the more drugs and surgeries they say that I need. In 2010, I had two very unpleasant interactions with medical professionals.

    First, in early 2010, orthopedic surgeons told me that I would die unless they amputated my right leg because of a severe diabetic ulcer; I did not have the amputation, and my leg healed fine.

    Then a few months later, cardiologists told me that I could die at any moment unless they did quadruple coronary artery bypasses. I did not have any bypasses, and I have no chest discomfort as long as I avoid very large meals. Heart problems? Maybe, but perhaps a hiatal hernia, or GERD.

    But I learned two lessons:
    1. Stay away from orthopedic surgeons if you want to keep your limbs intact.
    2. Stay away from cardiovascular surgeons if you want to keep your heart intact.

    As a rule, I give my body time to heal itself using natural defenses that developed over many millions of years of Darwinian evolution. As a result, many doctors have called me crazy and suicidal. And I call those doctors (expletive deleted).

  9. Seth Roberts Says:

    Thanks. I have posted a reply to that post. Not yet approved. Here it is:

    There are many factual mistakes in your comment on my article.

    1. “Roberts displays a persistent bias toward downplaying the benefits and exaggerating the risks of tonsillectomy while accusing the medical establishment of doing the exact opposite.” I do not say that the Cochrane reviewers exaggerate the benefits of tonsillectomies. Your post does not contain a single example where I say the medical establishment exaggerates the benefits.

    2. “Roberts fails to mention that the benefit described above – one fewer sore throat – was for the mild group only.” That’s wrong. I do mention it. Rachael’s son would have been in the mild group. I wrote “(two instead of three for children like Rachael’s son)”.

    3. “In his article Roberts assumes that the only indication as a preventive measure for tonsillectomy is for recurrent sore throats.” Nowhere do I assume that. You give no examples.

    4. “while not understanding the evidence.” I failed to find any examples in your post of my “not understanding the evidence.” I omitted some of the evidence for benefit because that was not the main point of my post. Omission of evidence does not equal misunderstanding of evidence.

    5. “Roberts accuses physicians of ignoring relevant information about tonsillectomy, but he ignores published practice guidelines that look much more deeply into the issue than is reflected in his analysis.” I said that doctors ignore relevant information about tonsillectomies when making statements to parents about the risks of tonsillectomies. For example, they fail to tell parents that tonsils are part of the immune system. What you say about practice guidelines does not contradict that.

    6. “Roberts engages in very simplistic reasoning – the tonsils are part of the immune system, removing them therefore compromises immune function and is a bad idea.” Because tonsils are part of the immune system, removing them runs a considerable risk of compromising immune function, just as removing part of the brain runs a considerable risk of causing brain damage. I say this in the post. It is common sense.

    7. “He ignores the fact that those tonsils that are removed are unhealthy.” What you call a “fact” is not a fact — it is a theory. As you say yourself in the next sentence (“perhaps they have become counterproductive”).

    8. The “summary of current thinking” is a theory of unknown validity. By failing to say this, you overstate your case.

    9. “There are no studies to date that demonstrate a significant clinical impact of tonsillectomy on the immune system.” Since practitioners of evidence-based medicine refuse to take seriously evidence that doesn’t come from a placebo-controlled double-blind experiment, there will surely never be — for ethical reasons — a study that “demonstrates a significant clinical impact of tonsillectomy on the immune system.” To say that one’s point is supported by the absence of evidence that cannot exist is not serious argument.

    10. “Roberts’ endorsement of the naturopathic approach to chronic sore throats. . . . he then offers as an alternative that is blatantly not evidence-based.” I suggest you look further at the Vitamin D evidence I link to. There is evidence that Vitamin D supplementation helps. Rachael searched for evidence. My post includes a long paragraph about her search. To call what she did “blatantly not evidence-based” is like saying white is black.

    11. A biased view of evidence is shown by the following which you quote approvingly: “However, available scientific evidence does not support claims that larch bark is effective in treating cancer or any other disease in humans. Early laboratory evidence suggested that larch arabinogalactan may stimulate the immune system. However, a more recent study in mice contradicts this finding.” In other words, there is some evidence supporting the value of larch bark (“early laboratory evidence”) and some evidence (“a more recent study in mice”) not supporting the value of larch bark. Given this, to say “available scientific evidence does not support claims . . .” is false. An accurate statement is that some evidence does and some evidence doesn’t.

    12. You recommend “summaries of the evidence prepared for the non-expert.” The Cochrane review that I discuss included a summary of the evidence for non-experts. That summary — the only summary for non-experts I found — was grossly misleading. Unless you can point to a tonsillectomy summary for non-experts that is not misleading, the available evidence (one bad summary, zero good summaries) contradicts your recommendation.

    13. Here are your most serious factual mistakes: “In none of the cases [of bad side effects] is a cause and effect established. He wonders why doctors do not list all of the complications he found – that’s why.” I listed more than a dozen bad side effects associated with tonsillectomies (polio, obesity, etc.). The associations — association is not causation — were made by the authors of the articles and PubMed indexers, not me. Mistake One: I did not claim these associations reflected cause and effect. Mistake Two: I did not “wonder why doctors do not list all of the complications he found” — I simply pointed out that the Cochrane reviewers did not list them.

    These are serious factual mistakes because they reflect a poor understanding of risk and what parents (and other people contemplating medical treatments) want to be told. They go to the heart of my objection to how “evidence-based medicine” is practiced. Consideration of evidence is good, of course. Omission of evidence is bad. Omission of evidence of danger, when telling parents about the pros and cons of a treatment, is very bad. Right here you endorse exactly that — omission of evidence of danger. You are not alone, of course. “Evidence-based medicine” practitioners endorse omission of evidence over and over and over. If it were called “some-of-the-evidence-based medicine” it would be less deceptive.

    Risks are inherently uncertain. In contrast to benefits, risks are usually low probability or hard to measure. It will always be difficult (and sometimes impossible) to go beyond association to causation. To wait for certainty of causation before mentioning them is to deprive parents of useful information. Parents do not want to wait for certainty before being told of the risks of tonsillectomies. If tonsillectomies have been associated with obesity, they want to be told this. They do not want this information to be omitted simply because it hasn’t yet been established that the association reflects causation. If tonsillectomies have been associated with a 50% increase in heart attacks, they want to be told this. They don’t want this information to be omitted because it is uncertain whether it reflects causation. Yet you endorse that omission.

  10. Seth Roberts Says:

    Thanks, Jeff. Again, please note my reply (above).

  11. Seth Roberts Says:

    It would be interesting to know if people who had their appendix removed show signs of lowered immune function or have an increased risk of gut diseases.

    I agree. The 2011 study that associated tonsillectomies with a higher rate of heart attacks found a similar but weaker association with having your appendix removed.

  12. Seth Roberts Says:

    Science-based medicine purports to be more scientific than evidence-based medicine,

    I thought they were similar.

  13. jeff borsato Says:

    Great response Seth.

    Im torn because I value the analysis from Science Based Medicine as much as I value your approach to medical issues.

    I believe an important conversation is taking place here and hopefully they respond to your post.

    I do think that debates about “evidence based” vs. “science based” and the like detract from the ultimate good both sites are hoping to achieve. SBM does a great job of dispelling myths that are perpetrated in the absence of truth or evidence. Essentially saying that evidence must consist of something showing at least some effect as claimed. The reason their attack against chiropractic has worked is because Chiro’s have long been able to claim that people confirm pain relief after their treatment but no evidence can support their reasons why people enjoy pain relief.

  14. worthwords Says:

    For the appendectomy query above. The primary indication for an appendectomy is acute appendicitis. The consequences of not removing an appendix that is likely to to burst is likely to be feaces entering the abdominal cavity causing a septic shock–> death. For a doctor, missing a presentation of appendicitis case can be a devastating experience.
    There was a time when the appendix would be removed prophylactically while performing other abdominal surgery, since it was seen in the patient’s best interest to avoid a future appendicitis.
    The appendix does seem to have a role in immunity, there were some theories about helping to recolonise the gut with bacteria post gastroenteritis. However, as with tonsillectomy – there is no global immunocompromise from having it removed, and immunological changes seem quite subtle rather elusive. It’s worth reading up on the sorts of awful infections a patients with AIDS to understand what a deficient immune system looks like.

  15. Deidre Says:

    Per this article, “Your Appendix Could Save Your Life”: http://blogs.scientificamerican.com/guest-blog/2012/01/02/your-appendix-could-save-your-life/

  16. Evelyn M. Says:

    I would like to respond, “Hear! Hear!” to Mr. Purdy’s advice. I worked for many years with physicians in public health. The key medical and scientific journals published in English all passed my desk. I never saw any articles describing research that was undertaken to bolster the claims made by the various specialties about the necessity for their patients to have annual physical examinations, certain laboratory tests, etc. One day I asked my boss, an M.D., MPH, about this. He replied that the standards we see are just made up out of whole cloth by the medical community. He added that as far as the medical community is concerned “a healthy person is just a patient who hasn’t been fully worked up.”

  17. ck Says:

    @Deidre
    Thanks for the link. Interesting article. Kind of what I expected from prior knowledge.

    Now the question is: Should people who had their appendix removed do things different? For example, should they eat more or less fermented food than people with intact appendix? Guess it is time for some n=1 experiments for me.

  18. Seth Roberts Says:

    Thanks, Jeff. They have yet to approve my reply.

  19. Tuck Says:

    Great response. Neither “evidence-based” nor “science-based” medicine is really adequate. But scientific medicine would leave doctors with little to do.

    @Seth: here’s the first post from SBM, explaining the difference between SBM and EBM.

    http://www.sciencebasedmedicine.org/index.php/hello-world/

    I’ve had lots of discussions in the comments there on various articles. The treatment you received is pretty typical.

    The best explanation I’ve ever heard of how modern medicine operates was from an old French play, reviewed here:

    “Get to Know Your Inner Hypochondriac”
    http://online.wsj.com/article/SB10001424052748703866704575224280938569458.html

    I saw the play based on that review and it was terrific, and deeply disturbing. Dr. Knock *is* modern medicine, and is in line with Evelyn M’s quote:

    “He added that as far as the medical community is concerned ‘a healthy person is just a patient who hasn’t been fully worked up.’”

    Or as Dr. Knock explains:

    “”To get sick, what does that mean? That’s a worn-out idea. It doesn’t hold up against modern science. . . . In my experience people simply are more or less sick, with more or less numerous diseases that progress more or less rapidly. Now naturally, tell people they’re well, they’re only too happy to believe you. But why lie to them?”"

  20. Bob Says:

    Seth, they approved your reply and posted it, followed by a couple of responses.

  21. Seth Roberts Says:

    Thanks, Bob. I saw it and wrote another response.

  22. Seth Roberts Says:

    Thanks, Tuck. Yes, I was wrong to equate science-based medicine and evidence-based medicine. I do think science-based medicine is an improvement for exactly the reasons they say.

    I hope to see “Dr. Knock” (the play) some time. I didn’t know about it.

  23. Ann Says:

    Funny. I had stomach problems my whole life. After my appendectomy, for acute appendicitis, my stomach problems went away.