Surgery, The Ultimate Placebo

1. Surgery's Perceived Effectiveness Often Exceeds Reality

For many complaints and conditions, the real benefit from surgery is lower and the risks are higher than you or your surgeon think.

Perception vs. Reality. The book challenges the common assumption that surgery is always the best or most effective solution for medical problems. It argues that the perceived effectiveness of surgery is often inflated due to factors like the placebo effect, natural healing, and biases in how results are measured and reported. This overestimation can lead to patients undergoing unnecessary procedures with potentially harmful consequences.

The Illusion of Causation. Humans are naturally inclined to attribute cause and effect when they observe one event following another. If a patient feels better after surgery, they assume the surgery was the cause, even though other factors may be responsible. This can lead to a false sense of confidence in surgical interventions, even when scientific evidence suggests otherwise.

Importance of Skepticism. The author advocates for a more skeptical approach to surgery, encouraging patients and doctors alike to question the evidence supporting surgical procedures and to consider non-surgical alternatives whenever possible. This skepticism is not meant to dismiss surgery entirely, but rather to promote more informed decision-making based on sound scientific principles.

2. The Placebo Effect in Surgery is Powerful and Multifaceted

The placebo effect is basically the perceived therapeutic effect, minus any specific therapeutic effect (even if there is no specific effect).

Beyond the Physical. The placebo effect is not simply about "mind over matter." It involves a complex interplay of psychological and physiological mechanisms that can influence a patient's perception of pain, well-being, and overall health. In surgery, the placebo effect can be particularly strong due to the invasive nature of the procedure, the high expectations surrounding it, and the therapeutic environment of the operating room.

Components of the Placebo. Several factors contribute to the placebo effect in surgery, including:

• The patient's belief in the effectiveness of the procedure
• The surgeon's confidence and enthusiasm
• The ritualistic nature of the surgical process
• The social and cultural expectations surrounding surgery

Sham Surgery Studies. The book highlights examples of sham surgery studies, where patients undergo a placebo surgical procedure (e.g., an incision without any actual intervention). These studies often reveal that a significant proportion of patients experience improvement, even though they received no specific therapeutic benefit. This underscores the power of the placebo effect in surgery.

3. Scientific Rigor is Essential to Determine True Surgical Effectiveness

The scientific method (so called ‘evidence-based medicine’) was the only way of reliably knowing things – that there were significant flaws in relying on observation and tradition.

Observation vs. Experimentation. The book emphasizes the importance of distinguishing between observation and experimentation. While observation can provide valuable insights, it is prone to biases and cannot reliably establish cause-and-effect relationships. Experimental studies, particularly randomized controlled trials (RCTs), are essential for determining the true effectiveness of surgical procedures.

The Gold Standard. RCTs, especially those that include a placebo or sham surgery control group, are considered the gold standard for evaluating surgical interventions. These studies help to isolate the specific therapeutic effect of the surgery from the placebo effect and other confounding factors.

Minimizing Bias. The book discusses various sources of bias that can distort the results of surgical studies, including:

• Selection bias
• Performance bias
• Detection bias
• Publication bias

By understanding and minimizing these biases, researchers can obtain more accurate and reliable estimates of surgical effectiveness.

4. Many Common Surgical Procedures Lack Solid Evidence

At the Federal Drug Administration in the US, and in similar bodies worldwide, surgical procedures are left out. There is no need to test a surgical procedure against anything, let alone in an experimental study, before using it.

Regulatory Oversight. Unlike pharmaceuticals, surgical procedures are not subject to rigorous pre-market testing and approval processes. This means that many surgical interventions are adopted into clinical practice without sufficient evidence of their effectiveness or safety.

Examples of Questionable Procedures. The book highlights several common surgical procedures that have been shown to be no more effective than placebo or non-surgical alternatives, including:

• Knee arthroscopy for osteoarthritis
• Vertebroplasty for osteoporotic vertebral fractures
• Surgery for tennis elbow
• Spinal fusion for back pain

The Need for Scrutiny. The author argues that these examples underscore the need for greater scrutiny of surgical procedures and a more rigorous approach to evaluating their effectiveness.

5. Human Nature and Biases Drive Ineffective Surgical Practices

The tendency for human beings to attribute cause to an effect when they see one thing follow another is hardwired.

Cognitive Biases. The book explores various cognitive biases that can influence surgical decision-making, including:

• Confirmation bias: Seeking out information that confirms pre-existing beliefs
• Availability heuristic: Overestimating the likelihood of events that are easily recalled
• Anchoring bias: Relying too heavily on the first piece of information received

The Desire to Treat. Doctors have a natural inclination to treat patients, even when the evidence supporting a particular treatment is weak. This desire to act can lead to overtreatment and the adoption of ineffective surgical procedures.

The Power of Tradition. Surgical practices are often passed down from one generation of surgeons to the next, with little questioning of their effectiveness. This reliance on tradition can perpetuate the use of ineffective procedures, even in the face of contradictory evidence.

6. Financial Incentives and Legal Concerns Distort Surgical Decision-Making

Industry sponsorship of research, for example, has been associated with better results than non-sponsored studies for various treatments, including surgical procedures.

Conflicts of Interest. Financial incentives can influence surgical decision-making, leading to the overuse of certain procedures. Surgeons who have financial ties to device manufacturers may be more likely to recommend those devices, even if they are not the best option for the patient.

Defensive Medicine. Legal concerns can also distort surgical decision-making. Surgeons may be more likely to recommend surgery, even when it is not clearly indicated, to avoid the risk of being sued for malpractice.

The Cost of Ineffective Surgery. The book emphasizes the significant financial costs associated with ineffective surgical procedures, including the direct costs of the surgery itself, as well as the indirect costs of complications, rehabilitation, and lost productivity.

7. Ethical Double Standards Hinder Progress in Surgical Evaluation

Scientific research is concerned with providing a reliable, precise, unbiased estimate of the truth, and will accept some imbalance between benefit and harm at an individual level in order to provide that estimate, because the results can be used to provide a better guide for future patients.

Research vs. Clinical Practice. The book highlights a double standard in the ethical oversight of medical interventions. While clinical research is subject to rigorous ethical review, clinical practice is often exempt from such scrutiny. This means that surgeons are free to perform new or unproven procedures without the same level of oversight as researchers.

The Ethics of Placebo Trials. The author addresses the ethical concerns surrounding placebo-controlled surgical trials, arguing that these trials are often necessary to determine the true effectiveness of surgical procedures. He contends that the potential benefits of these trials, in terms of improving patient care and reducing unnecessary surgery, outweigh the risks to individual participants.

The Need for Transparency. The book calls for greater transparency in surgical practice, including the routine collection and reporting of outcomes data. This would allow patients and doctors to make more informed decisions about surgical interventions.

8. Patients, Doctors, and Society Must Demand Evidence-Based Surgery

I hope you enjoy reading this book, but mostly I hope that it causes you to change the way you think about medicine, and surgery in particular.

Empowered Patients. Patients can play an active role in promoting evidence-based surgery by asking questions, seeking second opinions, and demanding transparency from their doctors. They can also participate in research and advocate for policies that promote more rigorous evaluation of surgical procedures.

Responsible Doctors. Doctors have a responsibility to stay informed about the latest evidence and to base their clinical decisions on sound scientific principles. They should also be transparent with their patients about the risks and benefits of surgical interventions and to involve them in the decision-making process.

Informed Society. Society as a whole can promote evidence-based surgery by supporting research, advocating for policies that promote transparency and accountability, and challenging the cultural biases that favor surgery over other forms of treatment.

Last updated: April 14, 2025