This has been another book that’s been good to have on hand in clinic. Many patients come to me while waiting for, or considering surgery. Ian Harris is an Australian orthopaedic surgeon, and it is his own area of expertise where he is most critical. Rightly so- it’s the one he’s most qualified to evaluate. While I was reading the book, patients came in and mentioned that they were at least considering:
- Spinal fusion surgery for disc, scoliosis and stability issues (among others)
- Shoulder surgery for impingement
- Knee arthroscopy for cartilage issues including arthritis
All three of these are discussed in chapter 6: “Today’s Placebo Surgeries”. You might be able to deduce that I don’t tend to recommend my patients pursue the surgeries without further reading!
Harris’ intention is to educate potential patients, and spends the first part of the book explaining the ins and outs of surgery, and research. This explains the title. In short, operations are not as well tested as we may assume. Procedures can go on, seemingly successfully, for years before it is realised that they are no better than placebo.
What exactly is placebo? A good test will pit the surgery in question against a sham (placebo). Often, patients unwittingly receiving placebo surgery will also improve. This is the placebo effect. This often happens when “improvement” means “being in less pain”, but can happen with operations for things like high blood pressure. It is important to compare both the real procedure against a sham, so the difference between the two improving groups is measured, rather than surgery vs nothing at all.
A patient looking for pain relief might be happy whether that relief comes from a “successful” or “failed” intervention. As long as it is successful by the patient’s standards, where’s the problem?
“[Spine fusion surgery] is expensive, often leads to complications, often requires further surgery, is associated with increased mortality, and often does not even result in the spine being fused.”
The problem is in the risks and the cost. If we can relieve pain without the risk of infection or death, and without costing the NHS thousands of pounds, then we need to know.
But it’s important to understand that the placebo effect is not always a bad thing. It is likely an evolutionary development. As social creatures, it benefits us to feel better after being cared for, physically and emotionally. It is the outweighing of the benefits by the costs that is problematic in these surgeries.
That’s not to say that I am anti-surgery. It absolutely has its place, and as an osteopath, it would be unethical not to understand my own limits and refer on when something it out of my remit. As Harris put it:
“Any surgeon can operate; a good surgeon knows when to operate, but the best surgeons know when not to operate”