Dr. Bob’s Book Reviews
The Ultimate Placebo
by Ian Harris,
Newsouth, Sydney, AU, 2016.
Ian Harris, an orthopedic surgeon in Australia, repeats his bold thesis very near the end of his book: “The main message of this book is that some surgical procedures, including many that are commonly performed, are possibly no more effective than placebo. Some may even be harmful, for no significant gain.” Harris makes it clear that determining which is which may not be easy even for a professional.
Interestingly, Dr. Harris waits until his final lines to add that, “I do not wish to leave the reader with the impression that all surgery is ineffective.”
Still, Harris has a much, much longer list of operations which he considers ineffective than effective. He merely notes hip surgery and replacements as well as cataract repair as being effective both therapeutically and cost wise. “My wish is to see more of that kind of surgery and less of the questionable or ineffective surgery, but that will only happen when we all start asking the right questions, and demand the evidence that allows us to determine the difference.”
Like Otis Brawley, physician author of How We Do Harm, Harris is convinced that surgeons like medical doctors often Do Harm because they ignore evidence. Some of which is available for practicing physicians to study and much of which has yet to be produced.
This is far more so the case with surgical operations than with drug therapies. Drugs have long been tested, compared, and evaluated against placebos (in the USA under FDA auspices), although often not effectively. But, similar investigations have been very slow to develop in the surgical arena. Many, many operations have never been evaluated in the present “scientific” manner.
There is no entity comparable to the FDA with regard to surgeons. Any surgeon can practically invent his own operation and start performing it with little or no input from the profession or beyond.
Harris admits that the case is neither bright nor cheery for much – maybe most – of modern medical or surgical therapy. “The problem, however, is that medical practitioners don’t know with any great certainty that any treatment is effective unless we subject it to scientific tests…. Medicine has been getting around this imbalance by assuming effectiveness in the absence of rigorous scientific tests. Once a practice become commonplace, it becomes ‘unethical’ to test them scientifically for fear of denying patients the (seemingly) effective treatment. We end up where we are today, with a plethora of treatments, some of which are effective, some of which are not, and no certainty regarding which is which.”
Along the way, Dr. Harris spends much time trying to explain “the placebo effect as one of perception over reality.” He freely admits that much of medical practice from ancient times to the presence has been pervaded by the placebo effect which is often as effective as the real treatment, but without the side effects and complications. The author begs but never answers the question, “What is real?”
Harris goes over what he calls the “scrap heap” of operations which have come and gone often – never having been tested after being touted as major benefits to human beings sometimes for years or decades. His list includes: Bloodletting, Radical mastectomy, Lobotomy, Extracranial bypass surgery, Surgery for plica syndrome. And those make for merely a small portion of operations rejected in ages and generations past.
Harris adds to his list numbers of procedures which have been tested against placebo treatments and shown to be lacking: Surgery for angina, Parkinson’s, Meniere’s, migraine; Arthroscopy for arthritis and torn meniscus, Intradiscal electrothermal therapy, Tennis elbow procedures, Vertebroplasty, High blood pressure operations.
Then, he shares his views on what he considers today’s placebo surgeries:
• Spine fusion
• Surgery for multiple sclerosis
• Caesarean section
• Knee arthroscopy
• Coronary stents
• Venous clot filters
• Shoulder surgery for impingement
• Floating kidney
• Tendon rupture (most notably of the Achilles’s tendon)
• Laparoscopy for bowel adhesions
• Fracture surgery
Surely his list could be expanded ad infinitum. That because around 9000 procedures are being performed today. Only half have been compared to non-operative treatments in randomised trials. Of those “being performed that had been subjected to comparative studies, about half of the studies showed that the procedure was not better than the non-operative alternative.”
Harris wants to remind readers that surgery is generally an option, it is rarely life-saving.
Bottom Line: Reader be forewarned that your elective surgery probably has never been tested. There is a good chance of complications arising from it. At best, your operation may merely be an expensive placebo.
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Down from Troy:
A Doctor Comes of Age
by Richard Selzer
William Morrow, NY NY, 1992.
Richard Selzer recounts growing-up days in upstate New York in this fine book. His early years were spent in the Depression Days and he then experienced a far different world than that of our modern times. His memory seems to have been finely honed and his writing exquisite.
Following his brother Billy into life, Dicky had a ringside seat for much that occurred in his small town of Troy on the Hudson River. Mother had dreamed of being on stage and frequently fell into song while raising her sons. Father was a physician who pointed him in other directions. [Julius Selzer died suddenly when Richard was only 13 years old.]
In either case, young Selzer was exposed to many experiences and opportunities to learn. But from early on, he was pulled in the two directions of medicine and artistry, eventually of the writing kind. Dr. Selzer turns back and forth between these sometimes opposing, other times complementary, parts of life in story after story.
From a practical standpoint, his Father had the greatest influence as he occasionally followed him in the office, made rounds in the hospital, visited homebound patients, and attended to prisoners at the Renssalaer County Jail. Father also introduced him to the Central Tavern and Mr. Duffy who held sway there for hours daily at the bar. Duffy, like his mother, taught the young Selzer about artistry. While it was common for Duffy’s listeners to react negatively to some of his tales, he would turn back to them saying, “We are not a liar. We are a story teller.”
Refreshingly, the author also takes detours far into the future at this turn and the next. So, the book is not totally chronological. He gives his opinions about medicine and hospital care, tells about his tour in Korea during that War, remembers a touching meeting in Texas with a Korean woman with whom he had a short-lived thirty years earlier during the war, discusses the wonders of anatomy and the gifts of Leonardo Da Vinci in that arena, recalls being exposed early in medical school to the “dungeon” like environment in which electro-shock therapy was administered, retells visiting a crematorium in his latter days.
Selzer’s detours come up unexpectedly. But they allow for breaks in the action and for rounding out his experiences. And, the reader is never sure what the next chapter, or page, will bring.
Comments may be sent to theportableschool at gmail dot com.
They will be appended here in a timely manner if the correspondent wishes.
by Richard Selzer
Picador, NY, NY, 1998.
This is a collection of Dr. Selzer’s stories gathered from several of his books. The potential reader should be aware that Selzer was not only a surgeon but a man who was attracted to human trials many of which ended in death.
At the same time, Selzer became a prolific writer. A sensitive, caring human being with insights, feelings and a will to share them rather openly.
Selzer was fluent with his pen. But, he also had a vital imagination and an eye to see things that surely few other physicians as well as fellow humans possess. In many vignettes, Selzer gives the clue that he perceived light, luminosity, ghosts shining from patients and in extraordinary incidents.
Practically all of his stories circle around illness and injury, medicine and surgery. But, he also places the narratives seemingly here there and everywhere. From the Pampas of Argentina to Tuscany, Honduras to Houston, Ireland to Norway and France, America to Africa. His stories also spread across time as well as space. A number of traditions and religions are represented in this collection.
While pain and suffering are common to The Doctor Stories, there are also moments of healing and transformation. The former are worthy of reading. The latter give the reader a bonanza for sticking through the struggles.
Comments are welcomed by email to the portableschool at gmail dot com. We will respond.