The One Factor Fallacy (also the One Fix Fallacy or the One Study Fallacy) leads to overdiagnosis and overtreatment in unsettled infants and breastfeeding women. Dr Pamela Douglas February 2024

Many of the problems parents with infants bring to their community-based health professionals are complex

Those of us who've had a generalist's training and clinical background know that the quick fix, with it's focus on a single solution or 'silver bullet'

• Often doesn't work, at least not for more than a short time

• Can actually do more harm than good in the medium or long term.

This is because people often come to see us concerned about one aspect of their health, but as generalist doctors or clinicians we quickly see that this one thing arises out of multiple interacting factors.

We operate as health professionals in very complicated contexts. Each of us as health professionals is doing our best to work pragmatically, to make a difference, and to establish credible reputations within our own contexts and health systems. As a clinician, you'll understand, as I do, the attraction of being able to send patients home with a (possible) solution.

Often we say to ourselves: "It can't do harm, anyway, and who knows, it might help." We offer the quick fix despite our misgivings. I've done this many times myself over the years. It might be because of time pressure, or because our clinical guidelines, which we feel obliged to follow, may be profoundly shaped by the One Factor or One Study or One Fix Fallacy.

What is reductionism?

The formal name for what I'm calling here the One Factor or One Fix or One Study Fallacy is reductionism. Our health system loves the reductionist lens. Reductionism suits biomedical technology and the pharmaceutical industries brilliantly, for instance. I remain very grateful for the miracle of medical technologies and pharmaceuticals. But they should be just one tightly regulated part of a health system response, featuring more prominently at the very expensive, downstream end of health care.

Frankly, biotech and pharmaceutical interventions bring Big Money with them, and many would argue this is why it's become disproportionately dominant within health system responses, relative to the upstream, affordable, preventative and early intervention approaches of primary health care.

The reductionist lens poses research questions and interprets the findings of research through a cause-and-effect, linear assumptions (A and B exist together, therefore A has caused B). This has been the dominant scientific mode of thinking in the West for a number of centuries, and suits the biomedical and pharmaceutical focus of contemporary health systems, health corporations, and research funders. For example, medications including antibiotics, for all their miraculous contributions to human health, are also often overused because of the One Fix Fallacy, which has resulted in the rise and rise of the corporate power of the pharmaceutical industry.

The advent of evidence-based medicine in the 1980s, just as I was starting out in general practice, has brought many benefits. But when I began to immerse myself in research in the late 1990s, worried about what was happening in clinical approaches to women and their babies, I could see that evidence-based medicine had a blind spot about the fundamental importance of theoretical framing. In my experience, those holding the power in the medical and health science departments of universities posed questions and interpreted their results through unconscious, implicit theoretical biases or lenses - which were typically reductionist. In the mid-2000s, when I published my first theoretical reframing paper, my efforts to context the reductionist mindset were regularly dismissed as flakey or ignorant!

In frustration, I published an article on both the need for, and the limitations of, evidence-based medicine in the care of families with babies in 2011 in an essay which I like to think still holds up today.

The reductionist lens continues to drive high levels of overmedicalisation and overtreatment, which are only worsening internationally, and which remain evident in the way we care for families with babies and toddlers and for breastfeeding mother-baby pairs. Often businesses educating health professionals in the field of families with infants invite researchers who've conducted a single study to present their work. These authors like to jump to clinical conclusions, and their audience isn't trained to think critically about methodological strength. (It seems impolite to speak out critically, anyway, and can make you unpopular!)

This is how the One Study Fallacy continues on amongst health professionals. I've watched favourite trends in the care of parents with babies and breastfeeding pairs blow around in the changing winds of the One Study Fallacy for decades now.

Unfortunately our complementary and alternative medicine (CAM) practitioners and bodywork therapists are equally susceptible to reductionism. In fact, at the moment in the care of parents with babies and breastfeeding pairs by CAM or body work therapists, a form of reductionism, associated with high levels of pathologising of normal (if diverse) infant anatomy and function, has really taken hold.

Here's some examples of solutions offered to parents with infants which arise out of the One Fix Fallacy. It's not that there's never a role for some of these interventions, but they are dramatically over-used. In the NDC or Possums programs, we discuss each of these in detail, looking at the research, and thinking through what might be more effective help to offer instead, using holistic, multi-domain clinical approaches.

For unsettled infants

• Anti-secretory medications including proton pump inhibitors

• Frenotomy

• Lactose free formula

• Special formulas (e.g. extensively hydrolysed formula)

• Anti-colic mixtures

• Lactase drops

• Sleep training

For breastfeeding women

• Maternal elimination diets (e.g. dairy elimination diets)

• Nifedipine for vasospasm

• Anti-thrush treatments such as diflucan for persistent nipple pain

• Antibiotics for mastitis (occasionally required but usually not)

• Breast massage, including lump massage, Therapeutic Breast Massage of Lactation and Manual Lymphatic Drainage of Lactation

• Therapeutic ultrasound

Why do health professional business interests and the corporate world promote reductionist solutions?

Money. I can't soften this. It's not that money is inherently bad - I need money to live, as do you. I do feel that my own professional contributions have been severely constrained by lack of money. But our planet is increasingly threatened by corporate greed, which permeates our daily lives in invisible ways.

In the part of the health system which offers clinical care for families with infants, money is power. Business interests are deeply invested in offering reductionist solutions to a wide range of the problems faced by families with babies and toddlersc, because these kinds of solutions sell.

Businesses and organisations who offer health professional training concerning breastfeeding, lactation, and infant care want to attract participants and provide what will be popularly received, reinforcing the dominant opinions (rather than less popular dissenting voices), because this ensures business viability. Conference presentations are a way that presenters raise their professional profile, which helps ensure the profitability of their clinical practices and educational efforts, which are small businesses.

Yet presenters at conferences in the fields of breastfeeding, lactation, and infant care are often (despite confidence in presentation and elegance of the PowerPoints) lacking the experience or capacity for a rigorous and critical analysis of existing research, simply drawing on dominant interpretations and perspectives.

In my view, as health professionals responsible for the care of families during an exquisitely vulnerable time of their lives, we need to think very critically about how money has influenced what we are being taught as evidence-based, including by noticing who is funding our education opportunities, and who are on the Boards of our professional bodies.

You can find out more here.

Selected references

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Hoffman T, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening and tests - a systematic review. JAMA Internal Medicine. 2015;175(2):274-286.

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Last updated 4 June 2024