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Armageddon and Surgical Outcomes ENT FEATURE Armageddon and surgical outcomes BY CHRIS POTTER n the excitement of the festive season I am sure many of you will have omitted to commemorate the 60th Ianniversary of a highly significant world event. According to a small apocalyptic cult led by a Chicago housewife named Dorothy Martin, the world was due to end by flood at midnight on 20 December 1954. Mrs Martin and her small group of believers expected to be rescued from this damp fate by a friendly UFO from the planet Clarion, and in preparation for this adventure many had given up their jobs, possessions and even recalcitrant spouses. Fortunately for posterity, their ranks had been swelled by three imposters: social psychologist Leon Festinger and two of his colleagues. Their account of the events surrounding December 20, When Prophecy Fails [1] remains a riveting read 60 years on and its findings deserve wider dissemination Leon Festinger (1919-1989). amongst surgical practitioners. On the night of the 20th the mood of the cultists reached fever pitch, but spread the word and find new converts to competent, compassionate professionals as the midnight hour passed a sense the cause. However, the more peripheral compared to all those other jackasses and of disappointment and bewilderment members of the group who had invested buffoons around us. Thus whenever we do prevailed. However the indefatigable Mrs relatively little time or effort quietly something obviously stupid, dangerous Martin received a dramatic new vision slipped away sadder but one hopes wiser. or embarrassing we must invest a at 4.45am wherein the space brothers Festinger had expected exactly huge amount of effort reducing CD by assured her that planet Earth had been this series of events. Those who had manufacturing self-serving explanations saved by the devotion and sacrifice of her invested most heavily in the imminent for this behaviour. For instance, that followers! A sudden sense of exhilaration Armageddon were far more likely to myringoplasty fell apart because the possessed the hard core believers, who justify their actions by confabulations patient must have got it wet somehow, started phoning the press to report the and risible ad hoc explanations to the Eustachian function was hopeless joyous news and some ran to the streets to maintain their self-esteem. Well, you and that useless Registrar put the pack in cry, what on earth can this bunch of all wrong. My personal technique and its tinfoil-hat wearing deluded barmpots execution were impeccable, and there is “Well, you cry, what teach us hyper-rational evidence-based no question of me altering my behaviour scientific surgeons? Dear reader, they as I remain a paragon of technical on earth can this demonstrated a classical case of cognitive excellence - otherwise I would be a clear dissonance (CD), a psychological concept and present danger to patient safety and bunch of tinfoil-hat of huge explanatory power and ubiquity. would voluntarily give up my licence wearing deluded CD is defined as a state of tension which to practice. occurs whenever a person holds two ideas, This may also explain a common barmpots teach beliefs or opinions that are psychologically patient behaviour following inconsistent. The natural inclination is to complementary therapies. No patient us hyper-rational try to reduce this dissonance; to live with believes themselves to be a gullible fool evidence-based two contradictory ideas in one’s head is to susceptible to the most risible expensive flirt with absurdity. quackery. Having undergone an ineffective scientific surgeons?” The fundamental source of CD is and potentially dangerous procedure, CD the need to maintain self-esteem. We will kick in to overemphasise any minor all believe ourselves to be sensible, benefits to justify the time and expense. ent and audiology news | JANUARY/FEBRUARY 2015 | VOL 23 NO 6 | www.entandaudiologynews.com ENT FEATURE Thus patient satisfaction with alternative that is the current MRCS-lite. Although References therapies remains stubbornly high despite almost nothing learnt during that year has 1. Festinger L, Riecken H, Schachter S. When masses of scientific evidence of their benefitted my patients, and I could not tell Prophecy Fails. The University of Minnesota, Minneapolis, USA; 1956. inefficacy. you today where the damn clavipectoral 2. Bretlau P, Thomsen J, Tos M, Johnsen When Festinger launched the concept of fascia condenses, I will still smile NJ. Placebo effect in surgery for Meniere’s CD, Behaviourism ruled the psychological nostalgically whenever the old primary is disease: a three-year follow-up study of roost in explaining human thoughts mentioned and tell my trainees they really patients in a double blind placebo controlled study on endolymphatic sac shunt surgery. and actions. We were all essentially missed out on something invaluable. I Am J Otol 1984;5(6):558-61. oversized laboratory rats acting rationally have retrospectively increased the value 3. Orr RD. Vertebroplasty, cognitive dissonance, to maximise rewards and minimise of a goal which really did not justify the and evidence-based medicine: What do we do when the ‘evidence’ says we are wrong? punishment by our behaviour. However, disproportionately heroic endeavour. Cleve Clin J Med 2010;1:8-11. one need only sit briefly on a health service Fraternities and secret societies learnt 4. Waber RL, Shiv B, Carmon Z, Ariely D. committee to see that human beings are long ago that long bizarre, byzantine, Commercial features of placebo and therapeutic efficacy. J Am Med Assoc self-evidently irrational and indulge in all humiliating initiation rituals led to greater 2008;299:1016-7. sorts of daft shenanigans which require loyalty and pride in one’s membership. enormous amounts of self-justification to Quite harrowing and disgusting hazing is explain away. commonplace in the army (and the odd Effort Justification is also a useful medical school rugby club) and behaviour explanatory concept in this field. Basically regarded as degrading and unacceptable in the amount of energy expended in any decent society is indulged with achievement of a goal affects the value a wry smile. an individual places on that goal. For The same factors unfortunately apply instance the old primary FRCS was an to patients and their travails at our hands. antediluvian load of nonsense whereby Measurement of the subjective benefits enthusiastic motivated young men (most of surgery is notoriously hampered by the young women were far too sensible to patient’s need to justify such unpleasant indulge) were forced to spend a year of and inconvenient experiences. We would their lives learning by rote large tracts of expect the more disagreeable interventions indigestible anatomy and embryology texts to cause more effort justification, and in order to regurgitate said drivel under indeed this seems to be the case. Sham Festinger’s seminal study of extreme duress to sarcastic crypto-fascist surgery is an enormously powerful placebo, cognitive dissonance in the field. pedantic old fossils in suits (no offence). as patients undergoing Endolymphatic I still vividly remember staring glassy- saccus decompression [2], Vertebroplasty eyed at the passage in Last’s Anatomy and Arthroscopy of the knee have on the attachments of the clavipectoral discovered [3]. We know that placebo pills fascia during Her Majesty’s speech to the that are perceived as expensive are more Commonwealth on Christmas Day 1995. effective analgesics than cheap ones, so it Now no rational human being would ruin may well be that enormously expensive their festive season, at least one serious operations will be perceived as more relationship and a whole year of their life subjectively effective than their cheap and just to tick a box. Certainly this was my cheerful NHS equivalent [4]. forcefully-expressed opinion in the months Thus we reach the paradoxical Chris Potter, immediately prior to January 1996. conclusion that thanks to CD the more MA, FRCS (Eng), FRCS (ORL), However, once I had safely cleared unpleasant, unnecessary and expensive Consultant ENT Surgeon, that hurdle my CD kicked in and I will surgical procedures we carry out on our Torbay Hospital, happily tell all trainees within earshot patients, the greater the esteem in Torquay, UK. that the old primary was a proper exam which they will hold us. On that thought E: potler@ doctors.org.uk which made me the man I am, and nobody may I wish you all a peaceful and should call themselves a surgeon after prosperous 2015. breezing through the facile charade ent and audiology news | JANUARY/FEBRUARY 2015 | VOL 23 NO 6 | www.entandaudiologynews.com.
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