Is surgery no better than placebo? Find out in this EndAllDisease exclusive interview with orthopedic surgeon Dr Ian Harris, author of the book Surgery: The Ultimate Placebo.
To order a copy of his book: Click here
I like to accommodate all learning styles, so below is the audio version as well as the video version, and I have transcribed the interview for you below that as well for those who enjoy reading.
Surgery – The Ultimate Placebo Interview with Dr. Ian Harris
Mark: Hey everybody, I’m here with doctor Ian Harris. He is a professor of orthopedic surgery at the University of New South Wales, orthopedic surgeon at Liverpool Hospital and a BMO at St. George and Sutherland hospitals. His interests include orthopedic trauma, evidence-based medicine and clinical research. He also wrote a book in 2016 called Surgery: The Ultimate Placebo and that is what we’re here to talk about today.
Questioning and examining the efficacy of certain surgeries – do they work or not? And if they don’t work, should we keep using them? That’s what we’ll let the evidence decide. So welcome to the show Dr. Harris.
Dr. Ian Harris: Thanks for having me.
What is your book about?
Mark: So I think I want to start with a brief ‘coles-notes’ synopsis of what you book is about.
Dr. Ian Harris: The book is, broadly speaking, it comes from my suggestion that the evidence and effectiveness of medicine is very much overestimated, and I think along with that is that the harms of medicine are also underestimated. And I chose surgery in particular because that’s my area of clinical work and also because people don’t often see surgery like that. I think if you said that you know, this drug was no better than placebo, people would believe and understand that not all drugs are effective. But when you say this surgical procedure actually doesn’t work – it’s no better than pretending to do it – that’s a little bit less obvious to people. It’s kind of like, ‘why would people be doing this operation if it didn’t work? It doesn’t make any sense.’ So the book was really to open up that conversation. It’s not just drugs or physical therapies and other things that are ineffective, it’s actual surgical procedures, many of which are ineffective. And so, the book covers the history of that, and also talks about why, the biases surgeons have, and the forces and enablers that contribute to this positive attitude we have towards surgery and how we can be more realistic about it.
Mark: That’s interesting. How did surgery become such a dominant mode of treatment in medicine?
Dr. Ian Harris: Yeah, the history is really interesting. The historical example that I use in the book is one of vivisection or bloodletting, because this was a very common tool, in fact it was one of the main tools used by doctors for hundreds or even thousands of years. Doctors used to use leeches to drain blood from the body, and they would drain different amounts of blood on different times of day depending on the illness. And this whole ‘science’ was developed around bloodletting and how to do it best and how to treat ammonia compared to something else.
And it was basically what doctors did and it got to a stage where it was really farmed out to those who held the lancet, or the knife, and they became the surgeons. And for some time there, the surgeons were combined with the fathers in the guild of fathers and surgeons in England. And they would cut your hair, they would take some blood off you, and extract teeth – all sorts of what were basically the beginnings of surgical procedures. But it wasn’t until anesthesia came out in the 1800’s that it became possible to do major operations, and then it was anti-sepsis that made those operations safe.
The two things that combined: One was being able to put the patients asleep and the other thing was the ability to ward off infection that made surgery a real possibility. And for some things it was great, but many examples simply tell you how misguided people were. Taking out lumps and bumps – we weren’t sure what we were doing back in those days. History of mastectomy is interesting. That was really a race to see who could do the most invasive procedure. They had mastectomies and they had radical mastectomies and they had super radical mastectomies where they would take off the breast and the muscles all the way down to the chest wall. These brutalizing, horrific operations that added nothign to the patient, it was just an idea that surgeons had that, if a radical operation is good then a really radical operation is probably better. And it’s this kind of – it sounds good and therefore it probably is true – mentality that drives all of the surgeries.
Many surgeries done today are the same thing. Instead of getting the scientific evidence to find out if a surgery does work, today surgeons are tending to just do it. A lot of the patients seem to get better so it’s probably working. In the 21st century that’s really no way to be judging the effectiveness of an operation. It really should be held to the same standards as drugs or as other forms of treatment.
Mark: It’s funny you mention that, I read the book The Cancer Industry by Ralph Moss, and some of the cancer treatments that they’ve been doing as recently as the 1970’s involved ripping out organs left and right. Moss talks about how, as a surgeon, the more you cut the more you get paid. Just from that alone, as a patient, I think it’s dangerous not to question whether these things are justified or not, so the fact that you’re bringing forward the evidence in your book gives people information that can help them decide what they want to do and I think that’s amazing.
Dr. Ian Harris: Yeah, people tend to think of cancer treatment as straightforward and well studied, and so they let doctors do it to them. But the evidence, particularly around end-of-life care, the evidence is a little skewed, where people are being subjected to horrific chemotherapy just on the hope that maybe it will work. For end-of-life care, maybe the patient is better off being at home with their family instead of spending the last 6 months of their lives in intensive care.
Another good example in the book is for breast cancer treatment. They developed treatment which was basically severe chemotherapy and it wiped out your bone marrow. And so they did a bone marrow rescue, basically like a bonemarrow transplant, and so this was the ultimate in radical treatment. It wiped out your entire body’s immune system. This became common treatment in the 80’s and it got to the stage where insurance companies, because it’s very expensive, so some health insurance companies in the United States would not cover it. Then suddenly insurance companies began being sued for not covering it.
It wasn’t until after this procedure became common practise that they found that the bone marrow rescue was no better or worse, so people stopped doing it. But it became this mentality that – it’s a stronger treatment and therefore it’s better, and it just wasn’t the case.
Mark: I actually wrote a book on cancer and as far as deciding what I want to do I always look first to evidence. And the oldest study that I found on the efficacy of cancer surgery was in the early 1900’s by scientists Marie and Clunet and they found that incompletely excised tumors from mice caused the cancer to spread. That was like the most common cause of metastasis and if you didn’t touch it, it wouldn’t spread. So, there’s some evidence that should make people at least want to question these things and I think that’s one of the biggest reasons I wanted to have you on the show and I’m really happy to have you hear.
The next question I want to ask: About 23 days ago I injured my knee, so going on three weeks here and I just had my MRI yesterday, so I’m getting to the point where my doctor is going to look at that and potentially recommend me surgery. Do you have a list of surgeries that you think may not be justified?
Dr. Ian Harris: I don’t really have a complete list. I cover a lot of it in the book. The example that you just referred to regarding your knee is widely covered. Some cancer surgeries, cancer screening is another thing – prostate and breast cancer screening, mamography, lung cancer screening, other types of thyroid cancer screening – these are programs that are widespread and sucking up millions of dollars going towards the industry that supports this kind of thing, and the evidence for them actually saving lives is very low or marginal at best.
Within my particular field of orthopedia surgery, two areas I focus on are knee surgery and spinal surgery, because there are a lot of spinal fusions being done for back pain and for other spinal conditions and the evidence for that is really not very good at all. If you look at the rate of spinal fusions being done today it’s completely off the charts. There’s something like 500,000 spinal fusions a year, and you look at other countries like the UK where the rate per 100,000 or per million people is much much lower. And even within Europe the number of spinal fusions done per country varies enormously. They haven’t done the studies that they need to do and one of my aims in my research is to do more of this research comparing surgery to placebo.
This is being done in knee surgery in meniscal tears, when arthroscopic surgery became possible it became popular. Because now you had a procedure where we could see inside the knee very clearly. We couldn’t see much on an x-ray, we couldn’t see much on an ultrasound and they didn’t have MRIs those days. But we can see with our own eyes the architecture on the inside of the knee. That was a big advancement, there’s no doubt about it. The trouble is everything we saw we thought was a problem.
In the early days we used to see these ‘holes’ in the lining of the knees and so when somebody came in with a sore knee and we saw the hole, we would do a surgery for it and it turns out the ‘hole’ phenomenon was normal and not a problem. So we chopped up knees left and right and it was completely unnecessary.
Same thing with meniscal tears, because as we age in particular we see dehydration and cracking in the cartilage and fibrillation of the lining of the joint and we see splits and fraying of the meniscus, just like we see all around the body in tendons, wrinkles in their faces and things like that. And so, we tended to think that this was the cause of the pain, and we do this all the time as human beings, we jump to conclusions. If we see something on a scan or a camera image, and the patient’s complaining of pain, we tend to blame the pain on whatever it is we can see. If you come to me with knee pain and I can see a small crack or a tiny split in the meniscus I’m going to say that’s the cause of your pain, even though studies have shown that patients with those tiny cracks or splits in their menisci, more often than not don’t complain of pain than do complain of pain. So it’s not all that clear, but we just jump to conclusions. It’s too easy just to match up what you see to the patient’s symptoms.
Mark: So it was the ability to see more clearly into the body with new technologies that leads to us seeing things that have never been seen before and to surgeons jumping to conclusions that may or may not be true.
I want to put on the screen now images of my ultrasound results and based on these the radiologist’s official diagnosis was that I had a ‘large knee effusion’.
Dr. Ian Harris: Now, can you see the structures inside the knee very clearly there?
Mark: No. I’ve never been trained to interpret an ultrasound but I don’t think so.
Dr. Ian Harris: What you see are a bunch of lines. That’s really unhelpful. Ultrasound of the knee is really not recommended. I’m surprised you had one.
An ultrasound of the knee is really no better than clinical examination. I can tell from looking at your knee if you’ve got an effusion in your knee or not. It’s swelling; it’s fluid in the knee. I can feel by touching your knee and even looking at your knee if you’ve got fluid in your knee or not. That’s a very simple thing to see.
Even if it’s small. If it’s of any clinical relevance at all. I’ve got a very very small effusion in my knee and I use it to show my students how to test for a knee effusion. I’ve never had a knee problem in my life, and it’s so small that it’s only a couple of mm. A knee effusion says there’s fluid in the knee. It doesn’t say what’s causing the fluid. So an ultrasound that says you’ve got a knee effusion is a complete waste of time. Nobody here [Australia] recommends ultrasounds to investigate a knee. It’s a low-yield test and it has low-specificity.
Mark: What about X-ray for looking at the knee. Would that be useful?
Dr. Ian Harris: Probably the two biggest things we use for a knee injury is an Xray: You can tell you’ve got a fracture, you can tell if you’ve got arthritis in the knee very easily on a plain X-ray. An MRI is a very detailed test with high sensitivity and high specificity that can show you not only the bones, because an X-ray just shows you the bones, but it can show you the menisci, it can show you the lining of the joint, it can show you the ligaments inside the joint if you’ve got a torn ligament from a sports injury it’s very easy to see on an MRI and impossible to see on an X-ray. So the two things that we do to investigate a knee basically 99% of the time is an X-ray and an MRI.
Mark: I’m very happy to hear that actually. One of the people I research whose work I enjoy reading is Dr. Ray Peat, and he’s been saying an MRI is one of the safest and most effective imaging methods to use.
Dr. Ian Harris: One of the reasons an MRI is safe is because it doesn’t involve the use of ionizing radiation. I recently had a twitter feud, I weighed in on this guy from Germany who said ‘it should be the right of every person to go to their doctor and receive a whole-body MRI every year’, to pick up things that might become a problem. On the surface that sounds reasonable, and somebody argued about cost, and I said cost aside, I still wouldn’t recommend it. And they asked ‘why I wouldn’t recommend something that would allow us to look at the body to allow us to pick out things that might cause problems so we can get to them sooner?’
Well, it just doesn’t work like that, for the same reason cancer screening doesn’t work. You do an MRI of your whole-body, you’re going to find all sorts of things. Then what are you going to do? Then we’re going to say, well gee, now we need a biopsy, and you get a complication from the biopsy or you get a complication from the stress of worrying what you’ve got. Now the doctors are really confused and they’re going to have to go in and take a chunk of your lung out just to be sure.
There was a great study done in the US on primary care physicians. And they said, for every patient that comes to you complaining of back pain, we’re going to randomize them to either get an X-ray or get an MRI of your back. You’d think the MRI would show more and would allow you to better treat the patient. They found out after 12 months, those who were randomized to get an x-ray were doing no better or no worse than those who got an MRI.
The only difference was that those who were randomized to get an MRI were more likely to have had a surgery in the meantime, because it’s more precise at finding things that doctors might think are a problem.
Mark: The more you get tested, the more likely it is you are going to be diagnosed with something.
Dr. Ian Harris: It comes back to the philosophy that diagnosis is a good. The idea that there can be no downside from being diagnosed with something, but that’s clearly not true and there’s lots of examples to show that.
Mark: One of the things about your book is that you’re talking about unnecessary procedures but also the virtues of placebo. What do you supposed the solution is? Should surgeons retire their scalpels and do sham surgeries without telling their patients, or should we look at the evidence and be more honest about which surgeries are and aren’t effective and simply never do them again.
Dr. Ian Harris: I think the latter. I’m not a fan of using the placebo effect for several reasons. And this has been suggested at all the talks I give it’s a common question that comes up.
I had dinner with a friend of mine who is also an orthopedic surgeon and we were talking about a study that had come out comparing knee arthroscopy surgery with pretended arthroscopy and it showed no difference. And he said I think that study is great, I’m doing more arthroscopy’s than ever. And I said, that doesn’t make sense – you should not be doing them now. And he said ‘no it’s great, because if you look at it, most patients got better in both groups.’ And he said ‘I don’t care whether it’s placebo or not, if I see patients getting better I’ll keep doing it.’ So he’s attributing it to the placebo effect and this is what a lot of people falsely do. Their thinking is that the patient still got better because of what they did, and that’s not true.
They’re still assuming causation and this is a fallacy that so many people fall for. They assume that what they do is causing the result, and when you look at the placebo effect and I think I probably regret calling it the placebo effect because it’s really not due to the placebo. Placebo by definition has no effect. So it’s confusing when we talk about the placebo effect. Most of it, is due to two other things and that’s 1) natural history and 2) regression: It’s basically what would’ve happened to the patient anyway.
When somebody goes to a homeopath with a cough or something, a homeopath would give them some medication and within a week the cough is gone, and they’ll say, ‘there we go… they got better because of my medication.’ Somebody else might say ‘no, they got better because of the placebo effect of what you gave them.’ But what I would say is they would’ve gotten better anyway. This is why every ‘cure’ for the common cold works: Because the common cold just gets better on its own.
In knee pain with arthritis and degenerative conditions, the same thing happens. I see patients all the time who’ve had bad knees for a while, sometimes worse than others, and last couple weeks it’s been really bad again. In a couple more weeks they’re going to be better again. It’s just part of the up and down of having an arthritic knee. But if I operate on them today and I see them in a couple weeks and ask them how they are feeling and they say ‘I feel pretty good, it’s a bit better than it was a few weeks ago’ and I would say ‘yeah, that’s due to the surgery I gave you.’
So no, I don’t think we should be using the placebo effect, because of the reasons I just explained and because of the costs involved and because of the potential harms of conducting surgery on someone for no conceivable benefit. What people call the placebo effect is mostly due to other things, but if there is one, it’s weak and short lived.
Mark: What do you think the chances are that if the doctor recommends me arthroscopic surgery, and I get it, that the procedure will benefit my knee?
Dr. Ian Harris: That depends on what’s wrong with your knee. If you’ve had an injury in your knee and you’ve had a torn ligament and your knees aren’t stable, then the surgery to reconstruct the ligament can be helpful. If you just have a very small meniscal tear and a little bit of fluid in your knee, I’d probably just sit on it and wait and see how it goes. But nobody’s going to do that until they do an MRI first and find out what’s wrong with it.
Mark: It’s amazing how far I’ve come within the past week. I’ve got from being completely dependent on crutches to being able to walk with a limp. I’ve been hitting the knee with near-infrared light multiple times per day and it seems to be working well. I don’t have a duplicate of myself with the same knee injury to not administer near-infrared light to see if it’s working or not but it feels like it’s very helpful.
My last question here: If there’s just one thing, one concept or idea that you think is the most important from your work that you’d like everyone in the world to know because it would reduce the suffering and make the world a better place what would it be?
Dr. Ian Harris: It would be to say the effectiveness of medicine is overestimated by those who are making the decisions and the harms are underestimated. The doctors that sell are overestimating the benefits and underestimating the harms. The way to correct that is to make doctors be more scientific about what they do, and also to educate the public to be more scientific about what they will have done to them. Don’t be afraid to look up the evidence. Ask your doctor questions. The simplest question of all, and it sounds dumb but so many unnecessary procedures could’ve been saved by asking this single question: What evidence do you have that doing this procedure to me is better than not doing it to me?
It’s a really simple question and that’s what it all boils down to. So if somebody says to you ‘I think you need a knee arthroscopy’ say ‘what evidence do you have that doing a knee arthroscopy on me tomorrow is better than not doing anything at all.’
Mark: Thanks for coming on the show Dr. Harris. It was a pleasure and I’m thrilled to help get your message out there to the public.
To learn more, you can purchase Dr. Ian Harris’ book Surgery: The Ultimate Placebo by clicking the image below: