Ian Harris: "Surgery, the Ultimate Placebo"

[TrixieStix]

"Ian Harris explains that more than half of commonly performed surgical operations may be placebos. Adequate studies using a blinded control group are essential."

"Ian Harris, a Professor of Orthopaedic Surgery at the University of New South Wales in Sydney, Australia, wrote a book titled Surgery, The Ultimate Placebo. It is an eye-opening evaluation of commonly performed surgical operations that have been tested and shown to be no more effective (and arguably worse) than placebo, or that have never even been tested. He covers the history of sham surgery studies, talks about placebo effects, and explains why so many surgeons ignore the evidence and continue to do ineffective operations. In the process, he provides a valuable education in critical thinking."

Article by Dr. Harriet Hall (SkepDoc) about the book:

https://www.skepdoc.info/ian-harris-on-surgery-the-ultimate-placebo/

YT video of Ian Harris talking about the subject:

 

[MeSci]

Note that he said somewhere around the middle that animal experiments were (almost always?) no good.

 

[Grigor]

Also talks about spinal fusion surgeries. Sadly only for one minute at 20:40.

(I only read the automated transcript)

"finally we get to spine
surgery something that has not been
subjected to a placebo trial there's
lots of different kinds of spine surgery
but probably one of the most
controversial is a spine fusion many of
you in the room may have had a spine
fusion particularly lumbar fusion you
can different fusions in the neck as
well but lumbar fusion for back pain is
a very common procedure so again in
America I think it's around 350 to 400
thousand spine fusions per year the cost
is about 100 thousand per case so start
doing the math as to how many billions
of dollars are spent on spine fusion and
in Australia it's not much better so
it's a very calm procedure there's not a
whole of evidence to support it the
randomised trials that have been done
have shown that it's no better than
alternative therapies and yet it's still
commonly done so that's an area that
needs a lot of work"

 

[oldtimer]

An interesting and cautionary video. As a non-scientist I had no idea how unrefined medical research in such an important area was. I'm a bit shocked really. Just as shocking is that a surgeon can try out a new procedure without ethical approval first. Maybe this is just in Australia.

The question which Harris states is "never" asked by patients, "What will happen if I do nothing?", has to be an exaggeration. Surely any sensible person would ask this - and surely surgeons would bring it up, even if just to sell their services.

When speaking about his father's prostate cancer surgery at the end, is he actually suggesting that his father should not have been told he had cancer?! Of all the examples of questionable ethics in the whole talk, that would have to be the standout example.

Yes, @MeSci, it was very nice to hear an authority saying experiments on animals almost never translate to humans.

 

[ME/CFS Skeptic]

Merged thread

The fascinating history of surgery: when placebo-controlled trials clash with common beliefs - ME/CFS Skeptic


I've made a new website for my articles and commentaries on ME/CFS research. I've just posted the first new blog post. https://mecfsskeptic.com/the-fascin...-controlled-trials-clash-with-common-beliefs/



It's about the history of surgical procedures showing how misleading clinical intuition can be and why it’s important to control for various biases in clinical trials.

In contrast to drugs, surgeons do not need to provide evidence of a new procedure to introduce it into medical practice. The results is a delay between the use of surgical interventions and scientific experiments that test if these interventions are effective or not. I think this has important implications for patients with poorly understood conditions (such as ME/CFS) where research is often of poor quality, and treatments are introduced prematurely.

Often RCT’s show that the surgery wasn’t effective after all. A review of randomized placebo-controlled trials for surgical interventions found that in half of these studies, the effect of surgery did not differ from that of a placebo.

Examples that are discussed in the blog include mammary artery ligation, fetal-tissue transplantation for Parkinson’s disease, PFO closure for migraine, vertebroplasty, arthroscopic surgery for osteoarthritis of the knee and fusion surgery for back pain.

In many of these cases, there was preliminary observational evidence and open-label trials suggesting the intervention was effective. When the methodological quality of trials was increased, however, the effect size disappeared.

I wonder how researchers of behavioral interventions look at this because trials that are blinded and placebo-controlled are not practically feasible in their field. How do we know if cognitive behavioral therapy is not like arthroscopic surgery for the knee?

Most of the information in this blog post comes from the book ‘Surgery: the ultimate placebo’ by Australian professor and orthopedic surgeon Ian Harris. Unfortunately, Harris has a problematic view of medically unexplained symptoms including CFS. He seems to think that these physical symptoms are the result of psychosocial factors, citing the Lancet article by Wessely and colleagues from 1999.

 

[ME/CFS Skeptic]

Would be interesting to hear if anyone knows of other examples in this list - of surgical interventions that were commonly performed and thought to be effective, only to be shown to be useless in randomized controlled trials.

 

[ME/CFS Skeptic]

I've read Harris book and thought it was really interesting.

I've written a blog post many of the examples he discusses (surgical procedures that were commonly performed but shown to be ineffective in randomized controlled trials). The blog post is discussed in this thread: https://www.s4me.info/threads/the-f...ash-with-common-beliefs-me-cfs-skeptic.18648/

Unfortunately, Harris has a problematic view of medically unexplained symptoms including CFS. He seems to think that these physical symptoms are the result of psychosocial factors, citing the Lancet article by Wessely and colleagues from 1999.

Perhaps it is worth trying to write a letter to him, explaining that this view is outdated (and not in line with his skeptical view - it's not that simple I'm afraid)?

 

[Jonathan Edwards]

Perhaps it is worth trying to write a letter to him, explaining that this view is outdated (and not in line with his skeptical view - it's not that simple I'm afraid)?

I am afraid this looks very much like the sort of guy who makes a big thing about weaknesses in methodology that actually everyone knows all about as if he was saying something dramatic. People like that tend to turn out not to have awfully good antennae in the end in my experience. So no surpirises that he thinks ME is psychosocial. And if he is suggesting that prostate surgery is not worth it you can put him firmly in the bottom drawer. Thanks God I didn't listen to those people - or more accurately that my wife refused to listen to them.

 

[ME/CFS Skeptic]

I am afraid this looks very much like the sort of guy who makes a big thing about weaknesses in methodology that actually everyone knows all about as if he was saying something dramatic.

But if everybody knows about this, how come there are still little randomized-placebo-controlled trials for surgical interventions and why are many surgeons still performing the ones that haven't been tested or have been shown in RCT to be ineffective?

I can't vouch for Harris his judgement but as someone who knew little about this, his book was an interesting read and good introduction to the subject.

 

[Jonathan Edwards]

But if everybody knows about this, how come there are still little randomized-placebo-controlled trials for surgical interventions and why are many surgeons still performing that haven't been tested or have been shown in RCT to be ineffective?

Because surgery is run by people who want to make money and don't care about whether the operations actually work. Nobody has called them out. The physicians know all about it but it seems mostly they don't want to upset the apple cart either.

You could ask why hasn't anybody called out a system that allows 100,000 people to die unnecessarily of an epidemic in a so-called advanced western country! The general public can't be bothered with making sure their health care system works properly until they find themselves at the sharp end and it is all too distressing to complain.

If you want an honest answer!

 

[ME/CFS Skeptic]

I am afraid this looks very much like the sort of guy who makes a big thing about weaknesses in methodology that actually everyone knows all about as if he was saying something dramatic.

If other people have a better view of this issue I'd be interested to read their books or articles. Reading tips are always welcome.

 

[Jonathan Edwards]

If other people have a better view of this issue I'd be interested to read their books or articles. Reading tips are always welcome.

I am not sure that anybody else thinks it is worth writing about. When I was a student I 1970 I remember being taught how the operation of tonsillectomy that was done by the hundreds of thousands had been shown to be useless and that this was an illustration of the typical situation in surgery - that nothing is ever tested properly. Every medical student knows this. Things may have changed a bit with NICE guidelines and restrictions on surgery within government health care but in private practice I don't think anything has changed.

I thought at least to some extent this was common knowledge amongst the educated general public but maybe that was twenty years ago. These days everything just seems to be propaganda.

 

[Arnie Pye]

Because surgery is run by people who want to make money and don't care about whether the operations actually work. Nobody has called them out. The physicians know all about it but it seems mostly they don't want to upset the apple cart either.

I've never understood why tonsillectomies are now derided as a waste of time and money, and totally useless. It was one of the few surgeries I've had that was, in my opinion, an absolutely amazing success with no obvious drawbacks since it was done. I used to lose a week off school about 3 or 4 times a year with me developing a fever of about 103F - 104 F and having a throat so sore that I couldn't swallow and often couldn't speak. Once I had my tonsils removed I got three episodes of a bacterial infection in the throat in the next 12 years, and have never had a repeat since then.

I remember back in the 1980s that a boss of mine was finally able to convince his doctor to refer him for a tonsillectomy after having had repeated problems all his life (he was in his late 30s). His quality of life improved immensely after he was operated on (and so did his breath!).

 

[Graham]

Very interesting. It's amazing what can be learned from medical history, and how little doctors have learned from it. There was an article recently about cholora being spread in mental institutions back in the 19th century, and the lessons learned there were not to transfer any ill person to a closed institution. Cue covid and care homes.

My wife viewed the knee arthhroscopy(?) with considerable suspicion for many years before the proof that it was worthless, simply by listening to patients a while after the operation. The same can be said of major sinus surgery.

One further problem is simply that surgeons do not follow up their patients after surgery beyond a few weeks, if at all.

 

[Grigor]

Thanks Michiel for writing and researching this. Great and important blog.

 

[Peter T]

I've never understood why tonsillectomies are now derided as a waste of time and money, and totally useless. It was one of the few surgeries I've had that was, in my opinion, an absolutely amazing success with no obvious drawbacks since it was done. I used to lose a week off school about 3 or 4 times a year with me developing a fever of about 103F - 104 F and having a throat so sore that I couldn't swallow and often couldn't speak. Once I had my tonsils removed I got three episodes of a bacterial infection in the throat in the next 12 years, and have never had a repeat since then.

I remember back in the 1980s that a boss of mine was finally able to convince his doctor to refer him for a tonsillectomy after having had repeated problems all his life (he was in his late 30s). His quality of life improved immensely after he was operated on (and so did his breath!).

I remember when I was training and then newly qualified as a Speech and Language Therapist lots of anecdotal evidence of harm from possibly/probably unnecessary tonsillectomies, particularly palatal incompetence, but more recently I am aware of several young adults having to research the criteria for the procedure themselves and desperately fighting the medical profession for the operation, which successfully ended years of repeated infections.

Perhaps both the historical over use of the operation and now its wholesale abandonment both illustrate that surgical practice is not always reliably based [on] research evidence.

[added]

 

[Hubris]

Because surgery is run by people who want to make money and don't care about whether the operations actually work. Nobody has called them out. The physicians know all about it but it seems mostly they don't want to upset the apple cart either.

You could ask why hasn't anybody called out a system that allows 100,000 people to die unnecessarily of an epidemic in a so-called advanced western country! The general public can't be bothered with making sure their health care system works properly until they find themselves at the sharp end and it is all too distressing to complain.

If you want an honest answer!

But, couldn't you say that there is huge political pressure to having less strict social distancing to try and lessen the economic consequences of a pandemic? Sure the medical committees have a lot of power, but so does the government and the stock market. It seems predictable that the resulting measures would be a compromise between these powers (with politicians being what they are). In the field of surgery (or any field of medicine) it's different, the medical establishment has all the power, and most people don't even know about these issues. Some people do, typically because they were personally affected, but they usually blame it on a bad surgeon, they don't seem to realize that it's a systemic problem. Same with the psychosomatic/functional thing, nobody knows about these issues and people assume that if doctors have all the power then things will be done properly. It seems to be that when politics are involved, everyone is happy to blame the politicians (rightly so), but when it's a systemic problem within medicine, nobody cares and doctors are completely untouchable.

 

[Jonathan Edwards]

but when it's a systemic problem within medicine, nobody cares and doctors are completely untouchable.

But that is what I am saying. People do not take healthcare seriously enough to make sure they get a good deal. They insist on safe airline pilots and aeroplanes but don't seem interested if there are unnecessary deaths to go unnoticed in health care systems. Doctors are only untouchable if nobody else can be bothered to call them out.

 

[Jonathan Edwards]

Perhaps both the historical over use of the operation and now its wholesale abandonment both illustrate that surgical practice is not always reliably based [on] research evidence.

That was the point being made to us as students - that nobody knows.

This article gives some idea of the complexity of the problem of tonsillectomy but perhaps the most salient message after reading it all is that still nobody knows.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883156/


There is a further irony exposed by this article: https://qz.com/1452056/study-88-of-uk-kids-who-got-tonsillectomies-didnt-actually-need-them/

This is about a study of unnecessary tonsillectomies done by none other than the Professor of General Practice from Birmingham who has been tweeting about how great the PACE trial was. The study seems to be a lemon, yet again. It does not assess outcome, just whether patients fit the arbitrary criteria.

 

[Mij]

Because surgery is run by people who want to make money and don't care about whether the operations actually work.

How often do they see the patient after surgery? Once?

I've seen horrific post-op surgeries performed by orthopedic surgeons that mangled peoples feet. The patients have more problems and suffer knee and hip pain as a result.