The tremendous and unquestioning regard, in which modern medicine has been placed, has been tempered somewhat by the realisation that every technological advance does not necessarily mean an improvement in disease outcomes. Better understanding of scientific methodology has led to the development of evidence-based medicine and evidence-informed healthcare.
In this book, Dr Ian Harris, a practising orthopaedic surgeon in Australia, examines the discipline of surgery with a sharp eye. His basic contention is that many surgical procedures do not have a sound basis. He makes a compelling case for the use of the methodology now available to us to put to test surgical procedures with a view to eliminating those which are not useful and which are being practised today merely because they have the sanctity of age.
He begins by emphasising the difference between a placebo and the placebo effect. A placebo, by definition, has no therapeutic effect. It is well known, however, that patients (and doctors!) may perceive an effect that is not actually there. The perception of an effect beyond that of any specific effect is defined as the placebo effect. Dr Harris emphasises that the benefit seen is not due to the placebo, which, by definition, has no effect.
The obvious question is, is that a bad thing? Surely anything which makes a patient feel better should be good, whether it is real or not.
In the chapters that follow, Dr Harris gives several reasons why the placebo effect is not a good idea. He argues strongly for the practice of medicine based on science. The three main objections that he explains are: first, it is not truthful, therefore not scientific, and puts the practitioner in the same league as non-science-based medicine. The second objection is the cost, both the direct financial cost, and the opportunity cost of paying for something not truly effective when the money could be better spent on proven effective therapy, or other socially useful expenditure. The third objection is the possibility of harm, because research shows that, globally, harmful outcomes complicate 3% to 16% of all inpatient surgical procedures.
It is therefore essential that all surgical procedures must be proved to be effective. The problem is that this proof is not always easy to come by Dr Harris makes a passionate plea to use the methods of science to validate all medical advice.
A large part of the book is devoted to examining what can be considered evidence, how evidence is developed and the need for evidence-based medicine. The language is clear and the explanations succinct. This is an important part of the book, because the methodology of scientific evidence has not been routinely taught in medical colleges till recently. It is my impression that a large number of medical practitioners worldwide are not familiar with rigorous scientific methodology. Perhaps this is true of researchers as well, considering the large number of papers of extremely dubious scientific methodology, which are being published in journals.
Dr Harris gives a number of examples of surgical procedures, across various surgical disciplines, for which there is no clear evidence of benefit. Some of these are: fusion surgery for back pain, surgery for multiple sclerosis, knee arthroscopy for arthritis, and coronary stenting. He emphasises that these procedures be tested in large trials so as to either prove or disprove their utility.
It may appear intuitive that if many doctors, all of whom have spent years studying, recommend a procedure, then it must be right. In a chapter titled “Why do we still do it?” Dr Harris suggests some of the reasons why surgeons continue to do procedures that have no clear evidence, and also, importantly, why patients accept these procedures.
The book ends with suggestions for change. Dr Harris urges patients to ask questions to their doctors. He also asks the general public to demand research in areas which they see as important. For doctors, his advice is to learn how science is done and the principles of critically appraising the available evidence, to participate in generating high-quality evidence, and to keep away from financial incentives in decision-making. There are suggestions for researchers, research funders, and health insurers.
This is an important book. It is written in a clear and readable style. It describes many statistical concepts and their importance with clear examples. These statistical concepts, so important in understanding research methodology and what scientific evidence really is, are the bugbear of most medical practitioners.
The main message of the book is a call for ensuring that all surgical procedures, and by extension, all medical advice, is based on a foundation of scientific evidence.