Back and shoulder surgery is often worse than useless

Millions of operations should be scrapped

SIX IN TEN Britons have surgery at some point. So do lots of Americans, at a cost of perhaps $500bn a year, a third of all spending on adults in the world’s biggest health-care market. Plenty of these procedures save lives, by removing tumours, transplanting new organs or mending broken ones. Many others make life better, say by restoring vision (cataract extraction) or hearing (tympanoplasty, for example). Yet a growing body of evidence suggests millions of surgeries performed each year are unnecessary—and, given the risk of complications when a person is sliced open, often worse than useless.

Of ten common orthopaedic procedures, a specialty which accounts for a quarter of all operations in Britain and a similar share in America, only three—for carpal tunnel and total replacement of knees and hips—offer outcomes that are clearly superior to non-operative care. Six, including common ones like lumbar-spine decompression, are no better than drugs, physiotherapy or just Father Time. Similarly, roughly two-thirds of excised appendices could have been fixed with antibiotics and many prostates, around 100,000 of which are operated on in Europe each year, are better off with watchful waiting.

For patients, needless surgery is a cause of physical pain and, especially in America, financial stress. For stretched health-care systems in ageing rich countries, it is a terrible waste of resources. A recent reduction in referrals for shoulder operations (just one of the six useless orthopaedic procedures) is saving England’s National Health Service (NHS) around £100m ($134m) a year, or 1% of its total surgical budget.

The main reason for the persistence of useless procedures is a dearth of clinical data on whether they work. Surgeons liken asking about this to wondering whether parachutes are useful when leaping out of a plane. If the patient gets better, the parachute is assumed to have been a success. Regulators do not require proof that it actually was, as they do with new drugs. Individual surgeons have neither the incentive nor the means to check for themselves. Contrast that with drugmakers, which bankroll big, costly randomised trials in the hope of making lots of money from pills that are proven effective.

Governments can start to correct this failure by running trials themselves. The NHS has already begun doing this, with some success. By testing procedures across many hospitals around Britain, it avoids the charge of impugning the skill of any individual surgeon or, conversely, of missing out the truly skilful. It and other public health-care systems should conduct more such exercises.

Once the results are in, it will be easier for payers, be they public systems or private insurers, to refuse to cover procedures that do not benefit patients. This will not only save money. Surgeons freed from performing unnecessary shoulder and back operations could spend more time on knees, hips and carpal tunnels. In systems where care is rationed, like the NHS, this would have the welcome effect of trimming waiting lists. In July 6.2m patients in England were awaiting non-urgent specialist treatment, a category that includes lots of surgeries.

Unlearning decades of modern medical practice will not come easily to health-care systems. It will be harder still for the surgeons. Like all medics, they believe that they are doing right by their patients. But if your only tool is a scalpel, everything looks ripe for cutting.

Jack the knife

Surgeons must therefore be taught, starting in medical school and then by their mentors in what remains an apprenticeship-based craft, to present patients with a range of options and choose the best one together rather than dictating it from on high. Such “shared decision-making” has become common among clinicians but remains alien to many surgeons. It is in everyone’s interest to make it standard.