A prominent Sydney surgeon has cast doubt on the efficacy of dozens of common procedures, arguing in a new book that many operations have become mainstream without proper evidence.
Orthopaedic surgeon Dr Ian Harris says doctors must be "more scientific" and should apply the questioning attitude they have towards other practitioners to themselves and their own practice.
In the book, titled Surgery: The Ultimate Placebo, Dr Harris also calls on professional societies to do more, and for GPs to "think twice" before referring patients.
Read the edited extract below and share your thoughts in the comment field.
The following is taken from Surgery, The Ultimate Placebo: A surgeon cuts through the evidence by Professor Ian Harris (NewSouth Books). RRP $24.99.
I am not suggesting that all surgery is ineffective or harmful. I am a surgeon and I spend a considerable part of my working life performing surgery.
It is fair to say that I am sceptical of many of the claims of surgery, because scientific inquiry so often shows the effectiveness of many treatments to be less than initially claimed.
I am not suggesting that surgeons are recommending operations knowing that the potential risks outweigh the potential benefits.
Largely, surgeons believe that they are doing the right thing, but often they are not aware of the strength (or weakness) of the supporting evidence or, what is more often the case, there is simply no substantial or convincing scientific evidence available.
Without good scientific evidence, surgeons perceive the procedures they recommend to be effective – otherwise their colleagues wouldn't be doing them, right?
Put simply, a lack of evidence allows surgeons to do procedures that have always been done, those that their mentors taught them to do, to do what they think works, and to simply do what everyone else is doing.
Relying on tradition and unsupported perception frequently leads to an incorrect assessment of the effectiveness of the treatment, and is therefore not good enough.
I know this because I have learned it the hard way. When I started training and then practising as a surgeon, decision making was relatively easy; paradoxically, the more you know, the harder it gets.
I have always been impressed by the scientific debunking of non-scientific beliefs. I remember many years ago, seeing a television program where two well known sceptics (James Randi and Dick Smith) showed water diviners to be no better than chance at detecting water in underground pipes, constructed as part of an experiment.
The water diviners felt that they had been about 90 per cent correct, but were only just over 10 per cent correct, in picking water from one of 10 pipes. I was fascinated by the reaction of the water diviners, who claimed interference from underground magnets and other things.
Water diviners, using forked sticks or other devices, had been finding water pretty successfully for generations, and relied on tradition and observation to justify what they knew: that water divining was a good way of finding water. The fact that you could find water just about anywhere if you dug deep enough was not considered.
To them, if science showed water divining to be ineffective, it meant that there was something wrong with the experiment; the science was wrong.
I started my career like the water diviners: doing what everyone else was doing and what I was taught to do. And I was happy. And I thought my patients were happy, and most of them probably were. I was finding water, so I didn't see much point in questioning the methods.
I started doing my own small-scale research (randomised trials comparing two treatments) to fill some gaps in the evidence, but soon became frustrated with my poor understanding of the scientific method.
I set out to obtain that knowledge, and in doing so I quickly realised that that the scientific method (so called "evidence-based medicine") was the only way of reliably knowing things – that there were significant flaws in relying on observation and tradition.
In short, I realised that the kinds of tests that were applied to the water diviners – properly conducted scientific experiments – needed to be applied to surgery, and we needed to adjust our thinking so that we didn't react like the water diviners when we were shown the evidence.
For many complaints and conditions, the real benefit from surgery is lower and the risks are higher than you or your surgeon think. There is a difference between any real, direct effectiveness of surgery and our perception of the effectiveness of surgery.
That difference, which we will call the placebo effect, is the reason why we tend to overestimate the true effectiveness of surgery.
When the results of observation and tradition are in conflict with the results of an experiment, what should we believe? Most people trust their own eyes – that is what got us humans so far, from the days before we had even invented science. We didn't need randomised trials or toxicology tests to tell us which foods to eat and which ones to avoid; we worked it out by observation and tradition. But as any magician, illusionist or mind reader will tell you, we humans are pretty easy to fool, and we can all perceive, and believe, falsehoods.
WHAT CAN DOCTORS DO?
Doctors need to [be] more scientific and questioning. They can do this by practicing what is referred to as evidence-based medicine, which I prefer to call science-based medicine.
This means that they need to use the least biased evidence available to them when making decisions about individual patients, not the evidence that best fits with their beliefs and their practice to date.
Basically, doctors need to apply the questioning attitude they have towards other surgeons, physicians and other health and alternative medicine practitioners to themselves and their own practice.
For many doctors, this is a big ask. With so much evidence out there, it is hard to evaluate every decision so carefully. Many do not know how to scientifically evaluate the evidence. Firstly, they should obtain that knowledge by learning about evidence-based medicine and the scientific principles of critically appraising the available evidence.
Secondly, the best available evidence is often summarised for them. There are many high-quality practice guidelines and summaries available for most common conditions and their treatment, including surgery.
This questioning attitude is particularly difficult to put into practice for trainee surgeons – junior doctors who want to be promoted and advance their position.
Often they are reluctant to challenge a superior. I know many trainee surgeons who know when their supervisor is doing unnecessary surgery, but they rarely speak up. I am occasionally challenged by those working under me.
Initially, I found this uncomfortable; now, I love it. I love that they feel that they can do this, that they have the confidence to do it, and the knowledge that feeds that confidence.
I can give many examples of how my practice has changed (for the better) due to my being challenged by a junior. I believe that if such interactions between surgeons are based on the science, and if the culture becomes more accepting and understanding of science, it will be easier for surgeons to question each other, regardless of their relative position.
Beyond using the available evidence, doctors should be generating new, better evidence. They should design, conduct or at least participate in clinical trials and other types of research aimed at answering important clinical questions about the effectiveness of surgical procedures.
Not only will this better answer the questions, but personal involvement in research makes one more likely to believe the outcome. Many surgeons participate in research, but often it is research that does not address important clinical questions or research that cannot properly answer the question it is addressing.
There is considerable waste in medical research (not just surgery), and better focus is required. Doctors also need to remove any financial incentives from their decision making. Financial structures that reward procedures rather than overall care tend to lead to higher rates of surgery. Financial interests in devices and device companies, through such things as royalties, speaker fees and education payments, can influence the decision making of surgeons. Currently, the system around the declaration of such conflicts is robust – but declaration of a conflict does not remove it.
Surgeons also need to talk to one another: isolated practitioners with little access to peer review tend to go off on a tangent. Having surgeons regularly meet in groups to discuss cases decreases practice variation. Attending meetings might seem like a waste of time, and peer review has been criticised (for example, when everyone in the group agrees on the wrong thing), but at least it is a leveller.
But it’s not all about the surgeons; the primary care doctors – the general practitioners – need to think twice before referring patients to surgeons. They need to be aware of the adage that ‘to a man with a hammer, everything looks like a nail’.
Surgeons operate – it is what they do. Given that medical students are mainly taught by doctors, there is considerable room for improvement in medical education. I learned very little of the scientific method in medical school, and almost nothing about how to critically appraise the research, or about bias. We need to create scientists who practice medicine, not doctors who know about medicine but little about the science that supports it.
Finally, professional societies can do a lot to improve medical practice. I believe that there is a greater role for professional societies in monitoring and improving the quality and safety of surgery. Many have done this, but many have not embraced this role, confining themselves to codes of conduct, specialist training and ongoing education rather than enforcing adherence to evidence-based guidelines, producing those guidelines
As a result of the increased awareness of medical harms (mentioned in the previous chapter), considerable work has been done to address error in surgery. This has resulted in a better culture of safety, and has involved changes such as the introduction of surgical checklists.
These checklists are used immediately prior to the surgery to ensure that the right procedure is being performed, on the correct side andon the correct patient, among other things.
I think that system changes that reduce error are important, but they also distract us from the important questions around surgery – the ones that are not on the checklist. Questions like ‘Is this surgery necessary?’ or ‘Are the results of this procedure clearly better than non-operative treatment?’
But of course we should be asking that question a little earlier in the game. A recent project, called Choosing Wisely, has been successful in getting professional societies engaged in disinvesting from low-value interventions. Professional societies were asked to generate lists of five interventions that should be questioned, and the response was very positive. Some of the recommendations are helpful to patients, like avoiding bed rest for back pain, not using testosterone for erectile dysfunction, and avoiding opioid medication where appropriate.
In my opinion, however, they fall short: the surgical societies are not strong on questioning surgery. The American College of Surgeons list of five interventions mentions only one operation – the rest were investigations like X-rays, CT scans and screening tests. The list from the American Academy of Surgeons does not refer to any operations, mainly listing ineffective non-surgical procedures. A fellow researcher has commented that the Choosing Wisely campaign has been used by specialist societies as an opportunity to cast the spotlight of ineffectiveness onto other specialities.