This story was first published on March 26, 2022 and has been resurfaced as the Listener brings back its best health features.
Dr Rachelle Buchbinder has been heckled and intimidated. Once, she had an email from a stranger suggesting that she put her head in a microwave and turn it on. And that was relatively mild compared with the more recent harassment she has experienced via email, social media, blogs and letter-writing campaigns.
“They’ve been trying to besmirch my reputation, get me sacked or not funded. It’s been vicious and horrible, and sometimes I ask myself why I’m doing this,” says Buchbinder, an Australian rheumatologist, epidemiologist and researcher.
The microwave-related message was an angry response to a 2002 study in which Buchbinder showed that ultrasound-guided shock-wave therapy is no better than a placebo when it comes to easing the pain of the foot condition plantar fasciitis. And the harassment that continues to this day was the result of her 2009 trial that found a procedure called vertebroplasty – injecting a type of acrylic cement into vertebrae that have collapsed or fractured – is no more effective than a sham treatment.
The abuse isn’t the only thing that has persisted. Both of these procedures continue to be performed, despite the science debunking their usefulness.
Given the personal cost and the apparent lack of impact, you might wonder why Buchbinder bothers. However, rather than allowing herself to be silenced, she has teamed up with Australian orthopaedic surgeon and author Ian Harris to write a book, Hippocrasy, that exposes the many ways modern medical professionals are betraying the ideals of the Hippocratic oath and the commonly associated pledge, “First, do no harm”.
“We’re both clinicians, and we’re increasingly aware of the harm that comes from overdiagnosing and overtreatment,” she says.
In the book, Buchbinder and Harris claim that one of the greatest threats to human health is, in fact, the healthcare system. Unnecessary tests are leading to treatments that may not benefit a patient and may even hurt them. Some of those treatments were accepted into practice before being properly evaluated, and the subsequent science is being denied or overlooked.
We are all at risk of too much medicine – it has been estimated that a third of clinical interventions are futile at best and medical care remains a leading cause of death.
Harris has written about this before, in his book Surgery, The Ultimate Placebo, but Hippocrasy goes further, looking at medicine from birth to death. The wide-ranging treatise covers the overmedicalisation of ordinary human experience; the perils of healthcare being run as a business; the routine screening that carries a risk of detecting abnormalities that may never have caused a problem; the creation of new diseases and the lowering of thresholds; the surfeit of end-of-life care; and the dilemma of doctors as they try to meet the expectations of their patients.
Critical thinking
Buchbinder and Harris stress that they aren’t anti-medicine and their aim isn’t to erode trust in doctors. What they are shooting for is science-informed healthcare, with more critical thinking from medics and greater health literacy among patients.
“Many doctors agree with us,” says Buchbinder. “Some with vested interests may not be so happy, but I think most are starting to see that this is the right way.”
One of the procedures they highlight is knee arthroscopy, a keyhole surgery that “cleans out” the knees of people with damaged cartilage or meniscal tears. Many studies have shown it to be no more effective than placebo or exercise therapy for most conditions, yet it is still often recommended to treat degeneration of the knee.
Harris has recently been engaged in a back and forth with some of his fellow surgeons over an arthroscopic shoulder procedure that involves shaving off bone to stop it impinging on the rotator cuff tendons. Two studies have shown this is no better than placebo surgery, he says.
“I explained how the evidence says this procedure doesn’t work. The final email I had from them said, ‘Well, that may be the case, but we think it works.’ And that’s really what it comes down to. They don’t believe the high-quality evidence because it conflicts with their beliefs.”
Financial incentives
Money is certainly among the reasons some low-value healthcare is happening – after all, medicine is a business like any other. “The whole medical system is structured so you get paid for doing things,” says Harris. “What surgeons earn from consulting just keeps things ticking over – they get paid to operate, that’s where they make their money.
“Everyone is incentivised to treat. You don’t walk away from a chiropractor having been told that your spine is straight and you don’t have any problems. Every time you see a physiotherapist, there is some muscle that needs fixing. The whole industry wants you to be a high-turnover doctor: the companies that make medical products and drugs, everybody wants turnover.”
Patient expectation also has a part to play – we want those tests to show us exactly what is going on and any treatments that might fix us. “It’s difficult to explain to people how getting a test that increases the information they have can be bad,” says Harris. “How can more knowledge be harmful? But back scans are a good example; every back MRI shows something. You’ve got a problem like low back pain, and then the scan shows an abnormality – a bulging disc or narrowed nerve canals – so therefore your problem must be due to the abnormality. In fact, it’s most often not.”
Back pain can resolve itself in time, while many of the treatments used to fix it are unproven and potentially harmful.
Also, since modern scanning machines are becoming more sensitive, they are picking up smaller and smaller abnormalities.
“The risk is that you pick up things that are irrelevant, that are going to worry the patient, worry the doctor, lead to more tests and then a cascade of treatments,” says Buchbinder, “when actually the best thing might have been to do nothing.”
An example she likes to use is the thyroid cancer “epidemic” in South Korea, where the incidence of this disease increased tenfold between 1999 and 2012. It became the most commonly diagnosed cancer for women and South Korea had the highest rates in the world. This has now been attributed to the widespread practice of screening for thyroid cancer using ultrasonography, which started in the early 2000s and resulted in the greater detection of small “clinically indolent” tumours.
“Young women in South Korea had their thyroids removed because of cancers that would never have harmed them,” says Buchbinder. “They now have a scar and need lifelong thyroid hormone therapy. It caused untold amounts of vocal cord paralysis and ended up saving no lives.”
Beware the hero
The more tests doctors perform on non-symptomatic people, the more likely they are to find “incidentalomas” — things that are normal for the patient’s age.
This can lead to surgeries that carry risks, and drugs that cause side effects, when possibly the “incidentaloma” would never have resulted in any problem at all.
Doctors may be unwilling to say no to patients. Their intentions are good, they believe they are genuinely helping and can fear missing a diagnosis, so order all the tests just to be sure.
“A doctor doesn’t want to be seen as a failure,” Harris says, “They have to come up with an answer.”
He advises people to beware of the hero surgeon, the one who does the huge operation no one else can do because they’re not as good or bold enough a doctor. “I’ve never known a surgeon to be scared of operating; they’re more than happy to operate. The reason no one else in the world does that operation is because it doesn’t work.”
One of the more common procedures in medicine is cardiac stenting. This involves a metal tube being inserted into a narrowed artery to widen it, and is often performed on people with what is called stable angina – they have chest discomfort when pushing themselves physically, which eases with rest or medication.
Harris and Buchbinder argue that although this treatment may make sense on the face of it, if the person wasn’t having a heart attack then the body must have adapted to the narrowing by opening up other arteries to maintain blood flow. Stenting surgery may bring complications. Anti-coagulant drugs will need to be taken for life to stop the stent blocking. There are clinical trials to prove that, for stable angina, stenting offers no more benefit than drug therapy alone and doesn’t reduce the chances of dying or having a heart attack.
“Stenting sounds appealing, but it’s not as simple as a plumber coming out and clearing the blockage and then it works forever,” says Harris.
Reframing pain
Often, measures taken with the best intentions can have disastrous consequences. The opioid epidemic is a compelling example. A huge crisis in the United States, it is now affecting developing countries around the world, causing many thousands of overdose deaths and addiction problems. And it is a tragedy caused by the medical system.
The roots of the problem lie in the 1990s, when the American Pain Society came up with the idea that pain should be the fifth “vital sign”. Screening patients for pain and treating them became accepted practice. Around the same time, a new, longer-acting and, as it turned out, potentially addictive opioid called OxyContin was released.
“How could this be bad? Let’s just stop everyone having pain. Won’t that be great?” says Harris, dryly. “But pain is there for a reason, and, particularly after surgery, it’s temporary.”
Framing things differently – letting patients know how much pain they can realistically expect and how long it will last – and using lower-risk therapies are likely to have better outcomes. In fact, new research from Australia, published in JAMA, the Journal of the American Medical Association, has shown that strong painkillers after surgery for a broken bone may not be necessary at all. Patients prescribed the strong opioid oxycodone had the same level of pain relief as those who took a far lower dose of codeine and paracetamol.
Pain, it could be argued, is a normal human condition. As is the weakening of muscles in older age, which, since 2016, has been recognised as a geriatric syndrome, sarcopenia, resulting in a variety of drugs being investigated as a potential treatment.
Thresholds for hypertension (high blood pressure) and type 2 diabetes have been decreased. Unhappy people are medicalised even though anti-depressants are ineffective for a large proportion of them. There is a move to classify those with a BMI of 25-30 as pre-obese rather than overweight, as if it is inevitable that they will become obese eventually. Rates of ADHD are climbing.
Buchbinder and Harris question how helpful some of these diagnoses are and whether there is anything to be gained by medicalising “normal”.
Screening pros & cons
Some of what they say is uncontroversial. No one is likely to take issue with the idea we should avoid using antibiotics unnecessarily. Many would agree that a comfortable death is preferable to aggressive care and intensive treatments at the very end of life.
More contentious is their opinion that screening for cancer in well people can do more harm than good. Public health programmes such as BreastScreen Aotearoa are seen as crucial for early cancer detection. And there is at least some evidence that the benefits outweigh the risks – a 2010 UK study of mammographic screening found that between two and 2.5 lives are saved for every overdiagnosed case.
The US Preventative Services Task Force has cited overdiagnosis as one of the chief potential harms associated with mammography because of the unnecessary treatments that follow. Previous estimates had the rate at one in three. However, the latest research suggests that the problem might not be as large as previously believed. A study from Duke University and the Fred Hutchinson Cancer Research Centre, looking at a large cohort of women, found that the rate of overdiagnosis may be as low as one in seven.
Meanwhile, routine prostate cancer screening has been shown not to reduce death rates from the disease. Buchbinder and Harris say the problem is these tests may not detect the very severe cancers that kill people, as they tend to grow rapidly and are unlikely to be caught at the moment of screening. But they will show milder forms of the disease, which are growing slowly or possibly not at all, and abnormalities that can be precursors for cancer.
The pair stress that they don’t want to dissuade people from getting screened, particularly if they are in a high-risk group. “But you always have to think about the potential downside, to balance the benefits against the potential harms,” says Buchbinder.
Hidden costs
Too much medicine doesn’t necessarily improve health; it may do the exact opposite. Resources are limited and money spent on unwarranted care is money that cannot be spent on necessary treatments.
The book cites a US Institute of Medicine (IOM) estimate that 30 cents of every dollar spent on healthcare in the US is for unnecessary care. According to a paper in the science journal PLOS One, the IOM in 2010 estimated the cost of unnecessary services was about US$210 billion of US$750 billion in excess spending each year.
Healthcare also has a high environmental cost. It requires a lot of electricity to run hospitals and manufacture drugs, and creates large amounts of waste. Some of the anaesthetic gases used have high carbon footprints. In New Zealand, the healthcare sector is estimated to contribute up to 8% of the country’s total greenhouse-gas emissions.
There is an emphasis now on improving sustainability. For instance, Counties Manukau District Health Board has reduced its carbon emissions significantly through measures such as better recycling and reducing anaesthetic gases. And in Christchurch, the Forté Health private hospital precinct has been certified carbon zero.
“If we get rid of all the unnecessary stuff, which we know is at least 30% of healthcare, that would be a huge shift for environmental costs,” says Buchbinder.
Given the distrust of medical researchers and doctors that has become much more evident and concerning in the Covid-19 era, is this the greatest timing for a book that risks eroding that trust further? “Yes,” says Buchbinder, who points out that lockdowns have created a backlog of elective surgeries, and there will be people who delayed having tests they needed for things such as cancer who will now urgently need care. “So, we need to direct our resources, and be even more sure we’re not doing overdiagnosis and overtreatment.”
There is a sweet spot between believing that everything works, with associated overtreatment, and the idea that nothing works. Medicine today is at the overtreatment end of the spectrum, Harris and Buchbinder argue. A lot can be done to redress the balance: better training for doctors to help them identify wasteful tests and procedures, more engagement from professional societies, disinvesting in low-value care by healthcare funders.
Patient power also has an important role to play, although the pair recognise that it can be difficult for people to question the authority of their doctors.
“You need to have some health literacy and a degree of scepticism,” says Buchbinder. “And you have to ask the doctors the right questions. What are the alternative treatments, what are the potential harms, what would happen if I did nothing?
“You shouldn’t accept anything in blind faith. If you’re not sure, then you should ask for a second opinion or a third. And take someone to the appointment with you.
“In my hospital, I keep pushing for health advocates who can be with the patient and listen, and then ask any questions the patient doesn’t feel able to ask. And I think we have to teach it in schools – teach about evidence, rationale and logic and apply it to health so that patients feel less awkward about asking what the evidence is for a treatment and whether it really works.”
Healthy scepticism
Both would like to see more scepticism on the part of patients, and less acceptance that a treatment must be good just because a doctor has offered it.
Ironically, the Covid-19 vaccine has been a rare example of this happening. Harris admits he finds the inconsistency frustrating. “All of a sudden, they’re sceptical. There are all these trials that show it works, but they want long-term trials. And then they’ll go to see someone who’ll say, ‘I’m going to fuse your back for your back pain.’ It’s a huge operation, with no benefit and high risks you could die from, and it’s like, ‘Yeah, give it to me.’”
In New Zealand, a bid to reduce unnecessary tests and treatments is being led by Nelson ophthalmologist Derek Sherwood and Waikato emergency medicine doctor John Bonning. They are behind Aotearoa’s participation in an international movement, the Choosing Wisely Campaign. Launched here in late 2016, there has been a positive response, on the whole, from medical professionals. The medical bodies have identified key areas where doctors should hold back – mostly tests that shouldn’t be ordered in various circumstances. Almost all the country’s DHBs are involved in the programme.
“Probably due to the financial constraints, the idea of being thoughtful about what tests you order and not overordering already resonated quite strongly with a lot of New Zealand healthcare professionals,” says Sherwood. “And Choosing Wisely is one of a number of initiatives that are all aiming to do the same thing – trying to get better shared decision-making and the right care for patients rather than unnecessary tests and treatments. Advanced care planning is another example.”
New Zealand’s situation is very different from that of the US, where overtesting and overtreatment have reached “grotesque” levels, says Sherwood. But we still have plenty of areas to tighten up. One issue that Choosing Wisely NZ has identified is inappropriate urine testing for urinary tract infections, which results in some women unnecessarily being given antibiotics to treat bacteria that are naturally present in their urine and not causing them any harm.
Another is CT scans as a routine part of a dementia diagnosis, says Bonning. “If someone has developed early dementia you would certainly be doing one – [or] if there’s an acute element, they’ve got a haemorrhage, that sort of thing. But it shouldn’t be routine; there ought to be a clear indication for it.”
Box-ticking tendency
This isn’t about saving money or rationing healthcare, Sherwood and Bonning are at pains to point out. The aim is to use the resources that we have to best effect, for a more effective and equitable system. One of the hardest things for a doctor to do is nothing. You never see newspaper reports about people who are angry because they had unnecessary CT scans. Omissions tend to be what doctors are punished for, so it may seem easier to order the tests than suggest a patient doesn’t need them.
“We’re working in clinical environments where people feel pressured for time and it’s easier to tick a box on a form and do a scan,” says Sherwood. “We may not have the language or confidence to talk to patients and explain why it’s probably better to wait and see.”
With the increase in virtual care, and doctors treating patients via Zoom or phone rather than in-person, inevitably more box-ticking will be going on.
For a time, Choosing Wisely NZ had the funding to have someone dedicated to working with professional medical bodies, educators and DHBs, getting them on board with the campaign. That supply of money has run out now, and the focus is on increasing the general public’s understanding that more is not always better.
“I see this as a problem that we will always have,” says Sherwood. “Each time a new technology, new drug or surgical procedure comes along, there is a tendency for them to be overused. We don’t want to scare people off having necessary treatment, but we do want to greatly improve health literacy and to get the community better at questioning medical technology.
“If people are more confident about discussing risks and benefits, I think they’ll understand that there are no certainties, tests are not always accurate and that it’s reasonable to question and weigh up the advice before coming to the decision that is right for them. It’s an ongoing maturation of us as a society in terms of our relationship to healthcare.”
Risks vs benefits
Questions to ask your doctor:
- Do I really need this test?
- What are the risks?
- Has this treatment been proven to work in high-quality studies?
- Are the benefits worth the risks?
- Are there simpler, safer options?
- What happens if I don’t do anything?
Hippocrasy: How doctors are betraying their oath, by Rachelle Buchbinder and Ian Harris. NewSouth Books, $39.99.
