Do surgeries work? Most of us assume they do, but is there any scientific evidence that they do?
In this episode, I talk to Dr Ian Harris who is a Professor of Orthopaedic Surgery at the University of New South Wales in Australia. He is a practicing orthopedic surgeon specializing in trauma surgery. Outside his practice, his research interests broadly cover the topic of surgical effectiveness and clinical research.
What we talk about
1:38 – Science as a way of knowing things
9:15 – Why medical professionals refuse to believe scientific evidence?
15:05 – What is a placebo?
19:16 – How strong is the placebo effect in surgeries?
22:05 – History of bloodletting in medicine and how we stopped this practice
24:31 – The myths of knee surgery
28:26 – Why doctors need to be held accountable
32:26 – Why are there no regulatory authorities in surgery like there are in new medicine?
35:14 – Latest studies on why half of the surgeries are ineffective
41:00 – Need for randomized trials for discovering which surgeries actually work
44:48 – Why is surgery the ultimate placebo?
47:12 – How much effort does it take to do a meta-analysis or a systematic review?
47:29 – How to improve meta-reviews via living systematic reviews
49:54 – What should you be asking your doctor if you are recommended a surgery?
Dive into Dr Ian Harris’ research
Notes and key insights
1/ What is a placebo surgery? It’s where you make an incision but not do anything.
It’s analogous to traditional placebo in medicine, where a sugar or salt pill is given instead of an active chemical to see whether the intended medicine has an actual impact.
2/ Majority of surgeries that Dr Ian Harris and other researchers have studied in fact are not more effective than placebos. This is shocking because even when we have no proof that they work, many of these surgeries are happening even today.
3/ Examples of such ineffective surgeries include back pain surgeries and knee pain surgeries. For such surgeries, randomized control trials have found that if you make an incision in the knee but don’t do anything, it’s as effective as actually conducting the surgery of the knee.
4/ Why do patients get better if the surgery doesn’t work? It’s because many diseases or pain have a natural progression, and we generally seek surgical/medicinal intervention when we’re in the worst condition. If the body heals / condition becomes better after that, we attribute improvement to the intervention rather than thinking it could have happened anyway (due to the natural course of the condition).
5/ As Dr Ian Harris said, the unsaid attitude could be stated like: “you have to operate on patients quickly before they get better“.
Remember: in many cases, if you get sick, you get better after that. And that is why placebos seem to work.
6/ It’s shocking to hear that randomized controlled trials (RCT) for many surgical interventions end up finding that they’re ineffective.
But what’s most shocking is that many other interventions have never been subjected to an RCT against a placebo. For many of the common procedures traditionally practiced, we don’t know whether they work at all or not.
7/ For sure, there are many studies that study variations of surgical methods. That is, they try to find out whether an incision from the left is better or from the right.
But very few studies try to find out whether the incision does anything at all for the patient. Shocking, but that’s the truth.
8/ In that sense, surgery is different than medicine. All new pharmaceutical molecules are subjected to rigorous clinical trials where they’re tested against placebo or doing nothing. In many countries, there’s no such procedure for surgical treatments. If there is a procedure for new surgical procedures, nobody is testing old ones that have been getting performed every day without evidence.
8/ If research indicates many of the currently practiced surgeries don’t work, why are they still practiced?
Well, if your salary depends on not believing something, you won’t believe it.
9/ And such denial is not new. The most common surgical procedure in history was bloodletting. This practice which lasted for thousands of years was only questioned in mid 19th century, and even after randomized trials showed that it hurt the patient, it wasn’t abandoned suddenly. It died a slow death as its practitioners started dying.
10/ Even today, the fact that practices like Homeopathy survive suggests that seeking evidence of what works isn’t a big priority for society. Perhaps keeping traditions is a bigger priority.
11/ But because it’s costly and risky to perform surgeries, the urgent question is: what surgical procedures are today’s equivalent of bloodletting? And those that we know are bloodletting, how do we get rid of them as a society?
12/ As a patient, what should you do? Dr Ian Harris recommends that every time your doctor recommends a medical procedure, ALWAYS ask for risks and benefits.
Risks are a given and doctors generally are happy to talk about them. But nobody asks for benefits because they’re assumed to be there.
Ask and confirm about benefits explicitly.
13/ What if the pain isn’t going away at all? Should you then get surgery?
Golden advice by Dr Ian -> “the severity of your symptoms does not change the effectiveness of the operation“