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Why do we still use ineffective treatments? One reason is that our expectations for the benefits of treatment are too high. Also clinical experience can be a poor judge of what does and does not work - hence the need for randomised controlled trials. Even when empiricism is satisfied we can be misled by looking at the wrong outcome. Indeed some treatments have harms that outweigh their benefits and are not evident in trials. Much of the clinical examination and diagnostic testing is more of a ritual than diagnostically useful. Doctors must be willing to continually question their own managements and investigate sources of information about what does work.