Got arthritis? Sham surgery is highly effective. Broken back? Sham surgery works. Torn meniscus? Have a sham.
Last week the New England Journal of Medicine published yet another trial showing that fake surgery can be as good as the real thing. This time the subjects were candidates for knee surgery, with a torn meniscus and debilitating pain. When they arrived in the operating room, study surgeons in Finland performed either a meticulous repair of the torn cartilage, or a charade. Incisions were made, and closed, with no other intervention. In case anesthetized patients could hear or understand, the doctors and nurses passed instruments, made surgical sounds, and pretended to do surgery for as long as the procedure would normally take.
Both surgeries worked. Unfortunately for proponents of the meniscus surgery, however, subjects who underwent the fake procedure experienced just as much improvement in pain and activity as those whose meniscus was actually repaired.
As odd as it may seem the finding that sham surgery works, and works as well as a highly-technical procedure, is not new. In 2009 two trials of vertebroplasty, a procedure to reconstruct vertebrae that break due to bone weakness, found the same improvements in sham and real surgery groups. In the 1950s a common heart procedure, mammary artery ligation, was highly effective for reducing heart pains, but no better than a sham. Knee surgery to repair arthritic joints, laser surgery to improve cardiac blood flow, and acupuncture for migraines all can improve patients' symptoms and function, and all were the same as a sham.
The effectiveness of fake procedures is a testament to the power of mind and body, and a critical window into human healing. But the results also cast a shadow. Either sham surgery researchers are choosing their marks carefully, or many common surgeries are scientifically worthless. And while it may seem useful to achieve benefits with a placebo surgery, operations routinely performed by physicians should, by ethical and scientific standards, be more than invasive, risky snake oil.
Moreover, the United States spends almost twice as much per capita on health care as any other developed nation, yet for a broad array of metrics including cure rates, disease management, longevity, child deaths, satisfaction, and more, we rank among the worst in the world for health and health care. So if all the money we spend isn't improving health, where is it going? One example: Meniscus surgeries cost an estimated $4 billion annually.
Trials like the one published last week may begin to shed light on a longstanding mystery in American health care. For decades economists and policy makers have known that expensive, non-beneficial care is swallowing resources that in other developed countries is used to provide insurance and basic care to all. In other words too much care for some has meant too little care for everyone else. The difficulty has been pinpointing the ineffectual care that is swallowing resources. Sham surgery trials are a good start.
But are they practical, or even ethical? When someone is bleeding internally after a car accident, should they be denied a real operation? Before you answer, consider that after a century of operating reflexively, surgeons found that many bleeding trauma patients fare best when left to heal without surgery. Similarly, spurred by cases of appendicitis at sea and in remote regions, rigorous trials have now shown that appendicitis, traditionally a surgical emergency, often heals with antibiotics.
To be sure, many conditions require surgery, and surgical procedures have contributed to important increases in longevity and quality of life in industrialized settings. But the few sham surgery trials that have been done have likely uncovered the tip of the iceberg. Among the most common surgeries in the U.S. are those for back pain, tonsillectomy, ear tubes, coronary stenting, gall bladder removal, and heart bypass surgery. None have been tested against a sham, and the few that have been tested in randomized trials of any kind have categorically failed.
The tragedy of Jahi McMath, a healthy 13-year-old now brain dead after a routine tonsillectomy, is a reminder that surgery of any kind should not be taken lightly. And the discovery that another routine surgery is no better than a sham should be a clarion call to start questioning even the most common surgeries, and demanding scientific proof of their worth.