Saturday, 12 March 2016

Book review, of my book: Surgery, the ultimate placebo.

This will be a test of how unbiased I am. Writing a review of my own book (regardless of any bias) seems like shameless self-promotion, but what the hell, it's better than just saying "Hey, I wrote a book".
In Surgery, the ultimate placebo Professor Ian Harris, an orthopaedic surgeon clinician and academic provides us with a view that is not often considered – that some surgery may be ineffective, or as effective as placebo. Much has been written recently about the interesting topic of placebos, and much has been written about ineffectiveness and overtreatment in modern medicine; Professor Harris ties it together and applies it to surgery.

The opening gives us historical perspective, then the first few chapters are mainly devoted to the placebo effect and how it works (or doesn’t, because placebos, by definition, don’t have an effect – this is explained). He makes the case for surgery having a strong ‘placebo effect’ because of the invasive nature, cost, technology and the attitude of the practitioners.

In the middle chapters, there are examples of placebo surgical procedures past and present. Some well-known and some not. Professor Harris is well known for some of these views, and there is a risk that his wish to show surgery as a placebo has biased his presentation of the evidence. Certainly, he only presents the less effective procedures, but his message is not that all surgery is placebo and he acknowledges this. His overall message is that the effectiveness of surgery (even in those procedures that are effective) is probably overestimated and that the harms are similarly underestimated. Sort of: if all of these previously well established procedures ended up being ineffective, what about the procedures we are doing now?

He provides some reasons why current practice continues, apparently often uncoupled from evidence, or without evidence, but this is coming largely from experience and conjecture and there is little data provided that might have provided more insight into the relative contribution of many of the factors mentioned. More like ‘food for thought’ but for a book (not a research paper), that’s OK. There are plenty of references provided at the end for anyone who wishes to pursue the evidence further.

The last few chapters ask us why we should care and what can we do about it. Like many books and articles pointing out the lack of effectiveness of modern medicine, solutions are generic (more information, better science, more scepticism) and more thought could have been put into concrete solutions that may be implemented.

Overall, the book provides an interesting read especially for those not familiar with this topic, mainly through the use of examples, and the explanations provided. While it might change a few minds, it is not likely to influence the larger problems (to which he refers) to any great extent. The aim of the book however, is to make people think differently about surgery and I think it will achieve that. For regular readers of the blog, many sections will be familiar, but I personally prefer having the whole message packaged in a tangible (and not too thick) book.

My verdict? I would buy this book if I hadn’t written it and been given a copy for free.


Surgery, the Ultimate Placebo is published by NewSouth Books (here) and available in paperback and Kindle (Amazon) through most outlets.

10 comments:

  1. Wow! What a seemingly unbiased review from the admittedly biased author! How much fairer could any reviewer be? I do wonder, however, why the criticisms he poses here were not addressed in the book itself. Hindsight, perhaps? Anyway, it sounds to me like an interesting book that I'll probably end up buying.

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  2. An impartial reviewer would have given some examples from the book of placebo surgery still in practice.

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    1. An impartial reviewer would (hopefully) have heaped endless praise on the book: "timely", "courageous", "undeniable logic", "opened my eyes" etc.

      Interesting though, with all the interviews I have done recently, this is the number one question: give us the list of procedures. I think the book goes further and challenges us to discover the evidence for ourselves and to make our own (better informed) decisions.

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  3. Great book. Easy read and full of profound insight into the nature of medicine. It is nothing less than a Novum Organum for thinking about surgery. It should be a must read for all medical students.


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  4. Le Médecin malgré lui "The doctor/physician in spite of himself" is a farce by Molière first presented in 1666. Bias goes way back! "This is the best craft of all; for whether you cure or make worse, you always get paid. We never have to bear the burden of bad work, and we cut, as we please, from the material that presents itself.
    A cobbler, in making shoes, cannot mis-cut a bit of leather without eating the cost; but here one can mishandle a patient without a loss. Botched results are nothing to us; for they’re always the fault of the patient that dies. And lastly, the best of this profession is that there is an honor among the dead, a discretion, that ranks as the greatest in the world;
    for no patient yet has carried a complaint against the doctor who’s killed him. -Sganarelle's Monologue

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  5. A spectacular book. I agree with the Dr. Covert that it ought to be required reading. My only regret is that I will finish it too fast!

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  6. Thank you for this website, and thank you for your book. Two very good orthopedic surgeons recommended surgery when an MRI showed a full-thickness tear of my rotator cuff. You gave me the courage to forestall the operation and pursue non-surgical management. This has been successful, and I am so grateful.

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  7. On August 3, 2016 Gina Kolata wrote an article for the New York Times called "Why Useless Surgery is Still Popular?" I just assumed she'd read your great book as I have but unfortunately there was no reference to it at all! I know you're on Twitter and so is she but I'm not. She needs to know about your book.

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  8. Modern medicine has brilliant skills in surgery, of that there is no doubt, but, as a profit-driven industry, surgery has become a commodity, to be marketed wherever possible. It is in essence the ice-cream of the medical world.

    My understanding was that the invention of antibiotics removed much risk from surgery and led to the explosion of surgical intervention, probably for more ill than any good, the cavalier removal of tonsils and adenoids from the beginning of the antibiotic era, being a classic example.

    One wonders how many doctors were taught in medical school about the recognised link between this practice and the incidence of severe paralytic Polio. I understand that whipping out tonsils and adenoids is now less common, but it still seems to be a solution too often used because there is nothing else modern medicine can do.

    Anything which reduces the prevalence of surgical intervention can only be a good thing and perhaps the demise of antibiotics will contribute to that positive outcome.

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    1. Thanks. I am not aware on any link between tonsillectomy and severe polio. Any references you could give me would be appreciated.

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