Transcript: A Q&A with Professor Ian Harris Interviewer: I am curious about your background and just as a context for the people who read and listen to this – could you just give us a brief history on your journey because actually I feel like we get to know you a little bit as well from the young surgeon all the way through to someone who becomes a little bit more wiser and changes his ideas on things. Professor Ian Harris: Yeah, so I went through the same process as most surgeons – did the usual training in Australia and learned how to do surgery and did a bit of extra training overseas and then started practicing. I’ve always been interested in science and questioning dogma, that kind of thing and I wanted to be a better scientist. And I didn’t really know how to go about it and I asked around – then I learned about clinical epidemiology or evidence based medicine and started down that path and that lead to a Masters then a Ph.D. then more research, things like that. Interviewer: Was there a series of events or particular point in your career or in your life that sort of really consolidated the idea of this book needing to be written or consolidated as something that you really needed to do? Professor Ian Harris: The book’s been building up for a long time. I think the big turning point for me was when I did the Masters in Clinical Epidemiology – and that to me was an eyeopening experience and the more I looked into surgery the more I found out that the evidence – and I think that I kind of knew that the evidence wasn’t that good – then I realized that the evidence is not only not that good but it’s also very biased. And surgeons are very biased and patients and the press and everyone’s very biased that surgery is fine, that there are no problems with it, it’s successful and this is not true, you know this is something that does not bear up. So the idea for the book – I wanted to write for a long time and I’ve been gradually writing it for many years. Interviewer: And it is something that has given you any professional grief? Professor Ian Harris: Yeah, a little bit probably a lot less than you would expect. I’m fortunately, I hold a fairly good position in the surgical community and that has not really come under significant attack. Most people that I know and I talk to either agree with me or at least understand my position and are happy to have the discussion. I think the people who don’t know me and maybe just read the title of the book or have heard things that I’ve said possibly misunderstand me. So I don’t think that it’s as big a deal as people think it might be. The surgeons by and large they want to know the truth.





Interviewer: And I think it’s one thing you make very clear – as a reader – it’s made very clear that you’re not saying that all surgery is going to affect you. You give your example of: hip surgery for fractures in the hip and it’s really just people are probably going to read the title and probably misinterpret or form an opinion without actually digging into the book. Professor Ian Harris: Yeah, I think so. Look, the response I’ve heard from my colleagues has been pretty positive. Interviewer: What conversation are you hoping opens up with your book professionally? Professor Ian Harris: Well I wanted to achieve two things: I wanted to just drift away the thinking that people have toward surgery. Just to entertain this idea that just because it is an operation doesn’t necessarily mean that it works or it’s needed. And professionally I wanted doctors as well to be more scientific. I want surgeons to understand the science behind the evidence and basically just be scientist surgeons, not just operators. Interviewer: Do you mind just sharing a little bit of the background of surgery – I found it interesting when you talked about the separation of the profession from the blood-letting and really we’re sort of let into the age of disease-illness paradigm. We sort of – I guess the remnants of that seems to explain a little bit of the model and our love for surgery as well. Professor Ian Harris: Yeah, surgery and medicine works separate, traditionally, previously. And they more recently came together. But surgery, probably of all the medical areas, is very much entrenched in this disease-illness paradigm where it’s turning out to be a simplistic way of looking at things – is that you have a complaint, I can find an abnormality in your skin, therefore your complaint is due to that abnormality and I just need to remove it. And whether it be a narrowed artery or dried out disc or torn meniscus, it’s just not that simple. Interviewer: Yeah. You made a great example of blood-letting like 3,000 years ago. Do you mind just quickly sharing that story for the people that’d be listening? Professor Ian Harris: Yeah, I think it’s a great example because blood-letting is probably one of the originals or certainly the most persistent placebo that persisted for 2,000 or 3,000 years. And this is largely what all of the elite doctors had – they had blood-letting. So if you had pneumonia or headaches or you had any kind of illness, we didn’t know what was causing it most of the time so doctors used to just prescribe blood-letting and they would let blood from different parts of your body, different amounts, using different techniques: using leeches, or knives and it became a pseudo-science. It became a science in itself – when to bleed, not to, how much to bleed and it was basically a huge part of medicine in the old days for centuries. And the interesting thing about it is that when it was kind of shown in the 1800s that it really doesn’t work – when you look at it objectively, I don’t think we’re helping anybody – the doctor’s just wouldn’t believe it. How could you say it, we’ve been doing it for 2,000 years and we see people get better after we do it. It’s that kind of simplistic logical fallacy of it follows therefore it is because of, that doctors today still fall for.

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Interviewer: And with the age of disease-illness paradigm, what do you think – when we look back in say 50 years time – the paradigm will be or where would you like to see it shift to? With that where would you look back in 50 years time and consider the blood-letting of 2016 and I think you go into some examples in your book specifically but in terms of the actual paradigm, what do you think we’ll look back in 50 years time and see the greatest change in? Professor Ian Harris: I think there will be a greater appreciation of the psychosocial determinants of disease. And probably one of the big blood-letting moments of our time is spine fusion for back pain. It is a worse problem in America – a million spine fusions done every year. It’s costing society billions of dollars every year and to think that we could cure somebody’s back pain which is largely associated with psycho-social conditions rather than the abnormalities in your back. To think that we can cure that by ravaging the spine and disrupting it all and putting screws and things in it is going to be seen to be pretty naïve and reckless in 50 years time. Interviewer: Yeah there’s certainly going to be big changes for everything: for imaging through actual the architecture of our systems geared toward that particular model so there will be a change on multiple fronts. Professor Ian Harris: It’s a one-way model where everything points from the GP to the imaging to the specialist to the intervention. It’s like Norman Swan described: it’s a train going somewhere, you don’t know where it’s going, but you can’t get off. Interviewer: That’s right. The title of your book: Surgery, the Ultimate Placebo – for people listening who don’t quite understand placebo, you mind quickly explaining placebo? Professor Ian Harris: I don’t mind explaining it, but I don’t know if I could do it quickly. Most people understand the concept of what a placebo is – so it’s something that it’s a pretend treatment that doesn’t actually affect the underlying condition. So a sugar pill is a simple one but it could be an injection of saline or water which doesn’t contain anything – any active ingredients. So that’s what a placebo is and most people understand that concept these days. But what’s difficult to understand is the placebo effect – because the definition of a placebo is that it doesn’t have an effect. So it all becomes really confusing, and really what we’re looking at with what we label the placebo effect is multiple things: it’s either the natural history of the condition – such as the common cold. So when you take your vitamin supplement or whatever cure you’ve got for the common cold and you get better, that’s a placebo effect. The pill you took didn’t get rid of the cold, it got rid of itself. And another phenomenon which is playing with patients’ expectations. So if you deliver a treatment – is it in a positive way raise patients’ expectations if you are authoritative when you deliver it, if it costs a lot, if it involves devices, high tech things and interventions that are elaborate – then it’s more likely to lead to the patients believing that they got better. So when you add up all of the things that make up this placebo effect, surgery basically ticks all the boxes and really is the ultimate placebo. And that’s why it’s important to check it against placebos wherever possible. 3



Interviewer: And I guess what I took out of your book, one of the main points you make, is that there are lots of techniques that are currently used that you’re not necessarily saying that they don’t work but that they just haven’t tested against placebo. And as a professional society we should be really looking to do that, and then you went on to talk about the imbalance between the double standards between research and clinical practice and is that something that you think will change? Professor Ian Harris: The thing that’s gonna change, I mean we’re wasting people’s time and society’s resources by doing operations where we don’t even know if they work or how well they work so I think that there are a lot of operations out there that either don’t work or they don’t work as well as we consider them to work and the thing about ethics is that one of the things that’s often thrown up against me is well you cannot do placebo studies because they’re unethical. They’re not unethical at all. If you look at the ethics of research, the ethics of science – it’s to answer your research question the best way possible, the least biased, most scientific way and that’s using a placebo. And as long as patients sign up for it and the harms are minimized, it fits in with the national guidelines on ethical research with humans. There is no problem with it. What is unethical is the fact that we are now fusing one million spines per year in the US and we don’t even know if it works. So we’re exposing people to risk we’re using up resources and we’ve been doing it for decades and we don’t know if it works. Surely, one or two small placebo studies done 50 years ago could have saved billions or trillions of dollars by now. Or a placebo study 50 years ago could have shown its effectiveness, then we would know better when to use it. Interviewer: A patient trying to navigate their way through this, and you do elude to this in your book, what questions do you think they should be asking someone – whether it be their allied health provider, their doctor, or their surgeon, when considering surgery I guess Professor Ian Harris: You’ve got to go into the consultation knowing what you want to get out of it. So if you’ve got a sore knee or whatever it is, you need to go in there saying what do I want to get out of it. I want to be able to play golf again, because I can’t do it now. Whatever it is that you want to get out of it, you’ve got to sit down with your surgeon and say to the surgeon: what is the probability that I will be able to get back to normal function or whatever it is that you want to get with this procedure and what is the evidence that this procedure will achieve that any better than nonoperative treatment? What’re the percentages? What’re the numbers? And they should know that and sometimes the answer is: well the best evidence we have is that surgery is effective but it is just as effective as nonoperative treatment. In which case, why would you do it? Interviewer: When you talked about the one-way train or one-way bus system: people have often visit their GP or their physio or their chiro before they get to the surgeon and the surgeon obviously did a lot of studies to get to that point where they are in their career and specialize in a particular area and people downstream didn’t have to study quite as much in that area and maybe giving the patient information that is incorrect, does that anecdotally have you noticed create problems for surgeons that then you patients arriving at your

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doorstep who have preconceived ideas that this is what they need and essentially the squeaky wheel gets the grease? Professor Ian Harris: I don’t think that’s a big problem but that is something that is raised by surgeons where they say well the patients want an operation and if I don’t give it to them – they’ll go next door and get it from another surgeon. To me, I’m kind of like well that’s that other surgeon’s problem. You don’t do an ineffective procedure because you think that someone else might do it. That doesn’t make any sense. But the other thing is that it’s easier to do the operation. It’s easier to sign the forms than to explain to them that they don’t need it. But I completely disagree with that – I’ve spent a lot of my consulting time seeing patients and explaining to them that they don’t need surgery and by and large they’re happy with that. Because if you say to a patient – you say look I know you’ve got a sore knee but you’re coping pretty well, I think you’re fine, I don’t think u need surgery and if you’re after an arthroscopy for this condition, the best available evidence that we have is that the arthroscopy would not be any more benefit to you than if we pretended to do the arthroscopy. The patients go: well in that case, I’ll be crazy to have it. If you explain it to them properly, the patient’s not an idiot, they don’t want to have something if it’s not gonna work. Interviewer: No, potentially if they have someone who’s potentially financially guiding them and telling them no you don’t need this and there’s credibility from that source. A lot of the people that reached out to me were companies that obviously deal with work cover and compensational third party payers. What do you think you need to change in the third party payer systems in Australia and then more broadly – I guess globally – where obviously it’s being documented the differences in our country’s back surgery versus compensational injuries versus noncompensational injuries? And if you could change one thing, what would you change? Professor Ian Harris: Well it’s a huge problem. The outcomes in that setting are definitely worse than outside of that compensation setting. Honestly, what I would do if I would change that is I would remove that system from health. I’m more than happy with compensating people for injury, there’s no argument with that, but I would remove them from the health system because the incentives to operate and the pressure to operate are so great in that system and the results so poor. It’s really a destructive system more than a constructive system in some areas. Interviewer: What steps can they take to achieve better outcomes in a workplace setting for example? Professor Ian Harris: It’s very difficult – it’s one of the greatest challenges I have is discussing – when I see a patient that’s been caught up in a compensation system for years, had multiple investigations, fouled operations, they’re still seeking the cure which they’re never gonna get because they’re so psychologically not in a good place. And to try and turn that around is very difficult. I try to explain to them sort of what’s going on and the whole system is so – so many bad incentives because the incentives for the patient is not necessarily to get better and they take this passive role where they’re kind of like: well you did this to me, now you 5



have to make it better, go on. It’s almost impossible to make someone better in that environment. They’re always gonna be miserable because they’ve been wronged or they feel they’ve been wronged. And they’re in this adversarial system where they almost have to prove that they were sick the whole time in order to get anything out of the system. It’s too big a problem for me to solve tonight I’m afraid. Interviewer: No, that’s fair enough. Have you seen any outreach initiatives that you feel is addressing that need for less surgeries and better outcomes? Professor Ian Harris: No, but there is a lot of work in the area and there’s a lot of people who understand this and there’s a lot of people who I think are doing good research on how to improve this system but the politics of it is then: we’re stuck with this system, it’s not going to change. And so there’s only so much you can do. Interviewer: You lay out a pretty damning case for some type of meniscus, shoulder impingements, Achilles tendon rupture. Why is there still third parties, like Medicare for example, and government funding these operations given that they are looking for better health outcomes and the evidence is pretty clear and conclusive on these types of surgeries? Professor Ian Harris: Well I think that governments are still funding it because governments are still funding the same things they funded 30 years ago. That really is a system that doesn’t get regularly updated shall we say. But also because some of those treatments can be useful in some situations. So I’m not a big fan of actually wiping out reimbursements for things that may actually be useful in some situations. But the thing is there are conditions, and you mentioned some of them, where we know that for certain indications these operations are probably not helpful. And yet there’s a whole bigger number of operations out there that haven’t even been tested properly. So we don’t even know if they’re useful or not. But I tend not to get into discussions too much about Medicare funding of things because it’s not a fruitful area of discussion. The decisions that are made are largely political and not necessarily always based on the best signs. And it then leads people to question my motives and my conclusions as well when I’m caught up in this sort of political side of it. So I try and keep to the sides. Interviewer: Yeah, absolutely. One thing you did mention in your book is that you felt that most surgeons do quite well financially without having to do unnecessary surgeries and that most of the surgeries that they do you would view as being unnecessary. It really seems to revert back to the triad that you talk about. Professionally within the triad and the new group of surgeons coming through, do you mind just quickly talking about the triad and maybe commenting on what you think maybe needs to change in the actual triading that will lead to better outcomes? Professor Ian Harris: Sure, so the evidence that supports much of the surgery that is being done is what I refer to as the “wobbly triad.” What holds it up is that you often got some animal or lab studies so nonhuman studies which support the possibility that this operation might work because that way you have a biologically plausible mechanism and you need to 6



have a biologically plausible mechanism for something to be believed to be effective. But I would say that you could think up a biologically plausible mechanism for just about any stupid operation you could think up. You really could, you could say well raises the levels to this or adjust this, therefore this compensates by that – I mean you just make stuff up. So a biologically plausible mechanism is no reason to do an operation. Lab studies are no reason to do an operation. Because time and again, they just don’t translate. How many drugs and chemicals and things have I seen injected into rats that completely healed their bones, completely cured their conditions and you put it in humans and it just doesn’t work at all. So that kind of thing is out and the third leg of the wobbly tripod is observational evidence, which is basically: well, we tried the operation and they seemed to get better. That’s a very weak level of evidence. Time and again it’s been overturned by higher level scientific evidence Interviewer: Yeah, absolutely. Well, Ian it’s been great chatting. I think we’ve covered and dived into some pretty huge stuff. Before we sign off, I was just wondering: if people wanted to read up or follow you or get a hold of your book, where can they do that? Professor Ian Harris: So the book’s available pretty much anywhere. It is in some book shops, you could get the Kindle version on Amazon and you could go to any Australian bookshop: Booktopia or whatever and get it or order it, and you could get it directly from the publisher at newsouthbooks.com.au, I think it is. Interviewer: Newsouthbooks.com.au. And are you on Twitter? Professor Ian Harris: Yeah, of course. @doctordoubter. Interviewer: Yeah, so if people want to follow you, they can follow you there. Professor Ian Harris: Yeah, d-o-c-t-o-r-d-o-u-b-t-e-r. Interviewer: Perfect, well I really appreciate your time. I know you’re super busy. I really enjoyed your book. I think it’s the way a book is meant to be written. I think it’s well balanced and I think it’s a book for everyone from patients all the way through professionals and I hope it sparks some conversations that need to be had. Professor Ian Harris: Same here, thanks very much. [END]

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