New Zealand Listener— For a doctor who’s taking a metaphorical scalpel to the operating decisions of his colleagues, it’s surprising Sydney orthopaedic surgeon Ian Harris doesn’t have a target on his forehead.In the past few months, Harris has been spreading the seedier secrets of the surgical world, chief among them that thousands of operations commonly performed in hospitals everywhere don’t actually work.Harris is not suggesting your surgeon necessarily knows this before he or she takes a knife to your knee, your spine or your belly, but says that the evidence that some operations are effective is lacking and many may be no better than placebo – or doing nothing.
In his new book, Surgery, The Ultimate Placebo, Harris lists a range of operations as “today’s placebo surgeries”, saying their effectiveness is “under question”. They include spinal fusion for back pain, knee arthroscopy, coronary stenting, some shoulder surgery and appendix removal, laparoscopy for bowel adhesions and repairs of ruptured tendons and some fractures.Procedures that are useful in certain cases are overused in others – he puts hysterectomy and caesarean sections in this category, pointing out wide variations in rates of the operations between hospitals, states and countries.
He says an absence of evidence that the operations are better than doing nothing allows surgeons to do procedures that have always been done, those that their mentors taught them to do and that everyone else is doing. And that, he says, is just not good enough.
“Surgeons do procedures that are not effective because they believe them to be effective. Their objective evaluation of the operation, and their understanding of the science, is not what it should be,” he tells the Listener from the Sydney orthopaedic research centre he directs.
“If there is a high-quality study that says this operation is not effective, the surgeon who doesn’t understand that methodology or the applicability of it and sees with their own eyes many patients get better believes their own eyes rather than a study done halfway across the world in a way they don’t fully understand. It’s very easy for them to say that study must be flawed.”He says in many cases the evidence for effectiveness is conflicting.
“When this happens, we find the likelihood of the procedure being performed is based on availability and perceptions of the surgeon and the patient regarding the likely effectiveness.”
You might expect Harris’ colleagues to be unhappy about him spreading this message of surgical waste and making a direct assault on their bottom line, but he says their response has been positive.
“People recognise there are problems out there, that we are overtreating, that the science isn’t that good and things need to be cleaned up.”
Somewhat surprisingly, Harris doesn’t touch on one of the most contentious operations of all – ACL (anterior cruciate ligament) reconstructions on the knee.
“My take is there is definitely a role for them, but that they’re overdone. It’s useful in patients who have severe or symptomatic instability who cannot do what they want to do, despite physiotherapy and non-operative treatment.
“The problem is what often happens is that anybody with a torn ligament gets a reconstruction regardless of whether they’re one of those patients who can’t cope without it. They don’t get the chance to try.”