Episode 43: Hippocratic Oath and the problem with modern medicine

Dr. Caroline West:
Hello and welcome to the NPS MedicineWise podcast. I'm Dr. Caroline West, and I'm a GP and a medical advisor to NPS MedicineWise. Healthcare is traditionally designed to improve our health and make us better, and certainly, the Hippocratic oath, which many medical students take involves, amongst other things, a pledge to first, do no harm. Yet, with an increasing number of us living with chronic conditions, it could be argued that there's an increasing pressure in modern medicine to do more, more tests, more scans, more operating, more prescriptions, but how efficient or effective is this type of healthcare? Are we at danger of over diagnosing and overtreating? Could we, in fact, be doing more harm than good? A new book called Hippocrasy, a play on words with the Hippocratic oath, explores this fascinating terrain, and the authors, Professor Rachelle Buchbinder and Professor Ian Harris, are joining me today. Rachelle Buchbinder is a clinical epidemiologist and professor at Monash University at Cabrini Health and is a practicing rheumatologist. Ian Harris is an academic and orthopaedic surgeon. Thanks for joining us today.

Rachelle Buchbinder:
Pleasure.

Ian Harris:
Our pleasure.

Dr. Caroline West:
What inspired you to write Hipocrasy? Can I start with you Rachelle?

Rachelle Buchbinder:
Well, Ian and I have been working together for quite a few years, and the more, and we're both practicing doctors as well, and our research has really led us to the field of low-value care or care that provides minimum benefit to the patient and sometimes can cause harm, and we see that in our practice as well. So we just decided that we'd write a book. I guess Ian can talk about it, but he's already written a book that is a similar book about surgery. So Ian asked me if I wanted to write a book, another book with him, and we went on a working holiday, and Ian's wife actually came up with the title because once we started to talk about what the problems of modern medicine are, it became clear that we could use the Hippocratic oath as the basis because the Hippocratic oath talks about all the problems that we're worried about.

Dr. Caroline West:
So Ian, is that the same story for you?

Ian Harris:
Yeah. I mean, we really wrote it to raise awareness of the problem because this is not a widely recognized problem. It's more and more being recognized within medicine, but it's certainly not well-known in the community. So, we wrote this book for everybody. It's not a textbook. It's not aimed only at doctors. It's also aimed at the public, and I think very readable for the public, but yeah, it's an antidote to the message that we normally hear about medicine, "Everything we do in medicine is good. Every new invention, every new procedure is better than the last and helps us," and it's so often not true, that new is not better and more is not better. A lot of journals have picked up this message as well with series of articles under the title of Too Much Medicine or Less is More, and things like that. So it's really expanding on that message and getting a broader audience for it.

Dr. Caroline West:
It's really interesting you say that because I've heard this statistics thrown around that, in fact, 30% of medical care is of no value, and 10% is actually harmful, which as a doctor, that came as a bit of a shock to me. I think I knew there was a portion of what we did that was of no value because it was hit and miss, but I had no idea that the problem was that extensive.

Ian Harris:
Yeah. I think that's easy to believe. I wouldn't have believed it when I started practice because I thought that everything worked. I thought that everything we did worked and just assumed that it did but didn't realize that a lot of the patients I was operating on perhaps would've gotten better anyway even if I hadn't operated on them. Once I started looking into the science or the true evidence behind what we did, I realized that a lot of it either didn't have evidence or had evidence that it didn't work.

Dr. Caroline West:
As health practitioners, that can sometimes be a very difficult pill to swallow in a way because I think we like to think that we're doing our best for our patients. We like to think that the management that we offer is actually scientifically based, but what you are saying is perhaps a gray zone where we like to think we're evidence-based and perhaps we're less. So Rachelle, what's your finding there?

Rachelle Buchbinder:
I think it's like the more you know the more you realize we don't know. We both had, earlier in our careers, had education about clinical epidemiology. For me, that was looking at something that we commonly do realizing that it was based on nothing or to give you my first example, we looked at a drug for lupus and found that we always put people on a drug called hydroxychloroquine and the evidence for that was a case series of a few patients in a book, but then it was common practice, everybody did it. So realizing that for many things that we do in medicine, we actually don't have the evidence. So in some instances, when the evidence is actually produced, we find out that not only didn't work, it may also have been harmful. I think that's a gradual realization. The problem is that we tend to not be very science literate. I don't think we teach it well enough. I don't think doctors practice it well enough, and they tend to be much more influenced by their peers or what's presented at meetings, and they don't take the time or don't understand how to actually critique the evidence and actually stop and think, "Well, am I doing the right thing? What's the evidence that what I'm doing is the best treatment? Would it be better if I do nothing? Would something else be better?" That was one of the main messages that we wanted to get across in the book that we don't think doctors are sufficiently science literate, and that's really the fundamental science of being a good doctor.

Ian Harris:
If I can pick up on that with what you are saying, we as doctors think that what we're doing is science-based and is effective. That's true, but unfortunately, that feeling that we think what we're doing is good gets transformed into doctors assuming that what they do is good without ever actually looking harder at the evidence for it. It's always struck me as a little bit hypocritical, if I can use that word, that doctors often criticize non-medical practitioners, alternative medicine providers or other areas of non-medicine and criticize them for not being science-based or not having randomized controlled trial evidence for what they do. Yet, many doctors don't look at that exact evidence for their own practice. So, there's this general assumption that, "Well, if it's medicine, if it's medical, it must be science-based," and so often it's not.

Dr. Caroline West:
So you've talked about this whole idea of low-value care, and I mentioned that statistic of 30% falling into that category where there's no benefit to the patient and then 10% being downright harmful. Your expertise, Rachelle and Ian, is in this musculoskeletal field as a rheumatologist and orthopaedic surgeon. Can you take us through a couple of the areas where we may have got it wrong, or we've been following a certain treatment path where the evidence has lacking and yet it has been rolled out with enthusiasm and partly by health practitioners who perhaps believe it works and consumers who are hungry for a quick solution? Can you take us through an example or two of something that fits into what we're talking about, Ian?

Ian Harris:
I was just pointing to Rachelle to go first, but I'm happy to go first. I mean, many people know that there's been a big change in the rates and the thoughts around knee arthroscopy, which is or was the most common orthopaedic procedure performed. This is keyhole surgery in the knee. It's done for different reasons. So sometimes it may be helpful, but by and large, it's done for degenerative knees. So it's done in people who are over the age of 50 mostly, and it's done for arthritic or wear and tear changes inside the knee. It's been shown fairly clearly that arthroscopic surgery for that particular condition, whether it be arthritis or a degenerative tear in the meniscus or cartilage in the knee, doesn't help, and it's been shown in many, many studies consistently. So the science behind it is very clear. In fact, the science behind it now is so clear that the recommendation is that we don't need to study this anymore. We know the answer that it's just not helpful, but because we're treating a fluctuating condition, people with arthritis in the knee don't have exactly the same pain every day. Sometimes it can be quite severe for a while and sometimes it can improve for a while. If you operate on somebody when they happen to be in a lot of pain at that particular time, the odds are they're going to not be in that severe pain in the near future. I mean, that's the natural history of the condition. It has ups and downs. So, when you operate on people when they're bad, they're always going to be a little bit better afterwards.
Surgeons tend to assume that the improvement that they see was due to what they did, and that's a very human response, but it's not a very scientific response because we know that they would've improved anyway. The number of times, and I used to do a lot of knee arthroscopies, but the number of times I used to see people in the anaesthetic bay before operating on them after they'd been on my waiting list and I'd say, "How's your knee going?" and they'd go, "It's been really good. It's been fine." This is before I had operated on them because they'd just been sitting on the waiting list, and I'd say, "Well, what are you doing here?" They'd say, "I just thought I'd get it done just in case." This happened repeatedly. It's a very common event because we're treating a fluctuating condition, and it soon made me realize that maybe this operation isn't necessary.

Dr. Caroline West:
Yeah. I think that a lot of patients assumed, as a GP, I'd get these questions around, "Well, obviously, I had an MRI done or I had a bit of scan done and it showed all of these bits of irregularities in my joint, so surely a bit of a clean-up would actually make it work more efficiently in the joint space." So they're sometimes looking for something that's going to save them six months of physio.

Ian Harris:
The problem is the way you pitch it and the way I would pitch it is that a lot of surgery makes sense on a superficial level. I mean, that sounds good. We can make any operations sound good, "Well, it's a bit messy in there. We'll go in and clean it up." I mean, who wouldn't want that operation? The problem is it just doesn't work. I think Rachelle could probably talk more about the problem with diagnostic tests. I mean, MRIs these days, they're always, I've never seen a normal MRI, I don't think. It's just there's always a page or two of things wrong with your back or your knee in anybody over the age of 40.

Rachelle Buchbinder:
Yeah. What we know about arthroscopy now, not only doesn't it work any better than placebo, we are now increasingly seeing evidence suggesting that it actually might be harmful. So it actually might increase the rate of progression of arthritis and lead to earlier joint replacements, particularly in older people. So this is something that wouldn't be possible to recognize without randomized controlled trials that follow people up longer term. So I think it's just one of many things in surgery that we now know doesn't work, and there are plenty of other examples. Another example that I was involved with was vertebroplasty, which is injecting cement into people that have fractures in their spine. It was performed for a decade before any good trials that even had a controlled group. When the first placebo-controlled trials were done, after this treatment was accepted into clinical practice for years just like arthroscopy, we found that it actually didn't work, and we increasingly can see that there's many harms from the vertebroplasty. There are now five trials that have all shown the same thing, but there are increasing reports in the literature about the cement migrating and perforating the heart causing death, causing paraplegia. So not only aren't we helping people for many of these surgical procedures, we're probably harming a proportion of people as well. That's where that 10% may be harmful figure comes from in that overall equation about low-value care.

Dr. Caroline West:
It's not just the physical or emotional side effects of having a treatment, it's also the cost. For a lot of people, they've had to endure out of pocket expenses with gap fees or things that are not covered by Medicare. So they've had to invest a fair amount into the procedure.

Rachelle Buchbinder:
Yeah. So stem cell therapy is another treatment that there's no good evidence for, and increasingly, the evidence looks like it doesn't help arthritis in the current way that they do stem cell therapy, but we both had people that we know who've delved, what do you call it, delved into their superannuation, sold their house, moved into state to get a treatment that actually there's no evidence that it works and it probably doesn't work.

Dr. Caroline West
In the orthopaedic space, in the musculoskeletal space, what about a lot of the injectables that we're seeing used as treatments? Can you comment on that particular trend?

Rachelle Buchbinder:
I certainly can. So we know that steroid injections do provide short-term relief of pain, and that's useful for people who are in severe pain. As Ian said, a lot of these conditions fluctuate, but when you're in severe pain, having temporary relief of symptoms might be very valuable, but many other injectables, and that includes hyaluronic acid and also includes plasma injections, have been shown over and over again in high quality studies to not be any more beneficial compared to placebo, and that applies to tendon, so tennis elbow. It applies to Achilles tendonitis, and it also applies to osteoarthritis. It's interesting when you look at the history of all of these newer procedures that we're introduced into practice before the trials were performed, and people believed in the procedures and it bypassed regulations. So could you imagine getting a new drug on the market and approved through the PBS and subsidized without the proper preclinical studies before the proper trials were done, before we could prove that it was efficacious and safe? That just wouldn't happen, but for a lot of procedures, you can bypass regulation, and PRP is a classic example that's not considered a device because it's the patient's own blood. It's not considered a procedure, and a lot of the preclinical studies weren't done. It was just thought to be a good idea. Then before you know it, there was industry invested interests and just a huge number of people having these treatments, and PRP injections are not subsidized. So these are injections that patients pay for. It said that you need at least three, and I've had patients who've had this, had it done six times, nine times. It didn't ever work, but then they're somehow invited to have it again, and you go, "Well, if it didn't work before, why would you think that it's going to work this time?" and the patients go, "Well, the doctor recommended it." So a lot of these sorts of things are happening without, as Ian said, stopping to think, "Well, what is the evidence that I'm actually helping the patient?"

Dr. Caroline West:
So just for the consumers listing, the PRP injections are taking your own blood. Just explain what that procedure actually is for me, Rachelle.

Rachelle Buchbinder:
So it's taking blood like you take blood, and you can actually inject that whole blood back into the site to wherever the painful area is, but what's happened is that people now take that blood, they spin it down in a centrifuge and just take out the platelets. There are special kits that do the centrifugation and make the procedure more expensive. Sometimes other products are added, and then that centrifuge, that concentrate of platelets is then just injected back into the patient. We've shown that not only do the platelets not work, the whole blood doesn't work. There's no difference between it. So that added expense of the centrifugation kits are not worthwhile, but it doesn't work anyway.

Dr. Caroline West:
So does this get back to the way that we've set up some of the healthcare systems? So what you are saying is that the evidence is not there for these kind of PRP injections, yet they're still being rolled out. Is it that doctors are genuinely thinking they're going to be doing some good or is it more complicated? Is it related to the way we incentivize the business side of medicine perhaps?

Ian Harris:
Yeah. I think nearly all of medicine is done with good intentions. I don't think people are giving PRP injections or doing other procedures that don't work because they know they don't work. I don't think that happens very much at all. So, it is a system problem. The medical system, we have incentivized interventions and procedures and activity. So, the profit in the private sector is almost entirely proportional to turnover without more operations, more procedures, more admissions, and people in beds. That's how they make their money. So it's a very, what's the word? It doesn't follow an economic model very well because in economics, you'd produce more and you'd do more and you'd make more money, but that doesn't necessarily make people better. We're not trying to make a profit, we're trying to improve health, but unfortunately, the system incentivizes healthcare activity rather than health. There's no health outcomes that we need to achieve to satisfy any requirements or any payments. There's no health requirements. There's only health activity requirements.

Dr. Caroline West:
So on that point of health activity, which is a really interesting one, if we wind back and look at the way the system operates, do we need to go back and have a think about how we're even embarking on a health journey? So what we're doing around diagnosis, for example, or indeed, what's normal and what's abnormal, for example, what about the first entry point into the system, if you like?

Rachelle Buchbinder
I think one of the things that's probably changed in our time of being doctors is that it doesn't seem any more acceptable just to do nothing, to let's just wait and see, that it's probably going to get better, you probably don't need any tests, you probably don't need any treatment, it will probably just get better by itself. That whole idea of the body healing itself not needing to intervene seems to have been forgotten. People seem to expect that we'll do something every time they see us. They want something. I'm not sure that seems to have been a societal shift. I'm sure that some of it's contributed to by us because medical care will fix everything, there's all these medical cures, but we don't just stop to think, "Well, maybe the body's resilient and will get better by itself." We now know that many tests have downstream harms, and people don't understand that at the decision point of having a test, that that's actually a decision point. We've done some work on overdiagnosis, and the segue between having a test and potentially being over diagnosed and overtreated is not really very understandable to consumers. They think that you make a decision after you have a test, let's get the information, more information must be good, and then we can decide. So, they don't understand that tests themselves have harm. I mean, things like X-rays and CTs have radiation, which are harmful in themselves, but we often find things on imaging that will lead to downstream harm. We might have more tests. We might have treatments that we didn't need. There are lots of cases where people have unnecessary investigations that cause them to die like the recent case in Victoria of a worker who had a CT, I think CT angiogram of her heart as part of a healthy work assessment and actually died from the contrast and had a completely normal heart and normal arteries. So, I think consumers need to be more aware that just doing tests may be harmful in themselves and may lead us down rabbit holes. If you do 10 tests, one will be abnormal by chance.

Ian Harris:
It's a very difficult concept that, as Rachelle said, how can knowing more be harmful. There's lots of very good examples of where tests have been rolled out and have caused widespread harm. In South Korea, which was a classic example, they rolled out widespread testing for thyroid cancer with the best intentions because they thought, "If we diagnosed more thyroid cancers, we'll save more lives." So, everybody profited from this. So, the people who were doing the scans profited. They detected many, many cancers because what they didn't realize is that a certain low-grade form of thyroid cancer is very common. It just sits there indolent and doesn't hurt you, but they were detecting it by the bucket load. People were being referred to surgeons. They were having their thyroid taken out. Well, that means their on lifetime replacement of thyroid hormone. Certain percentage of them accidentally had their parathyroids taken out at the same time, which is a complication of that procedure, which disturbed their calcium metabolism and required further lifetime medication. Many of them had the nerve that runs around the thyroid to the vocal cords damaged and so they lost speech, and all these other complications occurred by the thousands. In the end, the difference in mortality for thyroid cancer did not change one bit. The same number of people still died of thyroid cancer because the people who had the severe thyroid cancers had it anyway, and what they were taking out were the ones that weren't going to hurt anybody anyway. So they had a massive screening program, which surely must be good and it saved no lives, caused deaths, and thousands of complications over many years.

Dr. Caroline West:
I think you've both touched upon a really interesting point there that there is a perception out there that doing more is better. The number of patients who've said to me, "Oh, look, I'm happy to take that risk because I just want to know everything about what's going on, and then we can put it on the table and we can decide which way I'm going to go." I mean, it's the same with PSA testing for the prostate that some people choose to go down that path because they say, "I'd rather know than not what my PSA level is." For those listening, it's a nonspecific test. It's not cancer-specific, but people use it to look at markers around the prostate that may align with risk in some instances, but there are downsides to that, too, that have been well-documented.

Ian Harris:
Yes.

Rachelle Buchbinder:
Yeah. I mean, what we need to realize is that our tests are getting better. So minute changes are being picked up more often, and that applies to imaging. So, when you look at an MRI scan now, you can pick up tiny nodules in the lungs, and most of them will be nothing, and you can pick up in these troponin tests. Nearly everybody that goes to an emergency department with chest pain will have a troponin test, and many of them will be falsely elevated because the test is so sensitive. So that's something really important to explain to patients. We have these things that we call incidentalomas. You do a scan, and you'll pick up other things that are probably not pathologic, but then might send you down that rabbit hole and get treatment for something that would never have harmed you in the first place.

Dr. Caroline West:
I often hear from doctors, "Oh, well, you don't know what it's like to be in fear of litigation. Of course, I'm going to order the tests that I think are necessary because I don't want to leave any stone unturned in case somebody comes back to me and says, 'Well, you didn't investigate this particular symptom.'" Is that what you found that there's this general sense of anxiety around this responsibility to the patient, fear of litigation, fear of consequences that's driving some of this overdiagnosis, overtreatment?

Ian Harris:
Yeah. Defensive medicine is responsible for a portion of the overtreatment and overdiagnosis that we see. In a way, doing the test or having more knowledge in itself shouldn't be harmful. It's what you do with the information, and it's just very difficult once you get that PSA, which is, "Oh, it's a borderline PSA. We better do a biopsy," then that biopsy leads to, "Well, gee, there's a borderline thing here, margin. We're not really sure what to do." So, wherever there's any gray zone and, "Well, we don't know what to do with that smudge on your test. We don't know what to do with this borderline test and biopsy," is that people intervene. When in doubt, I have a policy in surgery when I'm looking at a patient and I'm thinking, "Oh, gee, I'm not sure if that fracture really needs to be fixed or whether it'll be okay," and there's a bit of a discussion about it and some of the surgeons will weigh in. Whenever in doubt, I don't do anything, but that's the opposite for most doctors. It's, "Well, we're not sure so we'll just do it," and, "At least we tried," and often, that's the wrong thing to do.

Dr. Caroline West:
Is there also this issue of a knowledge asymmetry that occurs here where the doctor or the health providers often giving the management advice or suggestions, and yet the patient's taking all the risk, but it's nevertheless this uneven playing field?

Ian Harris:
Yeah, and it's been shown that doctors who recommend certain treatments wouldn't necessarily take those treatments themselves. It's been shown in many areas. In end-of-life care, many people when in doubt, "We're not sure whether we should go the whole hog with this patient who is perhaps a terminal patient or has a condition that can't be cured. Well, let's just do it anyway. Let's give them this aggressive chemotherapy or let's put them in intensive care because we just don't want to be seen to be doing the wrong thing. I mean, we just want to do everything we can," but many doctors would never have that done to themselves.

Dr. Caroline West:
I know, Rachelle, you've been a champion of Choosing Wisely, which is a global initiative, which really looks at reducing wasteful healthcare. Can you take us through your involvement with Choosing Wisely and how that may be useful for health professionals and consumers?

Rachelle Buchbinder:
Yeah. So, Choosing Wisely is a worldwide group of people that is actually led by doctors, so that's crucial, and different groups of doctors in different areas of medicine have been thinking about, "What top things I'm doing that I should stop doing?" So, it's trying to get doctors to take responsibility for thinking about what they themselves do that may not be appropriate, might be harmful, may not be beneficial, might be costly but the costs, they're not worth it. So in my area of rheumatology, the Australian Rheumatology Association looked at the top five things that we should stop doing or we should advise patients that are not worth doing, and that's been repeated in other areas of medicine as well. So, I think that's a really good way of getting doctors to think about their own practices and reducing things that are unnecessary. They're not just five. They're, actually, when we did it, we found over 20, but we then chose the top five. I think we should do it again and choose another five and another five and another five. It's making doctors aware that they're doing a lot of things that are unnecessary and patients, they should expect that they'll receive good evidence-based advice to make the best-informed decision that they can about their health. So I think it's about giving a responsibility to doctors to reduce their own low-value care. It's also empowering patients to ask doctors questions. So in the book and Choosing Wisely and lots of people have recommended that patients come with a series of questions to ask their doctor, and I think it should be a sign in all practices that, "We're a Choosing Wisely practice. Please ask me questions." I expect you to ask me questions so that we can really get patients to think about asking important questions like, "Well, why should I have this test? What would happen if I didn't have it? Is there any alternatives to having the test? What would happen if we just wait?" and the same applies to treatments, "Do I really need to have this treatment? What would happen if I didn't have it? What are the other options? What are the potential risks of doing this not just the potential for benefit?" If people regularly did that in every single consultation with their doctor where it was relevant, I think we would help doctors to ask the questions of themselves because I don't think they're challenged enough, and we really need to change the system. We've talked about harming patients, but also, we are harming the sustainability of the healthcare system and we're also harming the planet. If you know, in Australia, 7% of the carbon footprint is due to healthcare. So lots of healthcare that we do is harmful to the planet, but even things like low back pain where most people don't need any imaging, an MRI scan or a CT scan has much higher carbon footprint than a plain X-ray, yet we know that people are increasingly getting these more sensitive tests rather than simple X-rays when no imaging or just an X-ray would be just as good. So I think we've got to start thinking about those bigger picture problems as well.

Dr. Caroline West:
Yeah. As you say, affordability and sustainability is really central to this discussion as well because every time, somebody just orders a bank of tests. For example, when somebody goes in for a hospital admission, often tests are repeated and repeated and repeated without any clear reason as to why that is happening. It's just habit. As you say, it's not great in that it delivers low-value care, but it also costs a fortune, and we can't continue along this trajectory or we'll be gridlocked in a matter of five or 10 years’ time, I would've thought.

Ian Harris:
It's the opportunity cost. I mean, that money could be spent on high-value care instead of low-value care.

Dr. Caroline West:
Preventative care, for example, where we know that there's a strong evidence base and perhaps are we investing too little in that end of the picture?

Ian Harris:
Definitely. This is because the emphasis is on treatments, not prevention. So there's so many examples of good preventive medicine and so much benefit has been afforded to society from large public health measures of clean water, things over history. These are the things that have really contributed to longevity and health. Smoking in Australia has been a success story by the reasonably aggressive anti-smoking legislations and campaigns have worked very well, and that saved a whole lot of people from having cardiovascular disease and lung cancer down the track, but when it comes to other things, we're not so aggressive. So fund surgery for obesity, and this is complex surgery. It's not without complications. It's often done in people who have been obese for a while and probably already have the secondary diabetes, cardiovascular problems, and other health problems from that, and are we not doing enough to prevent obesity in society in the first place? That's just not where the priority is. The priority is to fund more and more expensive, complicated procedures to treat people at the end of that course instead of changing their course at the beginning.

Dr. Caroline West:
So where does some of the solutions live? To look at this as a systemic problem, which obviously affects individuals, but if we look at the big picture, what do we need to be thinking about? If we started from a consumer point of view, what's something that would be valuable to consider there?

Rachelle Buchbinder:
So I think, I mean, some of the things that we've already talked about, so trying to get consumers to ask questions of their doctor. I mean, it's really hard when patients, I mean, it's trying to get them to understand that they need to ask questions before they have the health problem, I think, because when you've got a health problem and you go to the doctor, you're so worried about the health problem that you probably can't think outside that. So it's probably starting even before that. In schools, trying to improve health literacy in schools, trying to improve science and the fact that there is evidence that supports or doesn't support medical care. So if we could educate children and young adults earlier like we have science and we have arts in schools, but we should also have health literacy in schools. I think that would help. Then we need a societal change towards understanding that the endgame is improving health, it's not more healthcare. We should be promoting positive health and resilience. As Ian says, prevention is much better than cure. Then we need a systems approach. So then we need to think about what can doctors do, what can universities do, what can they do in medical training, what can specialist training do. I think we need much more. We're meant to do continuous medical education, but we go and listen to things about the latest, I don't know, antibody that might help rheumatoid arthritis. I think the time would be really well-spent if we had to have science literacy as a fundamental part of our practice. Then we should stop introducing new tests and treatments before they're properly evaluated. So that might be a regulation that needs to change. We need to address media stories that are spooking miracle cures that are unbalanced, that don't provide the potential conflicts of interest of the people that they're talking to. So I think there's a whole thing, a whole of system things that we need to do, and we can't just do one thing because it won't work unless we address the whole system. Whenever I start talking about this, I get a bit depressed because it's such a hard problem to change.

Dr. Caroline West:
I suppose, though, that it starts with initiatives that start as catalysts. We need to start somewhere, and having your book raises the profile of this topic. Having Choosing Wisely gives consumers and health professionals tools to at least start conversations. I know they're little things, but it'd be nice to think that those little things mattered and that they could lead to much bigger things. I think if you look at this whole area of sustainability and the interest there of the intersection of health and sustainability, and that's really taken off in the last few years, it's amazing how once the culture starts to shift a little in terms of questioning and really looking for the evidence behind what we're doing, hopefully we will see some pivots there in terms of how we do things differently. Can I go to you, Ian? This is a podcast so nobody has the joy of seeing your faces, but I can see that this is something that's aligned with what you've been working towards.

Ian Harris:
Yeah. I'm just going to go on from what Rachelle was saying. There's so many health system changes that we could do. I mean, I look around at the worker's compensation system, for example, which costs a lot of money and spends a lot of money on health. I mean, they're paying roughly around $100 for every spine fusion that they're funding for back pain, and the results are terrible. They're absolutely terrible, and they need to look at what they're paying for. It's very difficult for the surgeons to not do it when they're being paid $20,000 to do a single procedure. The hospitals want it. The patients want it. The system in worker's compensation is so ridiculous that the compensation that patients receive goes up enormously if they've had spine fusion surgery. If you have back pain, you're actually entitled to no impairment under worker's compensation, but if you have a fusion for back pain, you are automatically entitled to 25% impairment. These are these ridiculous system problems that actually propagate bad medicine and don't make any sense at all. So I agree with everything Rachelle said. I mean, we shouldn't be doing anything unless we've got evidence that it works. So there's no new procedures without testing, and stop funding procedures. If you look at the UK system, for example, where doctors are paid, full stop, a salary. They don't get paid to operate, they just get paid. You compare it to the US system where surgeons over there really get paid when they operate. You look at the rates of spine fusion between the two countries. There's something an eight to tenfold difference in the rates of surgery between those two countries, which is largely explained by the way the health system is funded.

Dr. Caroline West:
Just to be clear, you're saying that there's no evidence that spinal fusions work for-

Ian Harris:
For back pain.

Dr. Caroline West:
For back pain?

Ian Harris:
Yeah. Well, there's evidence that they don't work, but in the worker's conversation in particular, the need to have further spine surgery within two years is about 20%. The return to pre-injury duties rate is around 3% at two years and around 90% of patients are still getting major opioids and physiotherapy two years after their surgery. This is an operation that's meant to make them better. Yet, the operation means that they have ongoing treatment, don't go back to work, and have an increase in their impairment rating. Doesn't make any sense at all.

Dr. Caroline West:
So it's interesting how you say when something's incentivized like that it can totally shift the numbers in terms of how many people buy in to that treatment. Probably if you ask any of those surgeons who prescribe that treatment, as you said earlier in the podcast, people often in good faith repeat their management because they think, "I'm doing a good job. My patients love me. I've got good feedback."

Ian Harris:
"Well, the patient's got a problem. There's something I can see on the MRI. So why don't we just give it a go? We will never know until we try." I mean, it's easy to justify things like that. It's interesting that there's such a disparity between the spine fusion rate in the public sector where it is rarely done for back pain than the private sector. So why is that?

Dr. Caroline West:
Fascinating. In terms of your own experience, you've obviously become experts in this field and perhaps less is more, how have you integrated that into your own practice? Have you had to put the mirror up and go, "What am I doing myself in my practice? What could I be doing differently?" I mean, how do we as clinicians start that?

Rachelle Buchbinder:
Yeah. I actually often have to think because I'm so anti-everything, I have to stop and make sure, "Maybe I should do something in this patient." So I'm going a bit the other way, but I think now what I do when I'm thinking about doing a test, I need to understand why am I doing that test because I don't think we think before we do tests, and as you were saying before, people do batteries, batteries of tests. So we need to understand, "Will it change my management doing this test? What's the protest probability that I'm looking to change by doing the test? If it's not going to change, then maybe I shouldn't do the test." I think the other take home message is, "Could I harm the patient by just waiting?" because many things just get better, and maybe we can just review whether you need to do the test. I think that that keeps it safe. I think, like all doctors, I don't want to miss anything that's treatable, but I think that we can temper what we do. We can involve the patient in our decisions, and we can explain why less is more.

Dr. Caroline West:
Ian, how have you managed to process this on a personal level?

Ian Harris:
Yeah. My practice has changed enormously. So when I started practice, I used to do a lot of spine fusions, knee arthroscopies, fixed a lot of fractures that maybe didn't need fixing. So my practice has changed enormously. I have a very conservative practice and I'm known for that. So I'll often get referred patients from GPs because they know that I wouldn't recommend surgery unless it was really necessary. So maybe I get a bit of a slanted practice, but I think it helps because people see me and people train under me and I have orthopaedic trainees that work for me and rotate through and they get to see what it's like in my clinic when we treat fractures without surgery and how they heal and the patient does fine, and they often get surprised, but it's good to do that. This is how things change is that people change and then they influence other people and they change. I often ask my trainees when they come through. I'll be on call and they'll say, "Oh, I've got a patient with this, and I think they need surgery. I'll book them for tomorrow." I say, even for obvious things, I say, "Why? Why are you doing the operation?". Often, they're stuck. They're like, "Well, that's just what we do. Everywhere I've worked, this is what we do.". I go, "Why? Can you tell me that that's better than not doing it?". "Oh, I don't know." So it makes them think about it a little bit more, and that's what we need, I think.

Dr. Caroline West:
That's a great point in which to end that question of why and pause and consider your options very carefully getting back to the Choosing Wisely questions of, "What would happen if I did nothing?" So thank you so much for your conversation today. It's been a really interesting chat and very timely, indeed. I've been talking to Professor Rachelle Buchbinder and Professor Ian Harris, and they're both authors of Hippocrasy: How Doctors are Betraying Their Oath. Thank you both so much for being with us today. It's been a really fascinating conversation and I'm certainly going to go away and think about how I do things as a GP. And I think that anybody listening, who's a health professional, and indeed a consumer will be asking that question, why? It's such a good thing to always remind ourselves of. So thank you to Professor Rachelle Buchbinder and Professor Ian Harris, authors of hypocrisy, How Doctors Are Betraying Their Oath. It's certainly a very timely book, highly recommended, and it challenges our perceptions about modern healthcare. I've got a copy myself. I read it in no time at all because I thought it was just so riveting. Thank you for taking the time out to write it. It's no short project to write a book. It's one of those things that takes total focus, so well done to both of you. No conflicts of interest have been declared by the way. And if people would like any more information on this and information on CPDs for this podcast, please go to our website nps.org.au. I'm Dr. Caroline West, thanks for joining us. That's okay. Bye for now.