The Economist (“Many surgical interventions are little better than placebo“):
EACH YEAR, according to the World Health Organisation, over 300m operations are conducted worldwide. Patients in the rich world are more likely to go under the knife—about 60% of people in England are expected to undergo surgery at least once in their lifetime. Some of these procedures are clearly life-saving, such as organ transplants and emergency Caesareans. But as the number of other operations continues to grow, some in the field are starting to ask an awkward question: how many are really necessary?
Answers have long been hard to come by, in part because few randomised controlled trials (RCTs), the gold-standard type of research used to assess medications, were conducted on surgical procedures. That made it difficult to know if patients got better more often with surgery than they might have without. This is now changing. The number of surgical RCTs funded by Britain’s National Institute for Health and Care Research increased from 34 in 2011 to 188 in 2023, and national surgical-trials programmes are active across Europe as well as in Australia and Canada.
The results are upending the field. Removing an inflamed appendix, an operation that around 5-10% of people have had at some point in their life, has turned out to be no better for most patients than a course of antibiotics. Trials comparing different surgical techniques have also revealed that cheaper and less complex operations can be more effective. Most striking, the data show that some widely used surgical procedures, such as spinal fusions and rotator-cuff repairs, have effects indistinguishable from placebo or non-surgical care such as physiotherapy.
Worse, some types of surgery may do more harm than good. A trial in Britain found that prostate-cancer surgery had no effect on patient mortality 15 years on, but worsened sexual and urological problems. A Finnish trial of a common knee procedure, meanwhile, concluded that patients who had real surgery had more problems in the affected knee ten years on than those who had had sham surgery (anaesthesia followed by a superficial incision). David Ring, an orthopaedic surgeon at the University of Texas at Austin, reckons that most operations in his field may be unnecessary. Surgery itself, it would seem, could use a major intervention.
It turns out that most of the perceived benefits result from a combination of the placebo effect and the body’s natural healing.
Then there’s this:
The nature of a country’s health system also plays a role. Disfavoured operations decline faster in countries where surgeons are salaried, as in Britain and Scandinavia, than in countries such as America where they are paid per operation and act as small businesses. Shoulder surgeries to remove a bone spur fell from 28,000 in Britain in 2016-17 to 5,720 in 2019-20, after trials found that the procedure was no better in alleviating pain than sham surgery. In America the procedure remained popular.
But it is not just surgeons who need to trust the data: a growing number of patients insist on surgery on the basis of inconclusive tests. All too often, says Dr Ring, scans reveal abnormalities that are little more than tissue tears; as natural a by-product of ageing as wrinkles and grey hair. What’s more, he says, these things are unlikely to be what is causing patients’ problems. A growing number of studies, in fact, show that the abnormalities in knees, backs and shoulders that orthopaedic surgeons try to fix are very common in people who have no symptoms at all.
But the promise of a quick fix is hard to resist. “It is becoming more and more difficult to say ‘no’ to the patient,” says Dr Lohmander. In America some surgeons fear their patients will leave them a bad review online, and insurance companies still cover ineffective procedures for fear of losing customers to their competitors.
The free market at work!
