Hippocrasy: How doctors are betraying their oath

By Rachelle Buchbinder and Ian Harris

Two world-leading doctors reveal the true state of modern medicine and how doctors are letting their patients down. In Hippocrasy, rheumatologist and epidemiologist Rachelle Buchbinder and orthopaedic surgeon Ian Harris argue that the benefits of medical treatments are often wildly overstated and the harms understated. That overtreatment and overdiagnosis are rife. And the medical system is not fit for purpose: designed to deliver health care not health. This powerful exposÉ reveals the tests, drugs, and treatments that provide little or no benefit for patients and the inherent problem of a medical system based on treating rather than preventing illness. The book also provides tips to empower patients—do I really need this treatment? What are the risks? Are there simpler, safer options? What happens if I do nothing? Plus solutions to help restructure how medicine is delivered to help doctors live up to their Hippocratic Oath.

• Language: English
• Publisher: NewSouth
• Release date: Oct 22, 2021
• ISBN: 9781742238265

Book preview

Cover image for Hippocrasy: How doctors are betraying their oath, by Rachelle Buchbinder & Ian Harris

Hippocrasy

RACHELLE BUCHBINDER is a physician specialising in rheumatology, Director of the Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology at Cabrini Hospital and a Professor of Clinical Epidemiology at Monash University. She is known internationally as a vocal proponent of evidencebased medicine and for her landmark studies, particularly those examining treatments accepted into practice before proper evaluation. She has published more than 600 scientific papers and is in the top 0.1 per cent of the world’s most cited scientists. She was appointed an Officer of the Order of Australia (AO) for services to epidemiology and rheumatology in 2020, and admitted as a fellow to the Australian Academy of Health and Medical Sciences in 2015.

IAN HARRIS is an orthopaedic surgeon at Liverpool, St George and Sutherland hospitals, Professor of Orthopaedic Surgery at UNSW Sydney and an Honorary Professor at the University of Sydney. Known internationally for his research and his support of evidence based practice, he has led many surgical trials and published approximately 300 scientific papers. His work has highlighted the lack of evidence for many of the treatments used in medicine, and surgery in particular, including his previous book, Surgery, The Ultimate Placebo, published in 2016. He was appointed a Member of the Order of Australia (AM) for services to orthopaedic surgery in 2015, and admitted as a fellow to the Australian Academy of Health and Medical Sciences in 2016.

One of the hardest things for a doctor to do … is nothing. This superb book explains how in medicine and surgery less is often not just more, it’s closer to the oath we’re all supposed to practise by.

Norman Swan, award-winning producer and broadcaster of the

Health Report and Coronacast

This eye-opening and enthralling book on the medical and moral hazards which beset the health profession is a must-read for patients and practitioners alike. From ‘tooth-fairy science’ to medical disasters to the inflated business world of medicine, Hippocrasy is a profoundly thought-provoking and compelling work that challenges our perception of the practice of modern medicine.

Kate McClymont AM, award-winning investigative journalist for the Sydney Morning Herald/The Age

Doctors are educated to do good. Yet, as the commercial imperatives of the medical industrial complex tighten their grip, doctors are becoming more and more worried that they are inflicting harm rather than creating benefit. This book is for them and, perhaps even more importantly, for their patients. The road to hell is paved with good intentions: read Hippocrasy and turn back.

Iona Heath CBE, former President, The Royal College of General Practitioners

This brilliant book offers clear and compelling evidence that we’re all at risk from too much medicine. Using the best of science, these two respected doctors blow the whistle on harmful healthcare. Buchbinder and Harris reveal how overdiagnosis, overtreatment and the medicalisation of normal life are major threats to human health. But this brilliant book also brings hope that we can wind back the harm and waste of unnecessary tests and treatments, and focus more on the great benefits medicine has to offer.

Ray Moynihan, author of Too Much Medicine? and Selling Sickness, Assistant Professor, Bond University

About half of us in advantaged countries are now patients or ‘providers’, or both, and a third of clinical interventions are futile at best. Seeking health is daunting and we could benefit from a guide. Rachelle Buchbinder and Ian Harris have provided such with this volume.

Nortin M Hadler, author of The Last Well Person, The Citizen Patient and Worried Sick, Emeritus Professor of Medicine and Microbiology/Immunology, University of North Carolina

Throughout medical history, doctors have routinely ignored the fundamental Hippocratic injunction: ‘First, do no harm’. Most of their treatments produced lots of harms, with little or no benefit. This wonderful book punctures the hyped claims of modern medicine, showing that it is not nearly as scientific, safe, effective, and honest as it should be. Reading Hippocrasy is essential for doctors (to help make them become more cautious); but even more essential for patients (to help them become more self-protective).

Allen Frances, author of Saving Normal, Professor and Chairman Emeritus of the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine

A timely book from two leading doctors. They present evidence that despite medicine’s lip-service to evidence-based medicine, many unnecessary, wasteful and harmful investigations and treatments abound. Increasingly, the healthy are re-defined as having ‘predisease’ and drawn into questionable investigations and monitoring programmes. The book’s core message is that medicine’s hubris and a creeping scientism has come to overshadow the doctor’s commitment to care for and comfort their patients and, above all, do no harm. It is time to step back from the brink and revisit the founding principles and core values of our profession.

Trish Greenhalgh OBE, Professor of Primary Care Research, University of Oxford

This book is dedicated to our parents, without whom we would not have had the opportunity, motivation or ability to write this book, as well as to those who search for knowledge, rather than assume it.

Hippocrasy

How doctors

are betraying

their oath

Rachelle Buchbinder

and Ian Harris

Logo: Monash University Publishing.

A NewSouth book

Published by

NewSouth Publishing

University of New South Wales Press Ltd

University of New South Wales

Sydney NSW 2052

AUSTRALIA

newsouthpublishing.com

© Rachelle Buchbinder and Ian Harris 2021

First published 2021

This book is copyright. Apart from any fair dealing for the purpose of private study, research, criticism or review, as permitted under the Copyright Act, no part of this book may be reproduced by any process without written permission. Inquiries should be addressed to the publisher.

Internal design Josephine Pajor-Markus

Cover design Peter Long

Cover image Shutterstock

All reasonable efforts were taken to obtain permission to use copyright material reproduced in this book, but in some cases copyright could not be traced. The authors welcome information in this regard.

This book is printed on paper using fibre supplied from plantation or sustainably managed forests.

Contents

The Hippocratic Oath

Introduction

1First, do no harm

2Science matters

3Overtreatment

4Warmth and sympathy

5I know not

6Birth and death

7Treating the problem

8Prevention

9Medicalising normal

10Healing

References and further reading

Acknowledgments

Index

The Hippocratic Oath

Modern version by Louis Lasagna, 1964

I swear to fulfil, to the best of my ability and judgment, this covenant:

•I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

•I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

•I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

•I will not be ashamed to say ‘I know not’, nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

•I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

•I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

•I will prevent disease whenever I can, for prevention is preferable to cure.

•I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

•If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Introduction

While many medical students take the Hippocratic Oath or a similar pledge before graduating (reciting lines like first, do no harm) we’ve ended up with a healthcare system that’s one of the greatest threats to human health. Our own experience as doctors and researchers has shown that much of medicine doesn’t do what it’s supposed to do: improve health. Modern medical care is designed to maximise the number of encounters with the system, constantly prescribing, operating, testing and scanning, and prioritising business over science. It’s a system rife with perverse incentives and unintended consequences, producing health care without necessarily improving the health of the recipients of that care. The problem threatens the delivery of efficient and effective health care, wastes money and causes harm.

We’re both doctors in the field of musculoskeletal medicine. Ian is an orthopaedic surgeon and Rachelle is a rheumatologist. We’re also internationally acclaimed academics in science-based medicine. In our research, our aim is to determine the true value of specific medical practices, which is often very different from their perceived value. We’re both highly published professors: between us we’ve published about a thousand scientific and lay articles. Ian has also written a popular book, Surgery, The Ultimate Placebo, which exposed the lack of effectiveness of many surgical procedures. Hippocrasy goes further by looking at medicine as a whole, from birth to death. It’s informed as much by our clinical work caring for individual patients as by our academic work.

The more we see of medicine and the way it’s practised, and the more we learn from our research and the research of others, the more we’re convinced that doctors are getting it wrong. Doctors commonly overtreat, the harms of treatment go under-reported or under-recognised, and they often ignore or misunderstand the science, or don’t know it in the first place. And these problems are driven by the personal biases of the doctors themselves.

We trained under a system of apprenticeship, learning from the examples of others, assuming it was the right thing to do. It was only later, after we learned the skills of critical thinking and science, that we realised much of what we were doing was useless, harmful or both. We realised that doctors should look at medicine as any good scientist would look at a subject, by recognising and putting aside personal biases and questioning the current thinking using unbiased (scientific) methods.

Our training and working careers never overlapped but took very similar trajectories. After completing training in our specialist fields, we began to question the standard practices advised by our teachers. We both undertook Masters degrees in evidence-based medicine (clinical epidemiology) and later doctoral degrees in the same field. This further training reinforced our scepticism of modern medicine and provided us with the scientific tools to answer many of the questions we were asking. We began studying the effectiveness of common treatments and speaking out against what we saw as the harmful and wasteful use of ineffective treatments. Inevitably this led to us crossing paths, initially briefly when attending the same conferences, but most notably at the second international Preventing Overdiagnosis Conference in Oxford in 2014, where our alliance was forged. Since then, we have worked closely together on academic pursuits, including many successful grants, trials, guidelines and other projects.

We’re not alone in experiencing such an epiphany – many people have written about the harms and overtreatment rife in modern medicine. Leading medical journals and global movements have taken on the challenge of overtreatment, medical harm,

overdiagnosis and the medicalisation of ‘normal’. For example, the British Medical Journal (with ‘Too Much Medicine’) and the Journal of the American Medical Association (‘Less Is More’) have regular sections devoted to tackling the problem. Choosing Wisely, a clinician-led initiative that identifies the top five tests, treatments or procedures doctors and patients should question within each field of medicine, now has national branches in many countries. International meetings such as the annual Preventing Overdiagnosis Conference, and networks of like-minded doctors and other healthcare professionals, academics and consumers, such as the Australian Wiser Healthcare collaboration, specifically address the issues raised in this book. Unfortunately, these concepts haven’t broken through to become common knowledge or accepted by everyone – doctors and general public alike.

We’re not suggesting for a minute that doctors are malicious or deliberately advising ineffective or harmful treatments. Many doctors remain unaware of the criticisms and continue to act in good faith while contributing to the problem. We’re suggesting that doctors who base their practices on what’s commonly accepted, or on what they perceive to be effective, are often, unknowingly, wrong. And that’s bad for everyone.

Most people cling to the tradition that if a doctor recommends something then it must be good and we should act on their advice. How is it, then, that doctors differ so widely in their opinions? Why are they so likely to recommend treatments provided by their own specialty, yet talk down the treatments provided by others? Why is medical care, in itself, often listed as a leading cause of death? And if much of modern medicine is ineffective and harmful, why are doctors still providing it?

In Hippocrasy, we will use the Hippocratic Oath (see pages ix–x) – the series of pledges commonly considered to be the ethical basis and guiding framework for the practice of medicine – to answer these questions and more. We will show you how the medical community is betraying the ideal that the Oath represents.

Medicine’s betrayal of the ideals of the Hippocratic Oath is expressed in many ways: in unnecessary health care, in our overdependence on medicine in our daily life, and in the direct and indirect personal harms suffered by those who place their trust in medicine. Furthermore, this betrayal has come at great cost: the focus on unnecessary, expensive and ineffective tests and treatments has diverted our efforts and resources away from providing effective care to those who truly need it.

Doctors are rarely blamed for the problems with medicine, despite being in charge of much of it and being in a position to change things for the better. While unnecessary treatment is a big issue, many are reluctant to blame those performing the needless operations, writing the unnecessary prescriptions, and taking the incentives – the doctors themselves. Instead, ‘the system’ is blamed.

Medicine versus public health measures

Doctors (and modern medicine) are generally held in high regard, yet you might be surprised to learn that much of the success of modern medicine is more apparent than real. Most of the major advances in health and life expectancy over the past couple of hundred years weren’t due to modern medicine, but to public health, political and industrial achievements, such as clean water supply, sewerage separation, having enough food and avoiding war. Despite the enormous benefits that public health measures have brought, societies spend most of their resources on individualised health care – care that emphasises technological advances and expensive treatments rather than focusing on public health programs and other preventive strategies that are likely to have far greater positive impacts on health. Obesity, for example, is seen as a major contributor to poor health and high health costs due to its association with type 2 diabetes, heart disease, cancer and arthritis, to name a few. Yet rather than treating it as a public health problem, by modifying food legislation and incentives, educating the public and changing the ‘obesogenic’ culture to prevent it, the public, the doctors and other healthcare providers are focused on high-risk, high-cost medical treatments – such as gastric surgery, which provides inconsistent results.

Medical care has not universally or consistently improved health or quality of life. There are, of course, highly successful medical therapies, such as chemotherapy for childhood leukaemias, which have saved lives; and hip replacement and cataract surgery, which have improved quality of life for millions. But many other medical interventions, despite having proven ineffective and even harmful, remain in common use. Astoundingly, it has been estimated that about one-third of medical care is of no value, while another 10 per cent is actually harmful.

Yet despite widespread evidence of this, much of which is discussed in this book, many doctors continue to perform procedures and prescribe treatments known to be ineffective. Even when unhelpful or harmful practices have declined, it has usually taken many years, often decades. For example, arthroscopy to treat painful knees due to wear and tear was first found to be ineffective almost 20 years ago, but its use only started waning about a decade ago, and in some places hasn’t declined at all.

Many factors contribute to the failure to abandon ineffective medical practices, from ingrained and difficult-to-shift beliefs about their perceived effectiveness, to the conviction that doing something is better than doing nothing. While most people would agree that we should be cautious about introducing new medical advances into routine medical practice before they have been properly evaluated, we repeatedly fail to do so. Although driven by the well-intentioned desire to pass on the presumed benefits to society that new advances in treatment promise, their rapid introduction into routine care often backfires. Not only may the benefits be overestimated, but the harms may only become evident once those treatments have been introduced.

Since we started writing this book, the world has experienced the COVID-19 pandemic. In the early days, doctors and others were touting the benefits of the so-called miracle drug hydroxychloroquine, an effective antimalarial medication also commonly used to treat autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus (better known as lupus). It began being prescribed in large numbers to people with the virus. Australian doctors also started prescribing the drug for themselves and their family members as a ‘preventive’ measure. Despite the hype associated with the very early preliminary studies, however, it was subsequently found to be ineffective against COVID, with a risk of significant life-threatening side effects.

While many worthy efforts were directed towards finding effective and safe vaccines and identifying and evaluating promising life-saving treatments, the pandemic has highlighted many of the issues we describe in this book. Of all the widespread touting of drugs to both prevent and treat COVID-19, very few have so far been shown to be of any benefit. It has been public health measures that have been largely responsible for reducing infection rates. Countries that adopted public health measures such as working from home, social distancing, mask wearing and contact tracing have minimised the impact of the virus and, in many cases, eradicated community transmission almost completely.

Misplaced faith in premature results can also lead to other harms: in the case of hydroxychloroquine, the hype led to widespread shortages of the drug for patients, including our own, who were taking the medication for sometimes life-threatening diseases such as lupus. In Australia, the mining magnate and former politician Clive Palmer was given permission by Australia’s drug regulators to import millions of doses of the drug to add to government stockpiles, adding to the worldwide shortage. The pandemic has also offered opportunities to profit from peoples’ COVID fears by marketing fake treatments. Examples include the ‘BioCharger’ device (from chef Pete Evans) and peptides (from ‘Dr Ageless’, Shane Charter).

Medical harms and waste or ‘low-value’ care (where treatment is provided at some cost but offers no meaningful benefits) have been well documented over many years, but this message remains largely underappreciated. The default position is to believe that all medical tests and treatments are worthwhile, and the more medical care the better. Because the problem affects everyone, and because we all should have a say in how our health and our medical concerns are addressed, every one of us needs to understand these problems.

Why we wrote this book

We were motivated to write Hippocrasy by the daily reminders of the harms that come from society’s over-reliance on medicine; the waste from performing or prescribing unnecessary, ineffective or marginally effective tests, medicines and procedures; the problems that come from treating medicine as a business; and the misdirected incentives of a medical system that doesn’t necessarily work to improve health. Attempts to improve health care are also misdirected. The current worldwide ‘affordability’ crisis in medicine is too focused on reducing costs through economic and productionbased models of care (where more care is better but needs to be more efficient), ignoring the savings that could be achieved through reducing unnecessary, wasteful and harmful medical care.

Despite the COVID-19 pandemic, there’s no doubt that the biggest global health threat of the 21st century is climate change. We’ve recently seen stark examples of the impact of climate change on human health. This includes the unprecedented Melbourne ‘thunderstorm asthma’ epidemic in 2016, which resulted in 14 000 people attending hospital, a 3000 per cent increase in intensive care admissions, and ten deaths. The hundreds of bushfires that ravaged south-eastern Australia over the 2019–20 summer not only claimed lives but also caused air pollution many times above hazardous levels, with 11 million people experiencing some smoke exposure, and large numbers reporting physical and/or mental symptoms. While the long-term effects are as yet unknown, evidence from other severe bushfires indicates that this is likely to include extra premature deaths and cardiovascular and respiratory events, as well as anxiety, depression, substance abuse and post-traumatic stress disorder (PTSD).

What’s much less appreciated, however, is that health care itself damages the environment. A 2018 study published in Lancet Planet Health and led by Dr Forbes McGain, an Australian anaesthetist and intensive care physician as well as one of the world’s leading experts on the effects of health care on the environment, estimated

that health care produces about 7 per cent of Australia’s total carbon emissions. To put this into perspective, this is about half the total carbon emissions of the whole Australian construction industry, including construction of all buildings, pipelines, dams, oil rigs, roads and rail lines. Reducing unnecessary, wasteful and harmful medical care makes sense for the good of the environment and the environmental sustainability of the healthcare system, as well as our health.

What to expect from this book

Let’s have a brief look at some of the major themes we will explore in Hippocrasy.

Medicalisation

Medicalisation is the process by which ‘normal’ human conditions, such as sadness and grief, slightly elevated blood pressure, shyness,

menopause and ageing, come to be defined (and treated) as medical conditions. Perceived ‘deviations’ from normal are viewed from the perspective of a simplistic medical model called the disease–illness paradigm, which implies that every ‘abnormality’ has a traceable, direct physical cause. In short, any departure from normal is diagnosed as an illness, and, once diagnosed, the ‘illness’ is subject to medical treatment. The problem, of course, lies in who gets to decide what’s abnormal, what drives them to make that call, and whether it helps the people labelled as abnormal.

Medicalisation comes from the doctors themselves and the industry that supports the practice of medicine – drug and device manufacturers, hospital owners, and so on – but we’re all complicit and all too willing to believe that the process is in our best interests when the opposite is often true.

Other drivers of medicalisation include society’s over-reliance on the medical system to address what are simply the benign predicaments of life rather than diseases that would benefit from medical intervention. Unpleasant sensations like an ordinary headache, mild anxiety or irregular bowel habits, which were once considered a normal part of life, have become medical conditions requiring medical treatment. This has resulted in a decline in our resilience and ability to tolerate the usual ups and downs of life that create discomfort or unease. Instead, they are outsourced to the medical community, making coping a passive process. Yet there’s consistent evidence that coping is best performed actively by the person with the condition, and that our ability to cope and adapt in response to challenges is a measure of our health, and therefore not something we should delegate to others.

Despite easy access to medical information from Dr Google, doctors still hold the upper hand regarding medical knowledge.This ‘knowledge asymmetry’ between doctors and patients is a driver of medicalisation. It produces a moral hazard in which doctors make decisions yet the burden of risk is placed on the patient. It also allows perverse incentives to prevail, whereby doctors can easily justify treatments that will benefit them financially – for example, by recommending surgery for which they will be paid, further accentuated if they also own the hospital. This biases doctors towards intervening, and makes it easy for them to make a patient believe they need the treatment.

We cover medicalisation throughout the book, and in depth in chapter 9.

Overdiagnosis

Overdiagnosis occurs when someone is given a diagnosis that’s technically correct but won’t benefit them and might cause harm. It can occur when healthy people are screened for diseases such as cancer, and abnormalities are detected that would not have caused any symptoms or clinical problems in their lifetime. Not only would they never have known they had the condition, but they would have lived just as long had it not been diagnosed in the first place.

Overdiagnosis can also occur when people with minor symptoms are investigated unnecessarily. A scan might show an abnormality that could be an age-related change – it’s not the cause of their problem but is falsely assumed to be. Overdiagnosis occurs, too, when disease definitions are widened, officially or unofficially, resulting in people previously considered normal or within a spectrum of normal being classified as diseased.

Examples of overdiagnosis include the lowering of the threshold for hypertension (high blood pressure), osteopaenia (thin bones) and attention deficit hyperactivity disorder (ADHD). In the case of hypertension and osteopaenia, mere risk factors for disease (high blood pressure for heart failure and strokes, and thin bones for fracture) are now labelled as diseases in their own right. Overdiagnosis can also occur with the creation of new diseases, such as sarcopenia (weak muscles) and female sexual dysfunction.

In all of these cases, the diagnoses are technically correct (i.e. they’re not misdiagnoses), but detecting, labelling or redefining the problem as a disease doesn’t benefit the person being diagnosed. Apart from being unnecessary to the improvement of health, overdiagnosis often leads to psychological distress from being labelled, physical harms from unnecessary treatment, and financial costs to both the individual and society.

Overdiagnosis, which occurs as a result of overtesting and leads to overtreatment, is discussed throughout the book.

Overtreatment

Like overdiagnosis, overtreatment can be defined as health care (consultations, tests, drugs, procedures, and so on) that provides no benefit to the patient. It’s often driven by a distorted perception of medical care that overestimates the benefits and underestimates the harms. Other factors that contribute to overtreatment are the practice of defensive medicine due to fear of litigation, health systems that incentivise tests and/or treatments rather than health improvements, and equating a failure to treat with a failure to care.

We cover overtreatment in detail in chapter 3.

Medicine as big business

Modern medical care has been packaged into a business model for which it’s unsuited. Medicine doesn’t obey the laws of economics: for example, the increased supply of doctors