1 00:00:11,110 --> 00:00:20,579 I 2 00:00:26,589 --> 00:00:23,259 hello and welcome to the skeptic zone 3 00:00:29,499 --> 00:00:26,599 show number 52 for the 16th of oktober 4 00:00:32,350 --> 00:00:29,509 2009 Richard Saunders here with you 5 00:00:34,180 --> 00:00:32,360 today's episode of the skeptic zone is 6 00:00:37,420 --> 00:00:34,190 given over to an extensive interview 7 00:00:40,450 --> 00:00:37,430 with Professor Ian Harris by Iran so 8 00:00:44,110 --> 00:00:40,460 give this is a fascinating interview in 9 00:00:46,149 --> 00:00:44,120 Harris being an orthopedic surgeon Iran 10 00:00:48,750 --> 00:00:46,159 really gets to the nub of many important 11 00:00:51,549 --> 00:00:48,760 questions regarding our perception of 12 00:00:53,709 --> 00:00:51,559 modern medicine scientific medicine and 13 00:00:56,259 --> 00:00:53,719 I think you'll find Ian Harris's 14 00:00:58,720 --> 00:00:56,269 responses very interesting in fact I 15 00:01:02,169 --> 00:00:58,730 invite you after the show to click on 16 00:01:04,689 --> 00:01:02,179 the comments link at ww skeptics on TV 17 00:01:07,540 --> 00:01:04,699 and give us your thoughts about this 18 00:01:09,370 --> 00:01:07,550 interview before we start the interview 19 00:01:11,109 --> 00:01:09,380 and a quick announcement don't forget 20 00:01:12,669 --> 00:01:11,119 the Australian skeptics National 21 00:01:14,700 --> 00:01:12,679 Convention is going to be held at the 22 00:01:17,350 --> 00:01:14,710 end of november in brisbane australia 23 00:01:20,760 --> 00:01:17,360 please come along and see us or should 24 00:01:25,090 --> 00:01:20,770 be a great convention more details at ww 25 00:01:26,649 --> 00:01:25,100 skeptics kome you and why you're at this 26 00:01:29,080 --> 00:01:26,659 skeptics website don't forget to 27 00:01:33,310 --> 00:01:29,090 subscribe to the skeptic the skeptic 28 00:01:36,850 --> 00:01:33,320 magazine from Australian skeptics ok sit 29 00:01:38,499 --> 00:01:36,860 back have a nice ginger beer yes have a 30 00:01:41,469 --> 00:01:38,509 nice cool drink of ginger beer and enjoy 31 00:01:44,690 --> 00:01:41,479 this interview with Ian Harris by Iran 32 00:01:44,700 --> 00:01:53,350 you 33 00:01:57,590 --> 00:01:56,270 ian harris is a professor of orthopedic 34 00:02:00,050 --> 00:01:57,600 surgery at the University of New South 35 00:02:02,410 --> 00:02:00,060 Wales and the director of orthopaedic 36 00:02:05,330 --> 00:02:02,420 surgery at Liverpool Hospital in Sydney 37 00:02:06,590 --> 00:02:05,340 en has also studied epidemiology and is 38 00:02:08,300 --> 00:02:06,600 particularly interested in the 39 00:02:11,300 --> 00:02:08,310 assessment of the efficacy and safety of 40 00:02:12,830 --> 00:02:11,310 medical interventions I met Ian at his 41 00:02:14,150 --> 00:02:12,840 office in Liverpool Hospital to talk 42 00:02:16,310 --> 00:02:14,160 about how surgical techniques are 43 00:02:18,110 --> 00:02:16,320 assessed but ended up having a lot of 44 00:02:21,080 --> 00:02:18,120 what I thought were facts about medicine 45 00:02:23,240 --> 00:02:21,090 in general challenge so it's so in fact 46 00:02:25,610 --> 00:02:23,250 that if you really important issues had 47 00:02:27,050 --> 00:02:25,620 to be covered after the interview listen 48 00:02:29,420 --> 00:02:27,060 at the end of the interview for some 49 00:02:34,520 --> 00:02:29,430 more information but now here is 50 00:02:35,750 --> 00:02:34,530 Professor Ian Harris Professor Ian 51 00:02:39,170 --> 00:02:35,760 Harris thank you very much for joining 52 00:02:40,610 --> 00:02:39,180 us on skeptics on what further I would 53 00:02:42,260 --> 00:02:40,620 like to speak today about surgical 54 00:02:45,440 --> 00:02:42,270 techniques and how they might be 55 00:02:48,320 --> 00:02:45,450 verified we skeptical community will do 56 00:02:51,710 --> 00:02:48,330 by and large people will know about how 57 00:02:53,510 --> 00:02:51,720 double-blind tests are done on drugs but 58 00:02:55,520 --> 00:02:53,520 it doesn't seem like surgical techniques 59 00:03:00,380 --> 00:02:55,530 necessarily lend themselves to this kind 60 00:03:02,930 --> 00:03:00,390 of study so very strict and that is a 61 00:03:08,930 --> 00:03:02,940 fact that can be used to the surgeons 62 00:03:11,949 --> 00:03:08,940 advantage by avoiding such trials the 63 00:03:14,690 --> 00:03:11,959 bottom line is that randomized trials 64 00:03:17,990 --> 00:03:14,700 can be done in surgery and are being 65 00:03:20,090 --> 00:03:18,000 done in surgery however there are 66 00:03:22,280 --> 00:03:20,100 logistical problems with randomized 67 00:03:25,280 --> 00:03:22,290 trials particularly when it comes to 68 00:03:27,320 --> 00:03:25,290 blinding although they've been some very 69 00:03:30,949 --> 00:03:27,330 interesting examples where that has been 70 00:03:34,400 --> 00:03:30,959 overcome with with interesting results 71 00:03:38,360 --> 00:03:34,410 and I recently published an article on 72 00:03:41,509 --> 00:03:38,370 the need to be doing sham surgery for 73 00:03:45,110 --> 00:03:41,519 such trials in the australia new zealand 74 00:03:46,910 --> 00:03:45,120 journal of surgery sham surgical trials 75 00:03:48,800 --> 00:03:46,920 have been done in the past whenever 76 00:03:51,310 --> 00:03:48,810 they've been done they've always shown 77 00:03:53,650 --> 00:03:51,320 that the surgery has been not effective 78 00:03:57,170 --> 00:03:53,660 and i think that there's a role for 79 00:03:59,270 --> 00:03:57,180 doing them whenever it's raised in the 80 00:04:01,460 --> 00:03:59,280 surgical community and you say we'll 81 00:04:02,910 --> 00:04:01,470 look you know we're unsure whether this 82 00:04:05,970 --> 00:04:02,920 technique is really 83 00:04:08,940 --> 00:04:05,980 beneficial we need to do a proper study 84 00:04:12,000 --> 00:04:08,950 where the patients are blinded and they 85 00:04:13,890 --> 00:04:12,010 undergo some kind of sham surgery the 86 00:04:15,960 --> 00:04:13,900 answer not only the knee-jerk response 87 00:04:18,420 --> 00:04:15,970 is that oh you can't do that it's 88 00:04:23,430 --> 00:04:18,430 unethical but there's a bit of confusion 89 00:04:27,300 --> 00:04:23,440 I think with the ethics there is the 90 00:04:31,860 --> 00:04:27,310 ethics of medical practice of treating 91 00:04:33,810 --> 00:04:31,870 patients and and biologic surgery one of 92 00:04:38,700 --> 00:04:33,820 the codes that we live by is to do no 93 00:04:42,030 --> 00:04:38,710 harm so when in doubt you know we try 94 00:04:45,930 --> 00:04:42,040 and avoid harming the patient in any way 95 00:04:50,730 --> 00:04:45,940 and so on the surface of it to do a sham 96 00:04:52,800 --> 00:04:50,740 operation is in some way exposing 97 00:04:55,620 --> 00:04:52,810 patients to risk all those sham 98 00:04:59,010 --> 00:04:55,630 operations can be done in such a way 99 00:05:01,200 --> 00:04:59,020 there's quite a low risk but you're 100 00:05:04,830 --> 00:05:01,210 exposing the patient to some degree of 101 00:05:09,420 --> 00:05:04,840 risk and yet not offering them any real 102 00:05:11,730 --> 00:05:09,430 tangible benefit and so it appears that 103 00:05:15,870 --> 00:05:11,740 a sham surgical trial goes against the 104 00:05:19,230 --> 00:05:15,880 ethics of medical practice however it 105 00:05:25,320 --> 00:05:19,240 does satisfy the ethics of scientific 106 00:05:30,029 --> 00:05:25,330 investigation which is really to perform 107 00:05:33,900 --> 00:05:30,039 the best possible unbiased study that we 108 00:05:36,390 --> 00:05:33,910 can in order to investigate something 109 00:05:39,200 --> 00:05:36,400 properly and it's well known and in the 110 00:05:41,670 --> 00:05:39,210 past it's always been the case that 111 00:05:43,710 --> 00:05:41,680 scientific investigations in medical 112 00:05:46,890 --> 00:05:43,720 devices and even drugs and things like 113 00:05:49,290 --> 00:05:46,900 that may involve some small degree of 114 00:05:52,320 --> 00:05:49,300 risk to patients without any tangible 115 00:05:56,310 --> 00:05:52,330 benefit and the ethics gets broader as 116 00:05:58,850 --> 00:05:56,320 well because epidemiologists will argue 117 00:06:02,250 --> 00:05:58,860 with surgeons saying that it is 118 00:06:04,830 --> 00:06:02,260 unethical to be operating on patients 119 00:06:06,870 --> 00:06:04,840 without randomized control trial 120 00:06:08,779 --> 00:06:06,880 evidence that what we do is beneficial 121 00:06:11,310 --> 00:06:08,789 so it's really turning it on its head 122 00:06:12,890 --> 00:06:11,320 the surgeons will say it's unethical to 123 00:06:14,550 --> 00:06:12,900 do a randomized trial and 124 00:06:16,080 --> 00:06:14,560 epidemiologists will say it's unethical 125 00:06:21,990 --> 00:06:16,090 to be operating without 126 00:06:24,910 --> 00:06:22,000 and I think that history supports the 127 00:06:26,440 --> 00:06:24,920 epidemiologists unfortunately and you 128 00:06:31,000 --> 00:06:26,450 have to believe me because I'm a surgeon 129 00:06:35,320 --> 00:06:31,010 saying that and because in the past so 130 00:06:38,410 --> 00:06:35,330 many operations have been shown to not 131 00:06:42,760 --> 00:06:38,420 be as helpful as we once thought they 132 00:06:45,160 --> 00:06:42,770 were through you know good studies that 133 00:06:47,710 --> 00:06:45,170 were done I mean Ava if i'm not mistaken 134 00:06:50,170 --> 00:06:47,720 in any case when a patient enters a 135 00:06:52,330 --> 00:06:50,180 study there this sign and informed 136 00:06:54,340 --> 00:06:52,340 consent in which they know that they 137 00:06:56,800 --> 00:06:54,350 might be subjected to sham surgery sure 138 00:06:57,760 --> 00:06:56,810 yeah so it's the patient is involved in 139 00:07:00,490 --> 00:06:57,770 the decision it's not like you 140 00:07:02,110 --> 00:07:00,500 inflicting harm on a patient who doesn't 141 00:07:06,220 --> 00:07:02,120 know what's happening we're definitely 142 00:07:10,690 --> 00:07:06,230 um and all the studies have properly 143 00:07:13,630 --> 00:07:10,700 informed consent that is vetted by an 144 00:07:16,060 --> 00:07:13,640 ethics committee the trouble is there's 145 00:07:18,490 --> 00:07:16,070 this knee-jerk response and and I sit on 146 00:07:20,380 --> 00:07:18,500 ethics committee here at the hospital if 147 00:07:21,880 --> 00:07:20,390 you say to people on ethics committee 148 00:07:23,740 --> 00:07:21,890 all we want to do a study involving sham 149 00:07:25,270 --> 00:07:23,750 surgery though we can't do that it's 150 00:07:27,160 --> 00:07:25,280 just the automatic responses well you 151 00:07:28,840 --> 00:07:27,170 can't do that that's just you kind of do 152 00:07:31,480 --> 00:07:28,850 it and but when you actually sit at 153 00:07:33,850 --> 00:07:31,490 explain it to people they can see the 154 00:07:37,650 --> 00:07:33,860 benefit of it the problem with the 155 00:07:42,760 --> 00:07:37,660 patient sign the consent is there's this 156 00:07:44,200 --> 00:07:42,770 presumption of the of therapy even 157 00:07:45,730 --> 00:07:44,210 though you can sit down and explain to 158 00:07:47,680 --> 00:07:45,740 patients what's going on they're 159 00:07:50,440 --> 00:07:47,690 assuming that because the doctor is 160 00:07:55,630 --> 00:07:50,450 treating them that they're providing it 161 00:07:57,730 --> 00:07:55,640 with some kind of benefit but but you're 162 00:07:59,170 --> 00:07:57,740 right we're in these sham surgery trials 163 00:08:02,290 --> 00:07:59,180 that is explained to the patients that 164 00:08:04,300 --> 00:08:02,300 you may be randomized to an arm of the 165 00:08:08,560 --> 00:08:04,310 study that will afford you know 166 00:08:13,930 --> 00:08:08,570 possibility of benefit and the benefit 167 00:08:15,760 --> 00:08:13,940 yeah yes yes yeah because we do have the 168 00:08:17,350 --> 00:08:15,770 placebo effect yeah that size it was 169 00:08:18,880 --> 00:08:17,360 definitely it'll yeah and that's the 170 00:08:20,980 --> 00:08:18,890 thing about surgery surgery has such a 171 00:08:23,080 --> 00:08:20,990 strong pasiba effect so there's been 172 00:08:25,250 --> 00:08:23,090 studies which have some fascinating 173 00:08:29,000 --> 00:08:25,260 studies in medicine 174 00:08:31,490 --> 00:08:29,010 looking at the strength of the placebo 175 00:08:36,650 --> 00:08:31,500 effect so for instance if you're doing a 176 00:08:41,120 --> 00:08:36,660 trial and you deliberately make it known 177 00:08:43,070 --> 00:08:41,130 to the subjects that the drug they're 178 00:08:45,080 --> 00:08:43,080 receiving is or make them believe that 179 00:08:47,230 --> 00:08:45,090 the drug that they're receiving is very 180 00:08:50,780 --> 00:08:47,240 expensive you will get a much better 181 00:08:52,400 --> 00:08:50,790 placebo effect then if they think 182 00:08:54,230 --> 00:08:52,410 they're getting a cheap drug or an old 183 00:08:56,810 --> 00:08:54,240 drug you know I believe there's also a 184 00:08:58,790 --> 00:08:56,820 color effect if I member correctly I 185 00:09:01,010 --> 00:08:58,800 think it's the same even the same Smith 186 00:09:05,090 --> 00:09:01,020 and be the same study that showed that 187 00:09:08,180 --> 00:09:05,100 the color of the taking hello tablets 188 00:09:10,310 --> 00:09:08,190 actually has an effect as well yeah yeah 189 00:09:13,250 --> 00:09:10,320 and it's the end of the way it's sold to 190 00:09:16,190 --> 00:09:13,260 the patient as well so surgery has all 191 00:09:20,530 --> 00:09:16,200 the hallmarks of having a massive 192 00:09:25,220 --> 00:09:20,540 bow effect it's got a huge investment in 193 00:09:28,310 --> 00:09:25,230 trust cost time risk everything from the 194 00:09:29,840 --> 00:09:28,320 patient to go ahead with this they have 195 00:09:31,730 --> 00:09:29,850 to go through a lot of procedures before 196 00:09:34,820 --> 00:09:31,740 they even get to the hospital sign a lot 197 00:09:38,090 --> 00:09:34,830 of forms consent forms this is a big 198 00:09:40,610 --> 00:09:38,100 operation you're having done and then 199 00:09:41,720 --> 00:09:40,620 they go to this institution this 200 00:09:43,550 --> 00:09:41,730 hospital where they have to get 201 00:09:46,540 --> 00:09:43,560 undressed and change they get checked 202 00:09:48,860 --> 00:09:46,550 and double-checked they get needles 203 00:09:52,520 --> 00:09:48,870 injections they have a huge cut they 204 00:09:55,520 --> 00:09:52,530 have drips afterwards and it's a hell of 205 00:09:57,530 --> 00:09:55,530 a big procedure to go through and so I 206 00:09:59,390 --> 00:09:57,540 think their mind must be telling them 207 00:10:02,210 --> 00:09:59,400 they better get some benefit out of this 208 00:10:05,320 --> 00:10:02,220 you know there must be some kind of yeah 209 00:10:07,820 --> 00:10:05,330 why else would they do it you know and 210 00:10:11,930 --> 00:10:07,830 so you've really got to overcome that 211 00:10:14,980 --> 00:10:11,940 but you know I think we we need to do we 212 00:10:19,400 --> 00:10:14,990 need to do more studies in in surgery 213 00:10:23,420 --> 00:10:19,410 with a sham well I once they won such a 214 00:10:25,240 --> 00:10:23,430 sham surgery based study that I seem to 215 00:10:28,370 --> 00:10:25,250 recall it has to do with them 216 00:10:30,500 --> 00:10:28,380 arthroscopic surgery for the knees that 217 00:10:31,790 --> 00:10:30,510 was a great study this was a that was 218 00:10:33,350 --> 00:10:31,800 reported in the 219 00:10:37,160 --> 00:10:33,360 New England Journal of Medicine a few 220 00:10:40,600 --> 00:10:37,170 years ago and what they did is they took 221 00:10:44,930 --> 00:10:40,610 a whole bunch of patients who had 222 00:10:46,130 --> 00:10:44,940 mechanical problems with their knees and 223 00:10:48,380 --> 00:10:46,140 I think these were older patients I 224 00:10:53,569 --> 00:10:48,390 think it was a Veterans Affairs study in 225 00:10:56,540 --> 00:10:53,579 the US and they had symptoms which would 226 00:11:01,759 --> 00:10:56,550 often result in having an arthroscopy 227 00:11:04,360 --> 00:11:01,769 done and and I think they may have had a 228 00:11:06,710 --> 00:11:04,370 background of osteoarthritis in the knee 229 00:11:10,430 --> 00:11:06,720 but with mechanical symptoms and the 230 00:11:12,889 --> 00:11:10,440 theory is that you operate on it you 231 00:11:15,350 --> 00:11:12,899 find irregularities in the knee or rough 232 00:11:18,170 --> 00:11:15,360 patches or torn cartilages and you take 233 00:11:21,920 --> 00:11:18,180 them out and that smooth things over and 234 00:11:24,319 --> 00:11:21,930 gets rid of their symptoms and so what 235 00:11:28,040 --> 00:11:24,329 they did is a study where the patients 236 00:11:29,509 --> 00:11:28,050 in the sham group actually got incisions 237 00:11:32,930 --> 00:11:29,519 in their knees and arthroscopy is a 238 00:11:34,519 --> 00:11:32,940 fairly it doesn't involve any stitches 239 00:11:37,130 --> 00:11:34,529 in fact it's just two small holes in the 240 00:11:40,130 --> 00:11:37,140 knee camera gets put in and you do it 241 00:11:42,230 --> 00:11:40,140 all remote so it's not a very invasive 242 00:11:43,460 --> 00:11:42,240 procedure so it's easy to do a sham on 243 00:11:45,650 --> 00:11:43,470 that you just have to make two little 244 00:11:48,410 --> 00:11:45,660 cuts without any stitches the infection 245 00:11:51,380 --> 00:11:48,420 rates extremely low for such a procedure 246 00:11:54,850 --> 00:11:51,390 it's not a really big procedure and I 247 00:11:56,840 --> 00:11:54,860 think that they offered some benefit 248 00:11:58,310 --> 00:11:56,850 theoretical benefit to the sham group 249 00:11:59,269 --> 00:11:58,320 because think they washed out the name 250 00:12:02,470 --> 00:11:59,279 but they didn't actually do an 251 00:12:04,280 --> 00:12:02,480 arthroscopic procedure on them and 252 00:12:05,840 --> 00:12:04,290 apparently there's a documentary on 253 00:12:08,329 --> 00:12:05,850 another discovery channel which I would 254 00:12:12,260 --> 00:12:08,339 love to see but I haven't seen it but it 255 00:12:14,689 --> 00:12:12,270 shows patients who have had they have 256 00:12:17,060 --> 00:12:14,699 been in a study and they're now playing 257 00:12:19,160 --> 00:12:17,070 soccer with their grandchildren and 258 00:12:21,380 --> 00:12:19,170 saying what a fantastic procedure it's 259 00:12:25,340 --> 00:12:21,390 been another way they were in the shower 260 00:12:26,900 --> 00:12:25,350 affair so but that study showed no 261 00:12:31,030 --> 00:12:26,910 difference in the outcome between the 262 00:12:39,350 --> 00:12:35,780 that study opens up a whole a lot of 263 00:12:43,319 --> 00:12:39,360 questions because that study I would say 264 00:12:47,069 --> 00:12:43,329 has not changed practice one bit 265 00:12:49,189 --> 00:12:47,079 and that is this just in Australia or 266 00:12:53,489 --> 00:12:49,199 what do you see that's worldwide 267 00:12:56,429 --> 00:12:53,499 worldwide here particularly where 268 00:12:58,350 --> 00:12:56,439 there's private medicine where there's 269 00:13:00,689 --> 00:12:58,360 an incentive to operate and there's an 270 00:13:04,259 --> 00:13:00,699 expectation from the patients to operate 271 00:13:09,419 --> 00:13:04,269 and it's a customer service environment 272 00:13:11,699 --> 00:13:09,429 so in the private sector in Australia a 273 00:13:13,650 --> 00:13:11,709 patient with some clicking and 274 00:13:15,809 --> 00:13:13,660 mechanical symptoms perhaps locking in 275 00:13:18,059 --> 00:13:15,819 their knee who presents to an orthopedic 276 00:13:20,999 --> 00:13:18,069 surgeon will expect to have an 277 00:13:22,710 --> 00:13:21,009 arthroscopy by and large they'll be 278 00:13:26,369 --> 00:13:22,720 referred there from their general 279 00:13:28,169 --> 00:13:26,379 practitioner for an arthroscopy the 280 00:13:30,900 --> 00:13:28,179 surgeon will not have much else to offer 281 00:13:33,509 --> 00:13:30,910 them except an arthroscopy because there 282 00:13:35,160 --> 00:13:33,519 aren't that many alternatives they 283 00:13:37,410 --> 00:13:35,170 probably would have had a course perhaps 284 00:13:39,840 --> 00:13:37,420 of physiotherapy or tried some 285 00:13:41,999 --> 00:13:39,850 anti-inflammatory tablets and so that's 286 00:13:45,499 --> 00:13:42,009 really it's really like go away I can't 287 00:13:47,789 --> 00:13:45,509 help you or we'll do an arthroscopy and 288 00:13:50,129 --> 00:13:47,799 I'm trying to take the side of the 289 00:13:51,900 --> 00:13:50,139 orthopedic surgeons here but go away I 290 00:13:54,239 --> 00:13:51,910 can't help you is not very good for your 291 00:13:57,059 --> 00:13:54,249 practice and the patient will go to the 292 00:14:00,900 --> 00:13:57,069 next orthopedic surgeon down the street 293 00:14:03,359 --> 00:14:00,910 and get there ought to be done so by and 294 00:14:04,919 --> 00:14:03,369 large they just get done well as long as 295 00:14:07,559 --> 00:14:04,929 nobody offers them homeopathy that's 296 00:14:09,619 --> 00:14:07,569 fine in this respect that we should 297 00:14:12,840 --> 00:14:09,629 probably ask you so so are you in a 298 00:14:14,639 --> 00:14:12,850 clinical surgeon as well also do do you 299 00:14:17,129 --> 00:14:14,649 operate all right as well as but you're 300 00:14:19,650 --> 00:14:17,139 also says clinical academic on your head 301 00:14:21,569 --> 00:14:19,660 so does that mean you conduct studies 302 00:14:24,780 --> 00:14:21,579 yeah this is to that so what kind of 303 00:14:29,759 --> 00:14:24,790 proportions of your day are roughly 5050 304 00:14:31,949 --> 00:14:29,769 so I started out as a medical training 305 00:14:34,650 --> 00:14:31,959 here in university of new south wales 306 00:14:37,109 --> 00:14:34,660 and then did orthopaedic training 307 00:14:38,819 --> 00:14:37,119 locally and then started practices 308 00:14:41,039 --> 00:14:38,829 norfolk surgeon in my area of interest 309 00:14:43,530 --> 00:14:41,049 is in orthopaedic trauma so it's mainly 310 00:14:46,579 --> 00:14:43,540 factors broken bones cutting a car 311 00:14:50,549 --> 00:14:46,589 accidents motorbikes things like that 312 00:14:53,100 --> 00:14:50,559 and I was happy doing that but unhappy 313 00:14:56,879 --> 00:14:53,110 with the science behind what we did 314 00:15:00,600 --> 00:14:56,889 particularly in surgery they also found 315 00:15:02,850 --> 00:15:00,610 that I had a poor understanding of the 316 00:15:04,379 --> 00:15:02,860 science behind my own understanding of 317 00:15:06,239 --> 00:15:04,389 the scientific method wasn't very good 318 00:15:09,359 --> 00:15:06,249 and it isn't taught very well in 319 00:15:11,189 --> 00:15:09,369 medicine so I tried to get an 320 00:15:13,169 --> 00:15:11,199 understanding from from mentors and 321 00:15:15,960 --> 00:15:13,179 other people who seem to be able to 322 00:15:17,579 --> 00:15:15,970 critically appraise the literature in a 323 00:15:21,720 --> 00:15:17,589 scientific manner so I tried to learn 324 00:15:23,939 --> 00:15:21,730 that so I eventually did some courses 325 00:15:26,009 --> 00:15:23,949 then this led me to to study clinical 326 00:15:28,350 --> 00:15:26,019 epidemiology which is basically you know 327 00:15:33,059 --> 00:15:28,360 evidence-based medicine the science 328 00:15:36,350 --> 00:15:33,069 behind the the the studies that we do 329 00:15:38,789 --> 00:15:36,360 and so I did a master's degree in 330 00:15:41,159 --> 00:15:38,799 clinical epidemiology at University of 331 00:15:42,869 --> 00:15:41,169 Sydney which is a fairly it's a very 332 00:15:45,689 --> 00:15:42,879 good course run by the school of public 333 00:15:49,199 --> 00:15:45,699 health fair and the people there are all 334 00:15:52,079 --> 00:15:49,209 good skeptics very very soundly 335 00:15:56,340 --> 00:15:52,089 scientifically based and then I did a 336 00:15:59,159 --> 00:15:56,350 PhD in in surgical outcomes at 337 00:16:01,319 --> 00:15:59,169 University of Sydney as well and then so 338 00:16:04,519 --> 00:16:01,329 that you do other research projects and 339 00:16:08,400 --> 00:16:04,529 now I have students working for me and 340 00:16:11,460 --> 00:16:08,410 and and so I split my time between the 341 00:16:12,840 --> 00:16:11,470 academic activities I'm employed by the 342 00:16:14,789 --> 00:16:12,850 university of new south wales and the 343 00:16:16,499 --> 00:16:14,799 clinical activities which is looking 344 00:16:19,590 --> 00:16:16,509 after patients that come into to this 345 00:16:21,269 --> 00:16:19,600 hospital and the two crossover we do 346 00:16:24,139 --> 00:16:21,279 studies on the patients that come in 347 00:16:27,059 --> 00:16:24,149 here have you found that having studied 348 00:16:29,639 --> 00:16:27,069 epidemiology and being much more aware 349 00:16:31,229 --> 00:16:29,649 of the scientific mahou the scientific 350 00:16:32,909 --> 00:16:31,239 method can inform the way you treat 351 00:16:35,909 --> 00:16:32,919 patients that changed your practice 352 00:16:40,139 --> 00:16:35,919 definitely yeah i was already always a 353 00:16:44,039 --> 00:16:40,149 little bit wary but i would be probably 354 00:16:46,489 --> 00:16:44,049 the most conservative one of the most 355 00:16:49,999 --> 00:16:46,499 conservative orthopaedic surgeons around 356 00:16:51,989 --> 00:16:50,009 so when I go to meetings I got a lot of 357 00:16:55,829 --> 00:16:51,999 clinical meetings and meetings with 358 00:16:59,039 --> 00:16:55,839 other surgeons things I would tend to 359 00:17:02,249 --> 00:16:59,049 take up one end of the spectrum which is 360 00:17:04,889 --> 00:17:02,259 the non-operative end whereas some other 361 00:17:06,419 --> 00:17:04,899 surgeons are there is a lot that it can 362 00:17:07,710 --> 00:17:06,429 be quite aggressive and operate on a lot 363 00:17:10,230 --> 00:17:07,720 of patience 364 00:17:13,020 --> 00:17:10,240 where I would not operate on them and 365 00:17:17,850 --> 00:17:13,030 that's because my interpretation of the 366 00:17:20,039 --> 00:17:17,860 evidence is such that I from my 367 00:17:22,230 --> 00:17:20,049 experience and from my understanding of 368 00:17:25,590 --> 00:17:22,240 the literature if there is not good 369 00:17:28,919 --> 00:17:25,600 evidence for a procedure then the 370 00:17:33,029 --> 00:17:28,929 procedure probably doesn't work whereas 371 00:17:35,940 --> 00:17:33,039 the ver default position is well we know 372 00:17:38,430 --> 00:17:35,950 from experience in my hands that this 373 00:17:41,370 --> 00:17:38,440 procedure works so until evidence comes 374 00:17:43,320 --> 00:17:41,380 out that shows me otherwise I'm going to 375 00:17:46,470 --> 00:17:43,330 continue doing it and this is what this 376 00:17:50,130 --> 00:17:46,480 is medicine for the last you know 100 377 00:17:52,970 --> 00:17:50,140 years or 200 years is that people you 378 00:17:55,350 --> 00:17:52,980 know right back to the 1800s when they 379 00:17:58,440 --> 00:17:55,360 were doing bloodletting in Venice 380 00:17:59,850 --> 00:17:58,450 section on everybody and they finally 381 00:18:02,520 --> 00:17:59,860 came out with the evidence that it 382 00:18:05,340 --> 00:18:02,530 didn't actually offer any benefit people 383 00:18:07,560 --> 00:18:05,350 still did it because that's what they 384 00:18:10,440 --> 00:18:07,570 did and they saw patients get better 385 00:18:11,909 --> 00:18:10,450 after they did it not realizing of 386 00:18:15,720 --> 00:18:11,919 course the patients tend to get better 387 00:18:18,600 --> 00:18:15,730 anyway other cases where surgery might 388 00:18:20,190 --> 00:18:18,610 be obvious where you think studies are 389 00:18:21,930 --> 00:18:20,200 not required we're gonna give you an 390 00:18:23,850 --> 00:18:21,940 example that I might think of yeah a 391 00:18:27,090 --> 00:18:23,860 broken bone that hasn't set properly 392 00:18:28,919 --> 00:18:27,100 yeah oh well this is my field and I 393 00:18:33,899 --> 00:18:28,929 think subconsciously this is what's 394 00:18:36,360 --> 00:18:33,909 drawing me to to my particular area of 395 00:18:39,690 --> 00:18:36,370 super specialty within medicine which is 396 00:18:42,390 --> 00:18:39,700 basically fixing broken bones because 397 00:18:47,310 --> 00:18:42,400 it's such a clear-cut sort of black and 398 00:18:50,700 --> 00:18:47,320 white area however within this field 399 00:18:53,669 --> 00:18:50,710 this the evidence is still questionable 400 00:18:54,960 --> 00:18:53,679 for a lot of the things we do and I 401 00:18:56,909 --> 00:18:54,970 spend a lot of time arguing with 402 00:19:01,590 --> 00:18:56,919 patients who come to see me with it with 403 00:19:02,730 --> 00:19:01,600 a broken somewhere and the x-rays never 404 00:19:04,230 --> 00:19:02,740 looked perfect I mean if you treat it 405 00:19:06,090 --> 00:19:04,240 not operatively you still see the 406 00:19:10,409 --> 00:19:06,100 fracture and it's you know just roughly 407 00:19:11,580 --> 00:19:10,419 lined up which is fine and I better have 408 00:19:13,770 --> 00:19:11,590 to argue with the patients because 409 00:19:16,560 --> 00:19:13,780 there's this expectation the patients 410 00:19:18,840 --> 00:19:16,570 say to me but doctor how is it going to 411 00:19:20,880 --> 00:19:18,850 heal if you don't put it together you 412 00:19:22,800 --> 00:19:20,890 know if less you operate on it too 413 00:19:25,620 --> 00:19:22,810 put the bones together it will never 414 00:19:27,510 --> 00:19:25,630 heal this is the this is what we have to 415 00:19:31,050 --> 00:19:27,520 deal with this is the understanding of a 416 00:19:32,400 --> 00:19:31,060 lot of people and I have to go back to 417 00:19:33,780 --> 00:19:32,410 them to explain that bones have been 418 00:19:36,180 --> 00:19:33,790 healing for hundreds of millions of 419 00:19:40,140 --> 00:19:36,190 years without operations and quite 420 00:19:42,690 --> 00:19:40,150 successfully and evolution has has 421 00:19:44,520 --> 00:19:42,700 worked out over several billion years a 422 00:19:47,130 --> 00:19:44,530 way of making bones joined together 423 00:19:49,860 --> 00:19:47,140 which is quite unique and extremely 424 00:19:52,770 --> 00:19:49,870 involved and involving hundreds and 425 00:19:57,180 --> 00:19:52,780 thousands of mediator factors and 426 00:20:00,810 --> 00:19:57,190 proteins and local chemicals to make 427 00:20:03,900 --> 00:20:00,820 this process work when we operate on it 428 00:20:06,420 --> 00:20:03,910 we completely just remove all of those 429 00:20:09,630 --> 00:20:06,430 factors that are in there helping it 430 00:20:11,250 --> 00:20:09,640 heal and by large when we operate on 431 00:20:13,530 --> 00:20:11,260 things probably the chance of bands 432 00:20:15,390 --> 00:20:13,540 healing is lower one of the reasons we 433 00:20:18,330 --> 00:20:15,400 operate on bones is not to get them to 434 00:20:21,330 --> 00:20:18,340 heal when we operate its Norway to hold 435 00:20:24,690 --> 00:20:21,340 them in a position such that when they 436 00:20:26,940 --> 00:20:24,700 heal the function will be better so it's 437 00:20:29,010 --> 00:20:26,950 to deal with the functionality post post 438 00:20:31,230 --> 00:20:29,020 injury rather than with the healing 439 00:20:33,540 --> 00:20:31,240 process yeah that's a large part of it 440 00:20:36,630 --> 00:20:33,550 however there are examples where bones 441 00:20:38,970 --> 00:20:36,640 are very badly broken and they you can't 442 00:20:40,650 --> 00:20:38,980 control them you know classic example is 443 00:20:44,010 --> 00:20:40,660 probably the femur fracture so the thigh 444 00:20:46,230 --> 00:20:44,020 bone fracture is a good one forever 445 00:20:47,730 --> 00:20:46,240 they've been treated in traction and I 446 00:20:50,060 --> 00:20:47,740 remember at this hospital when I came 447 00:20:52,440 --> 00:20:50,070 here as a junior many many years ago 448 00:20:54,750 --> 00:20:52,450 there was a doctor still treating the 449 00:20:56,730 --> 00:20:54,760 retraction and in World War two and in 450 00:20:59,100 --> 00:20:56,740 the 50s and 60s there were whole wards 451 00:21:04,140 --> 00:20:59,110 full of young motorbike riders who were 452 00:21:06,660 --> 00:21:04,150 in traction for four months now they 453 00:21:08,580 --> 00:21:06,670 were healed and that hill satisfactorily 454 00:21:10,230 --> 00:21:08,590 they probably healed a lot of them 455 00:21:12,090 --> 00:21:10,240 healed with a bit of deformity so the 456 00:21:13,770 --> 00:21:12,100 hill a bit short and and slightly 457 00:21:16,110 --> 00:21:13,780 crooked and so people had a bit of a 458 00:21:17,910 --> 00:21:16,120 limp afterwards so I think our modern 459 00:21:21,000 --> 00:21:17,920 methods these days where we operate on 460 00:21:22,860 --> 00:21:21,010 them probably gets better function but 461 00:21:24,870 --> 00:21:22,870 the other thing is the imperative is 462 00:21:27,780 --> 00:21:24,880 that to leave every patient with a 463 00:21:29,070 --> 00:21:27,790 broken femur in hospital in traction for 464 00:21:32,230 --> 00:21:29,080 three months it's just not possible 465 00:21:35,500 --> 00:21:32,240 these days I mean that the cost 466 00:21:38,380 --> 00:21:35,510 to the hospitals the cost of the patient 467 00:21:41,230 --> 00:21:38,390 being out of work not being at home to 468 00:21:42,640 --> 00:21:41,240 look after their kids and everything to 469 00:21:46,900 --> 00:21:42,650 put some in a hospital for three months 470 00:21:48,970 --> 00:21:46,910 is unthinkable these days whereas it was 471 00:21:51,330 --> 00:21:48,980 just a matter of course in those days so 472 00:21:53,470 --> 00:21:51,340 we operate on every single thigh bone 473 00:21:55,390 --> 00:21:53,480 every single femur fracture that comes 474 00:21:58,990 --> 00:21:55,400 in and we fix them and they go home 475 00:22:01,450 --> 00:21:59,000 normally within a few days but we've 476 00:22:02,410 --> 00:22:01,460 increased the infection rate because of 477 00:22:05,770 --> 00:22:02,420 that because they never used to get 478 00:22:07,540 --> 00:22:05,780 infected so imagine with that yeah they 479 00:22:10,900 --> 00:22:07,550 always used to heal interaction here and 480 00:22:14,560 --> 00:22:10,910 they never got infected but they would 481 00:22:16,510 --> 00:22:14,570 have probably more residual deformity 482 00:22:18,640 --> 00:22:16,520 with that because it's difficult to 483 00:22:20,080 --> 00:22:18,650 control the alignment in traction it's 484 00:22:24,520 --> 00:22:20,090 easy to control the alignment when you 485 00:22:28,600 --> 00:22:24,530 put a big metal rod in there um so you 486 00:22:33,430 --> 00:22:28,610 know but but still the belief in surgery 487 00:22:35,770 --> 00:22:33,440 is so great amongst the people being 488 00:22:37,810 --> 00:22:35,780 operated on and the surgeons themselves 489 00:22:39,820 --> 00:22:37,820 and often have a bit of fun with the 490 00:22:44,740 --> 00:22:39,830 junior doctors when they come through to 491 00:22:46,930 --> 00:22:44,750 learn about orthopedics one big area of 492 00:22:48,970 --> 00:22:46,940 orthopedic surgery is the hip fractures 493 00:22:52,540 --> 00:22:48,980 in the elderly it's an extremely common 494 00:22:54,370 --> 00:22:52,550 condition and and most people have a 495 00:22:56,110 --> 00:22:54,380 grandmother or an RD or someone who's 496 00:22:57,910 --> 00:22:56,120 had a hip fracture and had a fixed or 497 00:23:00,250 --> 00:22:57,920 had it replaced or pinned or whatever 498 00:23:03,400 --> 00:23:00,260 it's very common we would do that 499 00:23:08,080 --> 00:23:03,410 operation every day in most hospitals in 500 00:23:09,580 --> 00:23:08,090 the world and they all undergo surgery 501 00:23:13,590 --> 00:23:09,590 whereas in the old days a lot of them 502 00:23:16,840 --> 00:23:13,600 were treated in traction or other ways 503 00:23:18,490 --> 00:23:16,850 but there's this belief that without 504 00:23:23,350 --> 00:23:18,500 surgery these patients are somehow 505 00:23:25,810 --> 00:23:23,360 doomed and there's an urgency associated 506 00:23:27,700 --> 00:23:25,820 with the operation and a lot of Surgeons 507 00:23:30,460 --> 00:23:27,710 believe that the patients have to be 508 00:23:32,470 --> 00:23:30,470 operated on immediately or within 24 509 00:23:36,520 --> 00:23:32,480 hours otherwise the mortality is 510 00:23:39,040 --> 00:23:36,530 unacceptable and if it's left wall in a 511 00:23:42,130 --> 00:23:39,050 few days then the patient's sort of you 512 00:23:44,600 --> 00:23:42,140 know deteriorate and it's it's really 513 00:23:47,390 --> 00:23:44,610 quite an emergency and often 514 00:23:49,010 --> 00:23:47,400 say to the junior doctors so what would 515 00:23:51,169 --> 00:23:49,020 happen if we treated this fracture not 516 00:23:54,620 --> 00:23:51,179 operatively if we treated it say in 517 00:23:56,000 --> 00:23:54,630 traction and they often kind of just 518 00:23:58,400 --> 00:23:56,010 laugh at me just think I'm having a joke 519 00:23:59,780 --> 00:23:58,410 and I go no I'm serious what would 520 00:24:03,650 --> 00:23:59,790 happen and they all the patient would 521 00:24:06,530 --> 00:24:03,660 die and I say well really what would 522 00:24:09,230 --> 00:24:06,540 they die off me and all they'd be 523 00:24:13,190 --> 00:24:09,240 immobilized in bed so they would get bed 524 00:24:15,950 --> 00:24:13,200 sores and pneumonia and urinary tract 525 00:24:18,230 --> 00:24:15,960 infections and terrible complications 526 00:24:19,760 --> 00:24:18,240 and they would the patients would 527 00:24:22,010 --> 00:24:19,770 deteriorate to such an extent they're 528 00:24:24,950 --> 00:24:22,020 elderly anyway in their reserves are as 529 00:24:26,810 --> 00:24:24,960 good and basically died the only 530 00:24:29,480 --> 00:24:26,820 randomized control trial has ever been 531 00:24:32,390 --> 00:24:29,490 done has done some time ago and it 532 00:24:35,240 --> 00:24:32,400 randomized patients to traction versus 533 00:24:38,060 --> 00:24:35,250 surgical fixation for hip fractures in 534 00:24:39,770 --> 00:24:38,070 elderly patients there was no difference 535 00:24:42,530 --> 00:24:39,780 in the mortality between the two groups 536 00:24:43,789 --> 00:24:42,540 and that's when it's quite obvious the 537 00:24:46,190 --> 00:24:43,799 difference would be quite obviously the 538 00:24:48,770 --> 00:24:46,200 patient yeah so it's not blinded it's 539 00:24:50,539 --> 00:24:48,780 yeah it's not it's not blinded is 540 00:24:52,909 --> 00:24:50,549 randomized in control it's I'm buying it 541 00:24:54,200 --> 00:24:52,919 yeah it's not blinded so you're going to 542 00:24:56,150 --> 00:24:54,210 be children operatively you're going to 543 00:24:57,530 --> 00:24:56,160 be treated operatively but there's no 544 00:24:59,240 --> 00:24:57,540 difference in the mortality you're no 545 00:25:01,039 --> 00:24:59,250 more likely to die if you get triggered 546 00:25:03,650 --> 00:25:01,049 on operatively then if you get treated 547 00:25:05,419 --> 00:25:03,660 operatively I need a few tell surgeons 548 00:25:08,120 --> 00:25:05,429 this they don't believe you most of them 549 00:25:10,970 --> 00:25:08,130 aren't even aware of the study that was 550 00:25:12,470 --> 00:25:10,980 done and the same thing with the urgency 551 00:25:14,830 --> 00:25:12,480 of the procedure if you look at the 552 00:25:19,669 --> 00:25:14,840 literature sign typically and if you 553 00:25:21,530 --> 00:25:19,679 control for the general condition of the 554 00:25:23,450 --> 00:25:21,540 patient there's really no difference if 555 00:25:26,090 --> 00:25:23,460 you operate on it within 12 hours or 24 556 00:25:28,850 --> 00:25:26,100 hours of 48 hours or probably 72 hours 557 00:25:30,470 --> 00:25:28,860 in fact that randomized control trial 558 00:25:32,180 --> 00:25:30,480 that I mentioned shows you that it's 559 00:25:34,190 --> 00:25:32,190 there's no difference in mortality if 560 00:25:35,900 --> 00:25:34,200 you never operate on them so it's hard 561 00:25:37,430 --> 00:25:35,910 to argue that you need to operate in a 562 00:25:38,690 --> 00:25:37,440 certain number of hours when we know 563 00:25:42,140 --> 00:25:38,700 that if you don't operate at all it 564 00:25:44,890 --> 00:25:42,150 doesn't make any difference and a lot of 565 00:25:47,690 --> 00:25:44,900 these studies tend to be biased because 566 00:25:49,460 --> 00:25:47,700 the patients that they're not controlled 567 00:25:51,110 --> 00:25:49,470 trials so the patient's you get operated 568 00:25:53,690 --> 00:25:51,120 on earlier of the fitter and healthier 569 00:25:55,490 --> 00:25:53,700 ones who are fit for the operation the 570 00:25:57,100 --> 00:25:55,500 patients who are medically unwell and 571 00:26:01,160 --> 00:25:57,110 need some work up 572 00:26:02,270 --> 00:26:01,170 transfusion or a pacemaker or something 573 00:26:03,470 --> 00:26:02,280 this they're the ones they go up wrote 574 00:26:05,090 --> 00:26:03,480 it on later and they're going to have a 575 00:26:07,370 --> 00:26:05,100 high mortality anyway because they're 576 00:26:10,550 --> 00:26:07,380 sicker so but good studies would 577 00:26:12,380 --> 00:26:10,560 actually look at yeah and the better 578 00:26:15,370 --> 00:26:12,390 studies that i slor' the variables and 579 00:26:18,320 --> 00:26:15,380 allow for this do not show this dramatic 580 00:26:23,330 --> 00:26:18,330 difference in mortality that the poorest 581 00:26:27,050 --> 00:26:23,340 studies show but unfortunately a lot of 582 00:26:30,860 --> 00:26:27,060 the people who are making the decisions 583 00:26:36,170 --> 00:26:30,870 about surgical treatment don't have the 584 00:26:39,230 --> 00:26:36,180 skills and the will to get to the bottom 585 00:26:42,620 --> 00:26:39,240 of the literature and you know I guess 586 00:26:44,600 --> 00:26:42,630 to be fair to them i mean there's data 587 00:26:47,210 --> 00:26:44,610 out there and how many medical articles 588 00:26:49,100 --> 00:26:47,220 are published every day and and in order 589 00:26:52,730 --> 00:26:49,110 to be a head of the medical literature 590 00:26:54,650 --> 00:26:52,740 you would have to read for you know 48 591 00:26:55,880 --> 00:26:54,660 hours a day or something just to just to 592 00:26:58,250 --> 00:26:55,890 stay on top of everything that's coming 593 00:27:00,440 --> 00:26:58,260 out but you know the evidence is there 594 00:27:01,520 --> 00:27:00,450 if you if you look for it and if you 595 00:27:03,830 --> 00:27:01,530 know where to look there's good 596 00:27:06,200 --> 00:27:03,840 summaries of the evidence Cochrane 597 00:27:08,630 --> 00:27:06,210 reviews and things like that which are 598 00:27:11,060 --> 00:27:08,640 which are very helpful so how do you 599 00:27:13,250 --> 00:27:11,070 change that culture of preferring 600 00:27:16,280 --> 00:27:13,260 clinical judgment of a science and 601 00:27:19,730 --> 00:27:16,290 studies that's a very good question 602 00:27:23,450 --> 00:27:19,740 because that's what we need to do we 603 00:27:27,680 --> 00:27:23,460 need to have the decision makers the the 604 00:27:30,050 --> 00:27:27,690 doctors basing their decisions on better 605 00:27:33,680 --> 00:27:30,060 science and have them able to interpret 606 00:27:36,920 --> 00:27:33,690 the data better okay the first answer 607 00:27:41,720 --> 00:27:36,930 that question is it is changing so a lot 608 00:27:42,920 --> 00:27:41,730 more people are savvy to the scientific 609 00:27:45,560 --> 00:27:42,930 side of things and evidence-based 610 00:27:47,540 --> 00:27:45,570 medicine and particularly for reasons 611 00:27:51,410 --> 00:27:47,550 I'm not sure of in the United States and 612 00:27:54,920 --> 00:27:51,420 Canada so in North America they're a lot 613 00:27:57,350 --> 00:27:54,930 more aware of these things and it has 614 00:28:01,430 --> 00:27:57,360 changed a lot in the last 10 to 20 years 615 00:28:03,020 --> 00:28:01,440 so it is changing what are we it's I 616 00:28:04,550 --> 00:28:03,030 would say the same thing for Australia 617 00:28:08,570 --> 00:28:04,560 in the UK other countries that can't 618 00:28:10,490 --> 00:28:08,580 really comment on but so what is that 619 00:28:11,890 --> 00:28:10,500 we're doing to make this change 620 00:28:15,310 --> 00:28:11,900 there's probably a little bit more 621 00:28:19,420 --> 00:28:15,320 emphasis on evidence-based medicine 622 00:28:24,740 --> 00:28:19,430 principles in undergraduate medicine 623 00:28:27,170 --> 00:28:24,750 it's it becomes a kind of 624 00:28:28,580 --> 00:28:27,180 self-propagating thing that people get 625 00:28:32,480 --> 00:28:28,590 interested in it and so they teach 626 00:28:34,040 --> 00:28:32,490 younger people about it and they become 627 00:28:36,080 --> 00:28:34,050 aware that this is the right way of 628 00:28:39,410 --> 00:28:36,090 seeing things and so they teach other 629 00:28:43,280 --> 00:28:39,420 people and it kind of spreads by 630 00:28:46,970 --> 00:28:43,290 influence and we've made an effort in 631 00:28:50,180 --> 00:28:46,980 the College of Surgeons in Australia now 632 00:28:53,870 --> 00:28:50,190 has a course which is run which is done 633 00:28:56,510 --> 00:28:53,880 by most young trainees which is a course 634 00:28:58,130 --> 00:28:56,520 that I'm involved in called the clear 635 00:29:00,050 --> 00:28:58,140 course which stands for critical 636 00:29:03,530 --> 00:29:00,060 literature evaluation and research which 637 00:29:05,540 --> 00:29:03,540 is basically just a two-day you know 638 00:29:10,940 --> 00:29:05,550 summary course about evidence-based 639 00:29:13,060 --> 00:29:10,950 medicine but I I do sometimes question 640 00:29:20,270 --> 00:29:13,070 the effectiveness of that course I think 641 00:29:23,900 --> 00:29:20,280 sometimes people will get really have 642 00:29:25,460 --> 00:29:23,910 their eyes opened by it and a very open 643 00:29:26,600 --> 00:29:25,470 to it and it changes their practice but 644 00:29:29,030 --> 00:29:26,610 some people just sit there and they're 645 00:29:30,920 --> 00:29:29,040 only doing the course because they have 646 00:29:32,930 --> 00:29:30,930 to get it ticked off on their CV or 647 00:29:34,430 --> 00:29:32,940 something like that and so it can be 648 00:29:36,590 --> 00:29:34,440 hard to get through to something what 649 00:29:38,360 --> 00:29:36,600 about you mentioned earlier the doctors 650 00:29:40,550 --> 00:29:38,370 are not actually trained very well in 651 00:29:42,230 --> 00:29:40,560 the scientific method while in medical 652 00:29:44,480 --> 00:29:42,240 school is that something that you 653 00:29:48,080 --> 00:29:44,490 believe can be changed or he's changing 654 00:29:51,470 --> 00:29:48,090 yeah I definitely can be changed I 655 00:29:54,200 --> 00:29:51,480 believe it is challenging but it's a bit 656 00:29:57,800 --> 00:29:54,210 hard to keep track of because I'm not 657 00:30:00,560 --> 00:29:57,810 directly involved in the course 658 00:30:02,810 --> 00:30:00,570 curriculum for undergraduate medicine 659 00:30:05,570 --> 00:30:02,820 and now particularly new south wales the 660 00:30:10,640 --> 00:30:05,580 last five years we've seen an extra one 661 00:30:14,900 --> 00:30:10,650 two three four five I think medical 662 00:30:17,330 --> 00:30:14,910 schools open up and I have no idea what 663 00:30:18,470 --> 00:30:17,340 they're teaching but there's so many you 664 00:30:21,230 --> 00:30:18,480 know when I went through there was only 665 00:30:22,280 --> 00:30:21,240 two medical schools and others until 666 00:30:24,320 --> 00:30:22,290 they must be up seven or eight in New 667 00:30:26,810 --> 00:30:24,330 South Wales but I assume that there 668 00:30:29,289 --> 00:30:26,820 there is a core curriculum for medicine 669 00:30:31,669 --> 00:30:29,299 in the rightful registration in yourself 670 00:30:34,279 --> 00:30:31,679 I'm not sure because I know that the 671 00:30:37,159 --> 00:30:34,289 course does vary a lot between the 672 00:30:38,990 --> 00:30:37,169 universities it varies quite a lot so 673 00:30:41,299 --> 00:30:39,000 I'm not sure whether there's a core 674 00:30:43,190 --> 00:30:41,309 curriculum I don't think it's like the 675 00:30:45,889 --> 00:30:43,200 HSC or anything about that where you 676 00:30:48,860 --> 00:30:45,899 have to cover cert things that's 677 00:30:51,680 --> 00:30:48,870 actually been scary because ain't nobody 678 00:30:56,629 --> 00:30:51,690 with Justin HSC would come near me with 679 00:30:57,950 --> 00:30:56,639 a knife well hopefully but all you have 680 00:31:01,460 --> 00:30:57,960 to get all you have to do to be 681 00:31:03,370 --> 00:31:01,470 registered just have a medical degree in 682 00:31:06,710 --> 00:31:03,380 order to get your medical degree 683 00:31:08,149 --> 00:31:06,720 accredited from the University so say 684 00:31:10,610 --> 00:31:08,159 for instance University of Western 685 00:31:12,710 --> 00:31:10,620 Sydney which has opened up recently they 686 00:31:16,129 --> 00:31:12,720 developed a medical course from the 687 00:31:17,450 --> 00:31:16,139 ground up now this is where it's not my 688 00:31:18,769 --> 00:31:17,460 area of expertise but I assume they 689 00:31:24,799 --> 00:31:18,779 would have had to have their medical 690 00:31:27,680 --> 00:31:24,809 course accredited and but what I can't 691 00:31:30,470 --> 00:31:27,690 tell you is what how stringent that is 692 00:31:32,600 --> 00:31:30,480 or what criteria there are to have a 693 00:31:35,480 --> 00:31:32,610 medical course accredited you'll be 694 00:31:38,269 --> 00:31:35,490 interesting to find out to find out who 695 00:31:41,720 --> 00:31:38,279 the accreditation but who the 696 00:31:44,379 --> 00:31:41,730 accreditation authority is who's who's 697 00:31:46,759 --> 00:31:44,389 on it and how they evaluate their 698 00:31:48,139 --> 00:31:46,769 courses if you Father let me know 699 00:31:49,549 --> 00:31:48,149 because it would be interested yeah well 700 00:31:51,320 --> 00:31:49,559 I think I think it's very interesting 701 00:31:53,120 --> 00:31:51,330 and it probably leads up to my next 702 00:31:55,399 --> 00:31:53,130 question which is to do with public 703 00:31:57,169 --> 00:31:55,409 demand one of the things that we as 704 00:31:59,950 --> 00:31:57,179 skeptics do is try to educate the public 705 00:32:05,000 --> 00:31:59,960 how to think critically and not take 706 00:32:07,100 --> 00:32:05,010 claims at face value and try to explain 707 00:32:08,960 --> 00:32:07,110 to people why while science is 708 00:32:11,210 --> 00:32:08,970 definitely not perfect it's the best 709 00:32:13,159 --> 00:32:11,220 best method we have of finding what's 710 00:32:16,039 --> 00:32:13,169 true and what's not true and of course 711 00:32:19,090 --> 00:32:16,049 it's very true in medicine scientific 712 00:32:22,399 --> 00:32:19,100 medicine and I'm wondering whether 713 00:32:25,870 --> 00:32:22,409 educating the public to demand of the 714 00:32:28,789 --> 00:32:25,880 doctors demand of the authorities that 715 00:32:33,639 --> 00:32:28,799 treatments are based on science would be 716 00:32:37,850 --> 00:32:33,649 a good approach yeah i agree i think the 717 00:32:42,169 --> 00:32:37,860 public should be educated better I don't 718 00:32:43,730 --> 00:32:42,179 know whether they should be able to look 719 00:32:45,620 --> 00:32:43,740 at some of the evidence themselves or 720 00:32:47,149 --> 00:32:45,630 have some kind of access to the evidence 721 00:32:48,620 --> 00:32:47,159 behind the procedure that's been 722 00:32:51,710 --> 00:32:48,630 recommended to them or the drug that's 723 00:32:54,529 --> 00:32:51,720 been prescribed to them I think if they 724 00:32:56,060 --> 00:32:54,539 ask the doctors then there will be a 725 00:32:58,519 --> 00:32:56,070 tendency to get around it by saying oh 726 00:33:04,490 --> 00:32:58,529 yes the evidence is very good here's the 727 00:33:07,220 --> 00:33:04,500 tablet because the the patient's ability 728 00:33:11,570 --> 00:33:07,230 to interpret the evidence might not be 729 00:33:15,399 --> 00:33:11,580 very good the doctor's ability to convey 730 00:33:17,779 --> 00:33:15,409 the relative merits and strengths of 731 00:33:21,110 --> 00:33:17,789 different studies to a patient might be 732 00:33:22,399 --> 00:33:21,120 very difficult so in essence it's going 733 00:33:25,549 --> 00:33:22,409 to come down to just trusting the 734 00:33:27,110 --> 00:33:25,559 doctor's opinion again probably oh you 735 00:33:32,330 --> 00:33:27,120 know there's there's this thing I'm 736 00:33:34,789 --> 00:33:32,340 actually not so sure that I would like 737 00:33:38,029 --> 00:33:34,799 to believe that that's the case and I'll 738 00:33:39,769 --> 00:33:38,039 probably explain why that you know they 739 00:33:44,450 --> 00:33:39,779 always say half the population it has 740 00:33:45,560 --> 00:33:44,460 below-average intelligence but also half 741 00:33:48,169 --> 00:33:45,570 the population has above-average 742 00:33:50,389 --> 00:33:48,179 intelligence and half the population has 743 00:33:51,830 --> 00:33:50,399 above-average education levels and you 744 00:33:53,990 --> 00:33:51,840 don't have to educate a hundred percent 745 00:33:55,430 --> 00:33:54,000 of the population but you have if you 746 00:33:57,379 --> 00:33:55,440 have say twenty-five percent of our 747 00:33:59,269 --> 00:33:57,389 population who are able to understand 748 00:34:01,909 --> 00:33:59,279 what studies are all about and are able 749 00:34:03,110 --> 00:34:01,919 to ask the doctor what was the evidence 750 00:34:06,619 --> 00:34:03,120 for this treatment that you're 751 00:34:08,960 --> 00:34:06,629 recommending to me and what what are the 752 00:34:11,510 --> 00:34:08,970 risks what are the percentages get into 753 00:34:13,460 --> 00:34:11,520 it in detail that's an it you don't need 754 00:34:15,349 --> 00:34:13,470 a hundred percent to claim to require 755 00:34:17,659 --> 00:34:15,359 that if you have twenty twenty-five 756 00:34:20,270 --> 00:34:17,669 percent require that doctors will get in 757 00:34:21,950 --> 00:34:20,280 the habit of knowing yes it's not even 758 00:34:23,899 --> 00:34:21,960 about explaining it's about knowing the 759 00:34:27,740 --> 00:34:23,909 evidence yeah and they might actually 760 00:34:28,639 --> 00:34:27,750 get into a mode where they treat you 761 00:34:30,649 --> 00:34:28,649 know 762 00:34:31,849 --> 00:34:30,659 choose treatments based on evidence 763 00:34:33,169 --> 00:34:31,859 because they have to explain this to 764 00:34:37,399 --> 00:34:33,179 twenty twenty-five percent of their 765 00:34:40,309 --> 00:34:37,409 patients yeah I agree yeah I agree and 766 00:34:42,409 --> 00:34:40,319 if I go to the doctor or I take a family 767 00:34:44,750 --> 00:34:42,419 member to the doctor um I've asking the 768 00:34:50,510 --> 00:34:44,760 questions and i'm looking it up before I 769 00:34:52,490 --> 00:34:50,520 know so I have some experience with that 770 00:34:58,370 --> 00:34:52,500 but it's asking the right question as 771 00:35:02,240 --> 00:34:58,380 well I mean there's a lot of things out 772 00:35:05,839 --> 00:35:02,250 there that in medicine that there is 773 00:35:09,260 --> 00:35:05,849 evidence that they work for a certain 774 00:35:13,760 --> 00:35:09,270 outcome that they might have they then 775 00:35:18,019 --> 00:35:13,770 might not work overall so what are some 776 00:35:23,170 --> 00:35:18,029 of the classic examples classic example 777 00:35:32,710 --> 00:35:23,180 would probably be in surgery carotid 778 00:35:37,490 --> 00:35:32,720 bypass surgery for preventing strokes 779 00:35:41,839 --> 00:35:37,500 which was very popular in probably 20 780 00:35:45,200 --> 00:35:41,849 years ago or so and if you look at the 781 00:35:47,210 --> 00:35:45,210 evidence of whether it reduces the risk 782 00:35:51,190 --> 00:35:47,220 of stroke which is what you're 783 00:35:54,069 --> 00:35:51,200 interested in then it looked very good 784 00:35:59,329 --> 00:35:54,079 that's if you excluded the patients that 785 00:36:02,180 --> 00:35:59,339 died from the operation or perhaps had 786 00:36:06,710 --> 00:36:02,190 an early massive stroke things like that 787 00:36:10,670 --> 00:36:06,720 so in the end when you looked at it it 788 00:36:11,720 --> 00:36:10,680 it was probably worse off there isn't 789 00:36:14,480 --> 00:36:11,730 any way of looking at it though 790 00:36:17,180 --> 00:36:14,490 eliminating them exactly oh well it's 791 00:36:18,440 --> 00:36:17,190 the old thing of disease specific 792 00:36:20,450 --> 00:36:18,450 mortality and what is happening sorry 793 00:36:21,799 --> 00:36:20,460 this is a real epidemiological argument 794 00:36:26,120 --> 00:36:21,809 because if you look at a lot of 795 00:36:29,680 --> 00:36:26,130 treatments they are very good at 796 00:36:32,180 --> 00:36:29,690 reducing the disease specific mortality 797 00:36:36,079 --> 00:36:32,190 so if you've got a treatment from breast 798 00:36:37,819 --> 00:36:36,089 cancer say like radiotherapy I think if 799 00:36:39,500 --> 00:36:37,829 you look there has been studies done if 800 00:36:40,790 --> 00:36:39,510 you look at radiotherapy for breast 801 00:36:44,150 --> 00:36:40,800 cancer 802 00:36:48,020 --> 00:36:44,160 matically reduces the risk of dying from 803 00:36:50,540 --> 00:36:48,030 breast cancer and so that's it end of 804 00:36:53,000 --> 00:36:50,550 argument I mean it's just sounds like 805 00:36:55,550 --> 00:36:53,010 radiotherapy is carcinogenic in Sunrise 806 00:36:58,160 --> 00:36:55,560 exactly but it increases the risk of 807 00:37:01,160 --> 00:36:58,170 dying from other things and so the 808 00:37:02,600 --> 00:37:01,170 actual risk of death after 20 years with 809 00:37:06,230 --> 00:37:02,610 or without radiotherapy is probably not 810 00:37:08,660 --> 00:37:06,240 a lot different and same thing with this 811 00:37:11,540 --> 00:37:08,670 is the the debate that goes on with mass 812 00:37:15,970 --> 00:37:11,550 screening for things because it will 813 00:37:22,700 --> 00:37:18,440 mammograms for breast cancer which are 814 00:37:25,040 --> 00:37:22,710 being pushed in this state anyway and in 815 00:37:27,560 --> 00:37:25,050 a lot of places because it sounds good i 816 00:37:29,960 --> 00:37:27,570 always say this to my students if 817 00:37:33,500 --> 00:37:29,970 something sounds good if it sounds 818 00:37:35,870 --> 00:37:33,510 biologically plausible then i'd say odds 819 00:37:38,480 --> 00:37:35,880 are it's probably not true because you 820 00:37:41,360 --> 00:37:38,490 can make anything sound biologically 821 00:37:43,340 --> 00:37:41,370 plausible and whereas that's what we 822 00:37:46,850 --> 00:37:43,350 used to hang our hat on the old days was 823 00:37:49,160 --> 00:37:46,860 making a biologically you know argument 824 00:37:50,570 --> 00:37:49,170 for something to justify yourself now I 825 00:37:52,880 --> 00:37:50,580 think you can make a biological judge 826 00:37:54,830 --> 00:37:52,890 argument for just about anything and 827 00:37:56,840 --> 00:37:54,840 that's what people do and time and time 828 00:38:00,770 --> 00:37:56,850 again it gets shown to to be not the 829 00:38:04,790 --> 00:38:00,780 case I mean I can't believe how people 830 00:38:09,430 --> 00:38:04,800 are so adamant that mammography breast 831 00:38:12,860 --> 00:38:09,440 screening is is saving countless lives 832 00:38:15,290 --> 00:38:12,870 when you look at the evidence it's very 833 00:38:16,550 --> 00:38:15,300 questionable I mean there's there's a 834 00:38:19,310 --> 00:38:16,560 lot of debates written about this and 835 00:38:21,740 --> 00:38:19,320 the bmj studies of hundreds of thousands 836 00:38:24,380 --> 00:38:21,750 of patients randomized to mammography 837 00:38:26,840 --> 00:38:24,390 versus no mammography in Scandinavia 838 00:38:28,910 --> 00:38:26,850 think another one from Canada I think 839 00:38:31,250 --> 00:38:28,920 all of the studies have shown a decrease 840 00:38:33,110 --> 00:38:31,260 in disease specific mortality because 841 00:38:34,900 --> 00:38:33,120 you're diagnosing breast cancer in so 842 00:38:40,610 --> 00:38:34,910 many more people you're just not saving 843 00:38:43,190 --> 00:38:40,620 any lives so the risk of dying period in 844 00:38:45,110 --> 00:38:43,200 some of these studies were the same in 845 00:38:48,020 --> 00:38:45,120 both groups so that includes obviously a 846 00:38:51,200 --> 00:38:48,030 look at the life expectancy not just her 847 00:38:53,870 --> 00:38:51,210 yes yes we all die yes sir 848 00:38:57,140 --> 00:38:53,880 yeah but over a certain period of time 849 00:39:00,530 --> 00:38:57,150 the mortality was insane in one of the 850 00:39:03,020 --> 00:39:00,540 the Scandinavian studies the overall 851 00:39:04,490 --> 00:39:03,030 mortality in the time period looked at 852 00:39:07,550 --> 00:39:04,500 was actually higher in the mammography 853 00:39:10,099 --> 00:39:07,560 group than in the control group so you 854 00:39:12,140 --> 00:39:10,109 were less likely to die of breast cancer 855 00:39:14,150 --> 00:39:12,150 but you are more likely to know how 856 00:39:18,800 --> 00:39:14,160 could something like this be explained 857 00:39:20,270 --> 00:39:18,810 it doesn't seem doesn't seem to make 858 00:39:23,420 --> 00:39:20,280 sense because my mother if he's not even 859 00:39:25,609 --> 00:39:23,430 a treatment yeah well the theory is that 860 00:39:27,109 --> 00:39:25,619 well it's an interesting thing about the 861 00:39:32,060 --> 00:39:27,119 disease specific mortality because what 862 00:39:36,140 --> 00:39:32,070 it does is it probably over diagnosis so 863 00:39:39,020 --> 00:39:36,150 you're picking up the so-called breast 864 00:39:42,620 --> 00:39:39,030 cancer in patients that would never 865 00:39:44,690 --> 00:39:42,630 present would never normally be 866 00:39:46,550 --> 00:39:44,700 diagnosed with breast cancer maybe die 867 00:39:48,530 --> 00:39:46,560 or something else first maybe never get 868 00:39:50,839 --> 00:39:48,540 it to a stage where it's clinically 869 00:39:53,630 --> 00:39:50,849 apparent or causing them significant 870 00:39:55,430 --> 00:39:53,640 concern so in the mammography group the 871 00:40:00,380 --> 00:39:55,440 rate of breast cancer is going to be 872 00:40:02,180 --> 00:40:00,390 hugely higher so your disease specific 873 00:40:03,650 --> 00:40:02,190 mortality is going to be lower because 874 00:40:06,079 --> 00:40:03,660 the only people that died of breast 875 00:40:08,589 --> 00:40:06,089 cancer in the non mammography group are 876 00:40:11,630 --> 00:40:08,599 people that actually really have a 877 00:40:14,660 --> 00:40:11,640 cancer that's causing problems in their 878 00:40:16,880 --> 00:40:14,670 breasts whereas the other group the 879 00:40:19,190 --> 00:40:16,890 mortality may be the same but half of 880 00:40:22,310 --> 00:40:19,200 them been diagnosed with carcinoma in 881 00:40:24,200 --> 00:40:22,320 sight you or all these sort of new 882 00:40:26,540 --> 00:40:24,210 diagnoses which never used to be called 883 00:40:28,460 --> 00:40:26,550 cancer before or something like that so 884 00:40:32,349 --> 00:40:28,470 they let they lower the threshold of 885 00:40:35,060 --> 00:40:32,359 what is a cancer and of course lasering 886 00:40:36,500 --> 00:40:35,070 also it has done research on or he's 887 00:40:38,870 --> 00:40:36,510 doing research on monitoring 888 00:40:42,170 --> 00:40:38,880 specifically I think also specifically 889 00:40:43,730 --> 00:40:42,180 about prostate cancer at least that's 890 00:40:45,710 --> 00:40:43,740 one of the areas that he's looking into 891 00:40:47,510 --> 00:40:45,720 and I think the results are very clear 892 00:40:50,660 --> 00:40:47,520 there as well they're lit monitoring 893 00:40:53,240 --> 00:40:50,670 leads to overdiagnosis treatment yeah it 894 00:40:55,130 --> 00:40:53,250 does and there's also the psychological 895 00:40:59,690 --> 00:40:55,140 harm in the Scandinavian study of 896 00:41:02,300 --> 00:40:59,700 mammography something like some tens of 897 00:41:04,190 --> 00:41:02,310 thousands of patients were falsely 898 00:41:07,010 --> 00:41:04,200 diagnosed with breast cancer 899 00:41:09,770 --> 00:41:07,020 and some thousands of those people ended 900 00:41:11,359 --> 00:41:09,780 up having a procedure you know so they 901 00:41:13,490 --> 00:41:11,369 thought they had cancer they ended up 902 00:41:14,810 --> 00:41:13,500 having to have a biopsy or an excision 903 00:41:20,359 --> 00:41:14,820 or some kind of procedure and the 904 00:41:23,480 --> 00:41:20,369 psychological side of that is huge and 905 00:41:27,650 --> 00:41:23,490 it's all unnecessary and two known net 906 00:41:32,180 --> 00:41:27,660 gain and and yet there's a there's a 907 00:41:34,490 --> 00:41:32,190 political a sort of a social side to 908 00:41:35,960 --> 00:41:34,500 this that if somebody gets up and says I 909 00:41:37,940 --> 00:41:35,970 think we should stop mammography 910 00:41:39,560 --> 00:41:37,950 screening because the evidence behind it 911 00:41:41,329 --> 00:41:39,570 isn't really very good and we need to 912 00:41:44,839 --> 00:41:41,339 rethink it or at least let's look at the 913 00:41:46,670 --> 00:41:44,849 evidence more objectively and it might 914 00:41:49,430 --> 00:41:46,680 not be a good thing you can't do that 915 00:41:54,109 --> 00:41:49,440 you can't get up and say that but they 916 00:41:56,839 --> 00:41:54,119 they had a one of my favorite programs 917 00:41:59,150 --> 00:41:56,849 is Norman swans Health Report which is 918 00:42:02,230 --> 00:41:59,160 very good I don't know Norman personally 919 00:42:05,930 --> 00:42:02,240 but I can tell you from a scientific 920 00:42:07,490 --> 00:42:05,940 standpoint he is excellent he asks to 921 00:42:10,940 --> 00:42:07,500 all the right questions and looks at the 922 00:42:12,559 --> 00:42:10,950 evidence really well and they produced i 923 00:42:15,290 --> 00:42:12,569 think it was alex barrett that actually 924 00:42:17,000 --> 00:42:15,300 did it who's a collaborator of less air 925 00:42:18,200 --> 00:42:17,010 wing yes yes she's a university student 926 00:42:21,140 --> 00:42:18,210 in school of public health and that's 927 00:42:24,440 --> 00:42:21,150 where I did my clinical epidemiology so 928 00:42:26,720 --> 00:42:24,450 that's why I know Liz and Alex they're 929 00:42:29,270 --> 00:42:26,730 very good that's a great unit but 930 00:42:35,240 --> 00:42:29,280 presented a very objective look at 931 00:42:37,490 --> 00:42:35,250 breast screening and and yet copped 932 00:42:41,270 --> 00:42:37,500 enormous flak from breastscreen New 933 00:42:44,660 --> 00:42:41,280 South Wales how dare they publish such a 934 00:42:47,420 --> 00:42:44,670 broadcast such an irresponsible article 935 00:42:49,430 --> 00:42:47,430 and think of the countless lives that 936 00:42:52,160 --> 00:42:49,440 are saved you know every day from this 937 00:42:56,120 --> 00:42:52,170 procedure and how could they dare to 938 00:42:57,950 --> 00:42:56,130 question the standard practice I think 939 00:42:59,540 --> 00:42:57,960 it probably talks to the lack of 940 00:43:01,819 --> 00:42:59,550 understanding of how science works in 941 00:43:05,540 --> 00:43:01,829 large parts of the population including 942 00:43:07,010 --> 00:43:05,550 people who should probably yeah and and 943 00:43:09,859 --> 00:43:07,020 this is the problem with it sounding 944 00:43:12,079 --> 00:43:09,869 good because it it's hard to argue 945 00:43:15,380 --> 00:43:12,089 against what you say you need to have a 946 00:43:17,160 --> 00:43:15,390 mammogram because you might have breast 947 00:43:20,430 --> 00:43:17,170 cancer because you're a woman is best 948 00:43:22,170 --> 00:43:20,440 is very common the only way you really 949 00:43:24,599 --> 00:43:22,180 know is a mammogram it's a much better 950 00:43:27,839 --> 00:43:24,609 test than it is just trying to diagnose 951 00:43:29,849 --> 00:43:27,849 it yourself and if we diagnose that we 952 00:43:31,980 --> 00:43:29,859 can treat it perhaps before it becomes a 953 00:43:33,839 --> 00:43:31,990 problem and I mean it's just hard to 954 00:43:38,010 --> 00:43:33,849 argue against that I mean it is just so 955 00:43:39,569 --> 00:43:38,020 logical and yet it really doesn't bury 956 00:43:42,569 --> 00:43:39,579 out there's lots of reasons why it might 957 00:43:45,839 --> 00:43:42,579 not bear out and there's a lot of 958 00:43:49,319 --> 00:43:45,849 interesting kind of fallacies and biases 959 00:43:53,370 --> 00:43:49,329 that can be built into this interval 960 00:43:55,349 --> 00:43:53,380 bias and things that are difficult to 961 00:43:57,089 --> 00:43:55,359 explain but there's lots of reasons why 962 00:43:59,460 --> 00:43:57,099 probably doesn't work and and 963 00:44:01,349 --> 00:43:59,470 interestingly one of them is that 964 00:44:02,910 --> 00:44:01,359 probably a lot of the treatments that we 965 00:44:06,390 --> 00:44:02,920 give aren't nearly as effective as we 966 00:44:08,309 --> 00:44:06,400 think they are surgery for instance you 967 00:44:09,599 --> 00:44:08,319 know radiotherapy chemotherapy a lot of 968 00:44:13,470 --> 00:44:09,609 these things aren't nearly as effective 969 00:44:16,140 --> 00:44:13,480 as the public believed them to be so but 970 00:44:18,599 --> 00:44:16,150 we do see a significant reduction food 971 00:44:21,420 --> 00:44:18,609 from deaths from cancer for example over 972 00:44:24,059 --> 00:44:21,430 there must know i think if you look take 973 00:44:25,859 --> 00:44:24,069 prostate cancer for instance because if 974 00:44:27,450 --> 00:44:25,869 you this is a classic example of 975 00:44:31,260 --> 00:44:27,460 jiggling the numbers to make things look 976 00:44:33,240 --> 00:44:31,270 but if you look at the survival rate say 977 00:44:35,520 --> 00:44:33,250 i don't know pick a time five years or 978 00:44:38,250 --> 00:44:35,530 ten years I don't have the exact data 979 00:44:42,089 --> 00:44:38,260 with me but in the 1950s for prostate 980 00:44:44,460 --> 00:44:42,099 cancer there was it was a significant 981 00:44:47,520 --> 00:44:44,470 mortality you associated with prostate 982 00:44:49,829 --> 00:44:47,530 cancer if you were once you were 983 00:44:52,230 --> 00:44:49,839 diagnosed with it there was mallets just 984 00:44:56,400 --> 00:44:52,240 for argument's sake let's just say it 985 00:44:59,940 --> 00:44:56,410 was fifty percent now over the years we 986 00:45:03,200 --> 00:44:59,950 have been faced with an increase in the 987 00:45:07,620 --> 00:45:03,210 number of patients with prostate cancer 988 00:45:09,930 --> 00:45:07,630 and a significant lowering of the 989 00:45:12,630 --> 00:45:09,940 mortality associated with the diagnosis 990 00:45:14,789 --> 00:45:12,640 of prostate cancer and treatments have 991 00:45:17,250 --> 00:45:14,799 changed so on the surface of it and the 992 00:45:20,819 --> 00:45:17,260 same thing for breast cancer we're faced 993 00:45:22,260 --> 00:45:20,829 with an epidemic okay and I've heard the 994 00:45:23,549 --> 00:45:22,270 Minister for health say the same thing 995 00:45:25,020 --> 00:45:23,559 about breast cancer I've got a quote 996 00:45:28,720 --> 00:45:25,030 here that i keep on my computer because 997 00:45:30,850 --> 00:45:28,730 it is so ill-informed but it was 998 00:45:33,160 --> 00:45:30,860 uh who is the Minister for federal 999 00:45:35,440 --> 00:45:33,170 minister for health some years ago said 1000 00:45:36,580 --> 00:45:35,450 isn't this terrible we're faced with an 1001 00:45:38,200 --> 00:45:36,590 epidemic of breast cancer where the 1002 00:45:40,240 --> 00:45:38,210 numbers are shooting up through the roof 1003 00:45:41,860 --> 00:45:40,250 i mean it's everybody's got at me out 1004 00:45:44,920 --> 00:45:41,870 you know where is it wasn't diagnosed as 1005 00:45:49,600 --> 00:45:44,930 much before so the rate has doubled and 1006 00:45:54,130 --> 00:45:49,610 yet the survival from breast cancer has 1007 00:45:55,960 --> 00:45:54,140 improved over that time as well and so 1008 00:45:58,270 --> 00:45:55,970 isn't this fantastic it must be the 1009 00:46:01,210 --> 00:45:58,280 treatment that's done it and partly 1010 00:46:04,570 --> 00:46:01,220 what's done it is that the threshold for 1011 00:46:06,670 --> 00:46:04,580 the diagnosis has gone down so as soon 1012 00:46:10,150 --> 00:46:06,680 as you start including things that were 1013 00:46:11,650 --> 00:46:10,160 once called benign cysts or customer 1014 00:46:13,860 --> 00:46:11,660 insight you soon as you start including 1015 00:46:15,850 --> 00:46:13,870 them as cancer all the sudden you've 1016 00:46:17,830 --> 00:46:15,860 increased the number of people with 1017 00:46:20,830 --> 00:46:17,840 breast cancer okay so that's that's 1018 00:46:24,280 --> 00:46:20,840 given us the epidemic and then you've 1019 00:46:26,080 --> 00:46:24,290 treated everyone now surprise surprise 1020 00:46:28,810 --> 00:46:26,090 the patients who have customer it's what 1021 00:46:31,060 --> 00:46:28,820 you do extremely well you know the the 1022 00:46:35,410 --> 00:46:31,070 survival for that is very very high and 1023 00:46:37,510 --> 00:46:35,420 so you end up with an increased 1024 00:46:40,050 --> 00:46:37,520 incidence and so the numbers they showed 1025 00:46:43,210 --> 00:46:40,060 with prostate cancer was that the 1026 00:46:46,210 --> 00:46:43,220 mortality fell from fifty percent to 1027 00:46:48,670 --> 00:46:46,220 five percent the numbers of people were 1028 00:46:52,870 --> 00:46:48,680 the numbers of prostate cancer patients 1029 00:46:56,650 --> 00:46:52,880 presenting went up and yet the number of 1030 00:47:00,670 --> 00:46:56,660 people who died each year from prostate 1031 00:47:03,850 --> 00:47:00,680 cancer actually went up you know so it's 1032 00:47:05,500 --> 00:47:03,860 so it just makes it sound good to say 1033 00:47:07,030 --> 00:47:05,510 everyone's got prostate cancer but no 1034 00:47:09,100 --> 00:47:07,040 one's dying of it anymore so basically 1035 00:47:10,720 --> 00:47:09,110 we're talking about that diagnosis tools 1036 00:47:15,010 --> 00:47:10,730 being better nowadays but treatment 1037 00:47:16,660 --> 00:47:15,020 tools not necessarily catching up no I 1038 00:47:18,490 --> 00:47:16,670 don't think diagnostic tools are 1039 00:47:21,420 --> 00:47:18,500 necessarily better I think that there 1040 00:47:25,930 --> 00:47:21,430 has been a change in the threshold for 1041 00:47:27,790 --> 00:47:25,940 diagnosis up but so say 34 years ago 1042 00:47:30,000 --> 00:47:27,800 mammogram didn't exist so you wouldn't 1043 00:47:33,490 --> 00:47:30,010 can't you wouldn't be able to see 1044 00:47:36,140 --> 00:47:33,500 cancerous or precancerous some 1045 00:47:39,800 --> 00:47:36,150 formations here but how is this helped 1046 00:47:40,940 --> 00:47:39,810 now it just increased its ad increase 1047 00:47:42,770 --> 00:47:40,950 the number of people who are diagnosed 1048 00:47:45,200 --> 00:47:42,780 it's similar to although although it's 1049 00:47:47,930 --> 00:47:45,210 only really diagnose Don biopsy so if 1050 00:47:49,849 --> 00:47:47,940 you have an abnormal mammogram it will 1051 00:47:51,650 --> 00:47:49,859 only lead you to have a biopsy if it's 1052 00:47:53,089 --> 00:47:51,660 suspicious so the dollar back that if 1053 00:47:54,589 --> 00:47:53,099 you look at the number of biopsies you'd 1054 00:47:56,870 --> 00:47:54,599 find that they've gone up as well yes 1055 00:47:59,150 --> 00:47:56,880 the other half so it's to me it's a 1056 00:48:01,900 --> 00:47:59,160 little bit like the whole autism 1057 00:48:03,980 --> 00:48:01,910 vaccination argument where the 1058 00:48:05,720 --> 00:48:03,990 anti-vaccination lobby claimed that 1059 00:48:08,300 --> 00:48:05,730 autism is obviously caused by vaccines 1060 00:48:11,510 --> 00:48:08,310 and the reason is they did their 1061 00:48:14,569 --> 00:48:11,520 evidence is that as vaccines vaccination 1062 00:48:16,430 --> 00:48:14,579 rates have gone up so have autism now in 1063 00:48:18,050 --> 00:48:16,440 what happened in the world is that in 1064 00:48:20,390 --> 00:48:18,060 certain places vaccination rates have 1065 00:48:22,309 --> 00:48:20,400 dropped so we had a natural experiment 1066 00:48:25,579 --> 00:48:22,319 unnatural epidemiological experiment 1067 00:48:27,349 --> 00:48:25,589 where the vaccination rates of job in 1068 00:48:29,660 --> 00:48:27,359 autism rates of course continue to rise 1069 00:48:32,300 --> 00:48:29,670 because it's got to do with a broadening 1070 00:48:34,400 --> 00:48:32,310 of criteria and with better diagnosis so 1071 00:48:37,010 --> 00:48:34,410 this gets a little bit it's a little bit 1072 00:48:39,140 --> 00:48:37,020 similar this get suttin yeah I on to my 1073 00:48:44,660 --> 00:48:39,150 next my next favorite topic which is 1074 00:48:46,910 --> 00:48:44,670 medicalization and yeah I don't know how 1075 00:48:49,370 --> 00:48:46,920 many kids and families I know have 1076 00:48:51,200 --> 00:48:49,380 autism now I mean nobody had it when I 1077 00:48:55,819 --> 00:48:51,210 was a kid now everybody's got some 1078 00:48:56,900 --> 00:48:55,829 degree of it and a lot of these kids do 1079 00:48:58,490 --> 00:48:56,910 you really want a school and they look 1080 00:49:00,290 --> 00:48:58,500 fine to me but i don't know i'm not an 1081 00:49:02,180 --> 00:49:00,300 expert and that kind of thing but yeah 1082 00:49:03,950 --> 00:49:02,190 surely it's diagnosed morning other than 1083 00:49:05,450 --> 00:49:03,960 ors before and it's not because it's an 1084 00:49:06,710 --> 00:49:05,460 epidemic it's probably because the 1085 00:49:10,550 --> 00:49:06,720 threshold or the diagnostic criteria 1086 00:49:12,410 --> 00:49:10,560 change and it's like depression you know 1087 00:49:15,079 --> 00:49:12,420 and and people i don't know people just 1088 00:49:17,540 --> 00:49:15,089 want to buy these things up it's in some 1089 00:49:19,370 --> 00:49:17,550 people's interests it's in the drug 1090 00:49:22,280 --> 00:49:19,380 company that makes antidepressants 1091 00:49:24,050 --> 00:49:22,290 interest to make depression appear to be 1092 00:49:26,720 --> 00:49:24,060 a problem i remember must be enough we 1093 00:49:27,829 --> 00:49:26,730 must be up to the stage now where 51% of 1094 00:49:31,370 --> 00:49:27,839 the people in the world have depression 1095 00:49:32,660 --> 00:49:31,380 you know the other fifty percent a to 1096 00:49:38,900 --> 00:49:32,670 hazard so when they need so they 1097 00:49:41,059 --> 00:49:38,910 normally yes by the way this thing about 1098 00:49:42,920 --> 00:49:41,069 over medicalization is not something 1099 00:49:44,839 --> 00:49:42,930 that only the scientific medical 1100 00:49:47,329 --> 00:49:44,849 fraternity 1101 00:49:48,469 --> 00:49:47,339 or so-called fraternities responsible 1102 00:49:50,349 --> 00:49:48,479 for it's something that we see in 1103 00:49:54,170 --> 00:49:50,359 alternatives to medicine as well and 1104 00:49:56,059 --> 00:49:54,180 where they make claims about how bad 1105 00:49:57,769 --> 00:49:56,069 things are but they also make claims as 1106 00:50:00,650 --> 00:49:57,779 to what they can treat of course they 1107 00:50:02,960 --> 00:50:00,660 treat with water or with you know making 1108 00:50:04,670 --> 00:50:02,970 you know making your back click it's 1109 00:50:06,469 --> 00:50:04,680 something that is that has no evidence 1110 00:50:08,779 --> 00:50:06,479 for so it seems to me like there's a bit 1111 00:50:11,029 --> 00:50:08,789 of a bit of a parallel here although I 1112 00:50:12,319 --> 00:50:11,039 would say one thing that you have to say 1113 00:50:14,660 --> 00:50:12,329 for a scientific medicine is that 1114 00:50:17,120 --> 00:50:14,670 there's at least the attitude that we 1115 00:50:19,279 --> 00:50:17,130 have to show scientifically what works 1116 00:50:21,620 --> 00:50:19,289 and what not I would say the big 1117 00:50:23,719 --> 00:50:21,630 advantage that medicine has over say 1118 00:50:32,779 --> 00:50:23,729 complementary alternative medicines is 1119 00:50:34,999 --> 00:50:32,789 that it is based on science okay so it's 1120 00:50:36,349 --> 00:50:35,009 using the scientific method and there 1121 00:50:38,719 --> 00:50:36,359 are a lot of people and especially the 1122 00:50:42,229 --> 00:50:38,729 you know the big names and a lot of 1123 00:50:45,829 --> 00:50:42,239 people in influence are using very good 1124 00:50:48,309 --> 00:50:45,839 scientific methods to to examine what 1125 00:50:52,130 --> 00:50:48,319 they what they're looking for the 1126 00:50:53,479 --> 00:50:52,140 downside of medicine compared to because 1127 00:50:55,069 --> 00:50:53,489 you've got to say okay somebody's sick 1128 00:50:56,870 --> 00:50:55,079 they got they got a pain in his stomach 1129 00:51:01,880 --> 00:50:56,880 should they go to a doctor or should 1130 00:51:04,039 --> 00:51:01,890 they go to a homeopath okay now your 1131 00:51:06,620 --> 00:51:04,049 argument then is well at least what the 1132 00:51:08,569 --> 00:51:06,630 doctors doing is is based on some signs 1133 00:51:11,440 --> 00:51:08,579 even though he may not necessarily be 1134 00:51:15,170 --> 00:51:11,450 able to diagnose them or he may be wrong 1135 00:51:18,589 --> 00:51:15,180 you know at least he's approaching in a 1136 00:51:19,880 --> 00:51:18,599 scientific manner well I would argue 1137 00:51:24,469 --> 00:51:19,890 that a lot of the time he probably isn't 1138 00:51:27,709 --> 00:51:24,479 but but having said that a lot of the 1139 00:51:30,019 --> 00:51:27,719 time they are that's the advantage the 1140 00:51:33,019 --> 00:51:30,029 downside is that the patient who goes to 1141 00:51:36,680 --> 00:51:33,029 the homeopath is much less likely to 1142 00:51:39,640 --> 00:51:36,690 have harm done to them whereas the 1143 00:51:42,709 --> 00:51:39,650 potential for harm being done to you by 1144 00:51:45,650 --> 00:51:42,719 attending a hospital is enormous 1145 00:51:48,979 --> 00:51:45,660 although you might say that going to a 1146 00:51:51,819 --> 00:51:48,989 homeopath can lead to the harm of not 1147 00:51:56,120 --> 00:51:54,529 yes this is where you might need yeah 1148 00:51:57,440 --> 00:51:56,130 but I think some of the time you can 1149 00:52:00,470 --> 00:51:57,450 still make an argument that they'd be 1150 00:52:02,990 --> 00:52:00,480 better off not being treated there's so 1151 00:52:04,190 --> 00:52:03,000 many examples it just has to be some of 1152 00:52:05,990 --> 00:52:04,200 the figures that come out when you look 1153 00:52:10,220 --> 00:52:06,000 into these things when you look at the 1154 00:52:14,390 --> 00:52:10,230 harm done in hospitals the deaths call 1155 00:52:18,440 --> 00:52:14,400 unnecessary deaths the deaths caused by 1156 00:52:21,140 --> 00:52:18,450 medical error medication errors all 1157 00:52:23,150 --> 00:52:21,150 sorts it's huge numbers that we're 1158 00:52:25,279 --> 00:52:23,160 looking at absolutely huge the studies 1159 00:52:30,499 --> 00:52:25,289 that were done out of Boston the studies 1160 00:52:32,779 --> 00:52:30,509 that were done here in in Australia it's 1161 00:52:35,900 --> 00:52:32,789 just the staggering how much have I need 1162 00:52:38,599 --> 00:52:35,910 to present this and the reaction to most 1163 00:52:40,640 --> 00:52:38,609 people is just well you know they will 1164 00:52:42,650 --> 00:52:40,650 probably stick anyway and it's you know 1165 00:52:47,059 --> 00:52:42,660 that's just you know good with the bad 1166 00:52:49,579 --> 00:52:47,069 and the canary in a very recent episode 1167 00:52:51,170 --> 00:52:49,589 of I have a segment called grain of salt 1168 00:52:53,539 --> 00:52:51,180 on the skeptics on podcast which were 1169 00:52:55,309 --> 00:52:53,549 recording for right now and in a recent 1170 00:52:56,630 --> 00:52:55,319 episode I actually spoke about that 1171 00:52:57,829 --> 00:52:56,640 statistical thing and I actually took a 1172 00:53:00,710 --> 00:52:57,839 different approach now I'd be interested 1173 00:53:02,089 --> 00:53:00,720 to hear how you would respond to that 1174 00:53:04,099 --> 00:53:02,099 because one of the things I said was 1175 00:53:08,539 --> 00:53:04,109 there's this number throwing about 1176 00:53:12,319 --> 00:53:08,549 18,000 people a year die of medical 1177 00:53:16,430 --> 00:53:12,329 error yeah what what I'd be interested 1178 00:53:18,349 --> 00:53:16,440 to to know and I didn't I was an actor I 1179 00:53:21,589 --> 00:53:18,359 wasn't actually able to find reliable 1180 00:53:25,160 --> 00:53:21,599 information is how many of these people 1181 00:53:26,870 --> 00:53:25,170 died because they were actually there 1182 00:53:28,730 --> 00:53:26,880 was some negligence involved that would 1183 00:53:31,579 --> 00:53:28,740 actually not they arrived at the 1184 00:53:33,289 --> 00:53:31,589 hospital healthy and or relatively 1185 00:53:35,870 --> 00:53:33,299 healthy would not would not have died 1186 00:53:38,779 --> 00:53:35,880 the other than through the fact that 1187 00:53:42,410 --> 00:53:38,789 they visited the hospital I think that's 1188 00:53:44,420 --> 00:53:42,420 a very important question to ask because 1189 00:53:46,039 --> 00:53:44,430 if you're talking about people who came 1190 00:53:48,859 --> 00:53:46,049 to a hospital and should have been saved 1191 00:53:50,329 --> 00:53:48,869 yeah but weren't yeah then that's a 1192 00:53:52,599 --> 00:53:50,339 completely different approach because 1193 00:53:54,440 --> 00:53:52,609 then you're comparing them to 1194 00:53:57,289 --> 00:53:54,450 alternative treatments that wouldn't 1195 00:54:01,510 --> 00:53:57,299 have helped them so yeah oh I think that 1196 00:54:05,780 --> 00:54:03,470 supposed to say hi or low because in 1197 00:54:08,240 --> 00:54:05,790 which way looking at but I think that 1198 00:54:11,359 --> 00:54:08,250 most people that present to a hospital 1199 00:54:14,390 --> 00:54:11,369 to give treated don't die vehicle death 1200 00:54:16,339 --> 00:54:14,400 rate in hospital isn't very high and so 1201 00:54:18,349 --> 00:54:16,349 I think most of those people that died 1202 00:54:20,570 --> 00:54:18,359 through medical error would not have 1203 00:54:21,770 --> 00:54:20,580 died anyway but I have to read the 1204 00:54:24,470 --> 00:54:21,780 studies again haven't read them for 1205 00:54:28,970 --> 00:54:24,480 years to look as it was broken down into 1206 00:54:33,170 --> 00:54:28,980 sort of actual sort of medication errors 1207 00:54:37,400 --> 00:54:33,180 and they had different categories of 1208 00:54:40,310 --> 00:54:37,410 adverse events but I see complications 1209 00:54:43,070 --> 00:54:40,320 all the time in the hospital it just 1210 00:54:45,140 --> 00:54:43,080 errors occur all the time but isn't 1211 00:54:46,609 --> 00:54:45,150 there the bias here okay I'll throw that 1212 00:54:49,580 --> 00:54:46,619 back at you because you look you look 1213 00:54:50,720 --> 00:54:49,590 you're a surgeon and I academic here you 1214 00:54:53,150 --> 00:54:50,730 look at things in terms of the 1215 00:54:55,880 --> 00:54:53,160 statistics side as well as the clinical 1216 00:54:57,890 --> 00:54:55,890 side and I'm just wondering you are the 1217 00:55:00,680 --> 00:54:57,900 hospital and you see those complications 1218 00:55:03,410 --> 00:55:00,690 could it be that you're a little bit 1219 00:55:04,880 --> 00:55:03,420 biased and just seeing seeing seeing the 1220 00:55:07,310 --> 00:55:04,890 complications I mean those patients just 1221 00:55:09,410 --> 00:55:07,320 go home a very small proportion actually 1222 00:55:14,120 --> 00:55:09,420 have complications i would assume these 1223 00:55:16,070 --> 00:55:14,130 days that first of all he's uh it 1224 00:55:23,500 --> 00:55:16,080 depends on kind of what area you're 1225 00:55:26,900 --> 00:55:23,510 looking at yeah complications are common 1226 00:55:30,170 --> 00:55:26,910 perhaps it's a question that should be 1227 00:55:33,380 --> 00:55:30,180 asked is because most complications that 1228 00:55:35,359 --> 00:55:33,390 I say aren't death there there are other 1229 00:55:37,780 --> 00:55:35,369 things where it's something wasn't fixed 1230 00:55:41,540 --> 00:55:37,790 properly and it needs to be redone and 1231 00:55:43,250 --> 00:55:41,550 you know they didn't use the right thing 1232 00:55:45,920 --> 00:55:43,260 here and now something else has to be 1233 00:55:47,510 --> 00:55:45,930 added to it or they neglected to give 1234 00:55:49,310 --> 00:55:47,520 them this medication and therefore they 1235 00:55:54,320 --> 00:55:49,320 got a problem the question there is 1236 00:55:56,810 --> 00:55:54,330 probably the so what factor because it's 1237 00:55:58,220 --> 00:55:56,820 interesting we worrying in orthopedic 1238 00:56:00,940 --> 00:55:58,230 trauma for insta I may be going off the 1239 00:56:04,220 --> 00:56:00,950 trachea so bring me back if if I am 1240 00:56:06,530 --> 00:56:04,230 fixing factors for instance we worry 1241 00:56:08,530 --> 00:56:06,540 about whether the bone heals or not okay 1242 00:56:11,329 --> 00:56:08,540 and so that's what we really hang out 1243 00:56:12,950 --> 00:56:11,339 our expertise on is we can get a bone to 1244 00:56:14,430 --> 00:56:12,960 heal and if we can't we consider that a 1245 00:56:16,020 --> 00:56:14,440 failure of treatment 1246 00:56:17,970 --> 00:56:16,030 and and a certain percentage of them 1247 00:56:20,280 --> 00:56:17,980 don't I mean if they're baby berrykin or 1248 00:56:22,680 --> 00:56:20,290 whatever and and one of our common 1249 00:56:27,000 --> 00:56:22,690 operations is to have to rio preto bones 1250 00:56:28,559 --> 00:56:27,010 to get them to hell and we consider that 1251 00:56:29,490 --> 00:56:28,569 a disaster that's a failure of treatment 1252 00:56:32,400 --> 00:56:29,500 the patients have to go to hospital 1253 00:56:35,490 --> 00:56:32,410 again they've had another procedure it's 1254 00:56:37,170 --> 00:56:35,500 it's quite a big deal and so we consider 1255 00:56:41,030 --> 00:56:37,180 that a bad thing and I think that should 1256 00:56:43,260 --> 00:56:41,040 be avoided however the patients don't 1257 00:56:44,190 --> 00:56:43,270 patients don't necessarily see that it's 1258 00:56:47,520 --> 00:56:44,200 a bad thing and I've done some 1259 00:56:49,500 --> 00:56:47,530 satisfaction surveys where the patient 1260 00:56:50,930 --> 00:56:49,510 satisfaction is completely unrelated to 1261 00:56:52,920 --> 00:56:50,940 whether they have a complication or not 1262 00:56:56,510 --> 00:56:52,930 or whether they need to have another 1263 00:56:58,950 --> 00:56:56,520 operation it's completely unrelated and 1264 00:57:00,930 --> 00:56:58,960 to give you an example if I had a 1265 00:57:03,780 --> 00:57:00,940 patient that I did an operational I 1266 00:57:06,809 --> 00:57:03,790 pinned their broken bone and the next 1267 00:57:08,339 --> 00:57:06,819 day I saw them and their leg was twisted 1268 00:57:10,349 --> 00:57:08,349 and it was in the wrong position and I 1269 00:57:12,030 --> 00:57:10,359 had done the operation incorrectly and 1270 00:57:14,220 --> 00:57:12,040 they had to go back and have another 1271 00:57:16,559 --> 00:57:14,230 operation to redo it now that's an 1272 00:57:18,750 --> 00:57:16,569 adverse event in any person's book it's 1273 00:57:21,599 --> 00:57:18,760 a complication you may even call it 1274 00:57:24,059 --> 00:57:21,609 negligence or not you know no attention 1275 00:57:25,680 --> 00:57:24,069 to detail but it's a bad result and it's 1276 00:57:31,440 --> 00:57:25,690 required another operation for the 1277 00:57:33,150 --> 00:57:31,450 patient however by and large patients it 1278 00:57:36,690 --> 00:57:33,160 will be very good about things like that 1279 00:57:39,359 --> 00:57:36,700 so if I say to the patient look we've 1280 00:57:40,800 --> 00:57:39,369 done your operation and he bones has 1281 00:57:42,300 --> 00:57:40,810 been stabilized but if you look at your 1282 00:57:43,950 --> 00:57:42,310 feet here if I just explained to you you 1283 00:57:46,079 --> 00:57:43,960 can see there's some malalignment it's 1284 00:57:47,460 --> 00:57:46,089 not it's not quite right and I think 1285 00:57:49,140 --> 00:57:47,470 that that should be corrected and in 1286 00:57:51,329 --> 00:57:49,150 fact the x-rays show that it's out by a 1287 00:57:53,550 --> 00:57:51,339 considerable amount and what I'd like to 1288 00:57:55,980 --> 00:57:53,560 do is take you back we operate on you 1289 00:57:59,700 --> 00:57:55,990 again and I'm very sorry this has had to 1290 00:58:01,440 --> 00:57:59,710 happen but it has and and what I'd like 1291 00:58:03,780 --> 00:58:01,450 to do is remove some of the screws 1292 00:58:06,990 --> 00:58:03,790 realign your leg and reinsert the screws 1293 00:58:09,120 --> 00:58:07,000 again in a better position and we can do 1294 00:58:11,430 --> 00:58:09,130 that for you as soon as we can we'll 1295 00:58:13,079 --> 00:58:11,440 book it for tomorrow morning and but you 1296 00:58:14,099 --> 00:58:13,089 a little menu in hospital for couple of 1297 00:58:17,430 --> 00:58:14,109 extra days and you do have to have 1298 00:58:19,309 --> 00:58:17,440 another operation but most patients are 1299 00:58:23,250 --> 00:58:19,319 find a better they really don't mind 1300 00:58:25,710 --> 00:58:23,260 which is interesting you know so when is 1301 00:58:28,480 --> 00:58:25,720 a complication a bad thing 1302 00:58:30,010 --> 00:58:28,490 most patients are happy with that result 1303 00:58:33,700 --> 00:58:30,020 and they will leave the hospital 1304 00:58:37,570 --> 00:58:33,710 satisfied however if they get a good 1305 00:58:40,090 --> 00:58:37,580 operation and I'm rude to them or I 1306 00:58:42,040 --> 00:58:40,100 don't see them afterwards I don't answer 1307 00:58:43,780 --> 00:58:42,050 their questions properly on dismissive 1308 00:58:45,370 --> 00:58:43,790 of them they will be completely 1309 00:58:47,350 --> 00:58:45,380 dissatisfied that will be dissatisfied 1310 00:58:49,260 --> 00:58:47,360 with the operation with the results of 1311 00:58:51,820 --> 00:58:49,270 the operation with the look of their leg 1312 00:58:55,110 --> 00:58:51,830 with the the scar that will be 1313 00:58:57,340 --> 00:58:55,120 dissatisfied with the whole procedure 1314 00:58:59,560 --> 00:58:57,350 whereas the other patient who's now got 1315 00:59:01,360 --> 00:58:59,570 two scars may be completely satisfied 1316 00:59:03,160 --> 00:59:01,370 look at how well those two scars healed 1317 00:59:05,860 --> 00:59:03,170 up and the doctor was really nice to me 1318 00:59:09,310 --> 00:59:05,870 so it's interesting about complications 1319 00:59:13,480 --> 00:59:09,320 so that's why we probably have to bring 1320 00:59:16,840 --> 00:59:13,490 it to more objective things like death 1321 00:59:18,970 --> 00:59:16,850 yeah well Beth is absolutely objective 1322 00:59:20,500 --> 00:59:18,980 but also and I think in that respect 1323 00:59:21,880 --> 00:59:20,510 probably should probably look at life 1324 00:59:24,670 --> 00:59:21,890 expectancy and I think one of the things 1325 00:59:29,230 --> 00:59:24,680 that to me are the clear indications of 1326 00:59:31,150 --> 00:59:29,240 the success of medical science is the 1327 00:59:34,740 --> 00:59:31,160 difference in life expectancy between 1328 00:59:36,790 --> 00:59:34,750 places that to have a disagreement I 1329 00:59:40,650 --> 00:59:36,800 disagree that the difference in life 1330 00:59:43,120 --> 00:59:40,660 expectancy is due to medical science I 1331 00:59:45,730 --> 00:59:43,130 that's been looked at and in some 1332 00:59:47,650 --> 00:59:45,740 studies they say that probably the 1333 00:59:50,260 --> 00:59:47,660 proportion of the difference in life 1334 00:59:52,780 --> 00:59:50,270 expectancy due to medical technology and 1335 01:00:00,960 --> 00:59:52,790 medical science is may be of the order 1336 01:00:08,500 --> 01:00:04,780 nutrition clean drinking water a good 1337 01:00:11,440 --> 01:00:08,510 food healthy lifestyle that kind of 1338 01:00:14,290 --> 01:00:11,450 thing rather than through the heart 1339 01:00:16,960 --> 01:00:14,300 bypass is in China a good example of not 1340 01:00:19,030 --> 01:00:16,970 because in China the main difference is 1341 01:00:21,820 --> 01:00:19,040 actually not there's increased 1342 01:00:23,440 --> 01:00:21,830 organization probably a life that's a 1343 01:00:25,330 --> 01:00:23,450 little bit less healthy we're going to 1344 01:00:28,840 --> 01:00:25,340 show me something on you we keep talking 1345 01:00:31,510 --> 01:00:28,850 I'll show you something here okay just 1346 01:00:33,010 --> 01:00:31,520 should probably tell listeners that ian 1347 01:00:35,290 --> 01:00:33,020 has just pulled out his laptop he's 1348 01:00:36,359 --> 01:00:35,300 looking for us some information there 1349 01:00:38,370 --> 01:00:36,369 I've done you 1350 01:00:40,710 --> 01:00:38,380 the deepest type of research it's called 1351 01:00:43,680 --> 01:00:40,720 googling and what the information I 1352 01:00:46,440 --> 01:00:43,690 found was that things like clean water 1353 01:00:48,150 --> 01:00:46,450 or nutrition have not actually changed 1354 01:00:49,890 --> 01:00:48,160 dramatically in China over the past 50 1355 01:00:52,799 --> 01:00:49,900 years but what has changed penetration 1356 01:00:56,489 --> 01:00:52,809 of of Western medicine into rural areas 1357 01:00:58,890 --> 01:00:56,499 as well as the big cities and there was 1358 01:01:01,529 --> 01:00:58,900 a suggestion that that has significantly 1359 01:01:04,289 --> 01:01:01,539 contributor to find an example where it 1360 01:01:05,880 --> 01:01:04,299 hasn't happened oh ok it's easy to pick 1361 01:01:07,650 --> 01:01:05,890 somewhere where it has but there's the 1362 01:01:09,359 --> 01:01:07,660 change in life expectancy over the last 1363 01:01:12,210 --> 01:01:09,369 300 years could you describe the 1364 01:01:14,849 --> 01:01:12,220 mathletes so the graph goes up from I 1365 01:01:17,700 --> 01:01:14,859 think that it's not exactly mark but are 1366 01:01:22,650 --> 01:01:17,710 under 40 so a life expectancy of under 1367 01:01:25,829 --> 01:01:22,660 40 in the year 1700 to pushing 80 around 1368 01:01:29,099 --> 01:01:25,839 San ladieswear dear 2000 yet but in a 1369 01:01:30,839 --> 01:01:29,109 way I I wish I could remember where I 1370 01:01:35,249 --> 01:01:30,849 got this from I think it's from the UK 1371 01:01:37,559 --> 01:01:35,259 actually elysees by the way that people 1372 01:01:40,529 --> 01:01:37,569 were not dropping off at the age of 38 1373 01:01:42,630 --> 01:01:40,539 in this joint I love dying young yes so 1374 01:01:44,069 --> 01:01:42,640 you're so dying at the age of 90 we were 1375 01:01:46,140 --> 01:01:44,079 also a lot more beer infant mortality 1376 01:01:49,319 --> 01:01:46,150 was very high and that skews the figures 1377 01:01:51,299 --> 01:01:49,329 a lot yeah but what you can see is that 1378 01:01:54,539 --> 01:01:51,309 ever so gradually the life expectancy 1379 01:01:57,150 --> 01:01:54,549 has increased over the last 300 years 1380 01:02:00,420 --> 01:01:57,160 and it's been increasing steadily and 1381 01:02:04,109 --> 01:02:00,430 it's probably plateaued more or less 1382 01:02:07,140 --> 01:02:04,119 compared to the rapid increase from 1702 1383 01:02:08,819 --> 01:02:07,150 1802 1900 and when we get to the ear of 1384 01:02:10,440 --> 01:02:08,829 modern medicine where medicine really 1385 01:02:12,359 --> 01:02:10,450 has actually made a difference I mean 1386 01:02:14,220 --> 01:02:12,369 you've got to be talking what not you 1387 01:02:17,789 --> 01:02:14,230 would say what nineteen fifty plus I 1388 01:02:20,880 --> 01:02:17,799 mean no real good surgery before before 1389 01:02:28,200 --> 01:02:20,890 then antibiotics not until nineteen dr. 1390 01:02:30,900 --> 01:02:28,210 World War two paths and so yeah and 1391 01:02:33,809 --> 01:02:30,910 that's when the that's the tail end of 1392 01:02:36,029 --> 01:02:33,819 it and so to attribute the changing life 1393 01:02:38,279 --> 01:02:36,039 expectancy from 40 to 80 over the last 1394 01:02:41,819 --> 01:02:38,289 three hundred years to a few medical 1395 01:02:45,620 --> 01:02:41,829 advances in the last 50 s probably 1396 01:02:48,550 --> 01:02:45,630 drawing a longbow the other one is that 1397 01:02:50,590 --> 01:02:48,560 his antibiotics is often quoted 1398 01:02:52,540 --> 01:02:50,600 is the famous one well I'll show you 1399 01:02:54,430 --> 01:02:52,550 another trend a hundred year trend 1400 01:02:58,720 --> 01:02:54,440 showing the gradual decrease in 1401 01:03:02,980 --> 01:02:58,730 mortality steady gradual decrease over 1402 01:03:05,140 --> 01:03:02,990 time in waterfront on TV yeah and then 1403 01:03:07,150 --> 01:03:05,150 you mark on there where antibiotics were 1404 01:03:09,940 --> 01:03:07,160 introduced it made knows no knowledge to 1405 01:03:13,710 --> 01:03:09,950 it at all it was just about any rough 1406 01:03:19,840 --> 01:03:16,110 uninterruptible trained from them from 1407 01:03:23,500 --> 01:03:19,850 1902 about nineteen eighty yeah and then 1408 01:03:25,860 --> 01:03:23,510 actually going up a little bit but in 1409 01:03:29,020 --> 01:03:25,870 the middle of the 1900s when antibiotics 1410 01:03:31,630 --> 01:03:29,030 for TB was introduced at the graph 1411 01:03:37,930 --> 01:03:31,640 continues in a linear fashion in the 1412 01:03:42,070 --> 01:03:37,940 same direction yeah okay we're almost 1413 01:03:45,520 --> 01:03:42,080 out of time mostly because the tape here 1414 01:03:47,140 --> 01:03:45,530 is about right now I swear we've enjoyed 1415 01:03:49,690 --> 01:03:47,150 the token we're talking for much longer 1416 01:03:52,120 --> 01:03:49,700 than I expected I want to go back to the 1417 01:03:53,860 --> 01:03:52,130 surgical studies good and something 1418 01:03:58,030 --> 01:03:53,870 something specific that you said earlier 1419 01:03:59,920 --> 01:03:58,040 to do with the throw scopic surgery for 1420 01:04:01,780 --> 01:03:59,930 the knees where you mentioned it's just 1421 01:04:03,400 --> 01:04:01,790 too little cuts not even stitches are 1422 01:04:07,270 --> 01:04:03,410 required but what do you do about things 1423 01:04:11,680 --> 01:04:07,280 that are either require a larger cut yes 1424 01:04:14,440 --> 01:04:11,690 or where the surgery is for a something 1425 01:04:16,030 --> 01:04:14,450 like open heart surgery you know like 1426 01:04:18,850 --> 01:04:16,040 these they're kind of things where you 1427 01:04:20,440 --> 01:04:18,860 do not just open the chest cavity just 1428 01:04:21,550 --> 01:04:20,450 in order to design well I think they did 1429 01:04:24,550 --> 01:04:21,560 it I think there was a sham surgery 1430 01:04:27,640 --> 01:04:24,560 study done a long time ago on ligation 1431 01:04:31,210 --> 01:04:27,650 of the internal mammary artery which is 1432 01:04:33,280 --> 01:04:31,220 inside the chest it's an artery inside 1433 01:04:36,640 --> 01:04:33,290 the chest which runs along the chest 1434 01:04:40,060 --> 01:04:36,650 wall and the it doesn't run to the heart 1435 01:04:42,460 --> 01:04:40,070 but it's a branch of a vessel that comes 1436 01:04:44,800 --> 01:04:42,470 from the same origin the theory and 1437 01:04:47,710 --> 01:04:44,810 again biological plausibility fantastic 1438 01:04:50,260 --> 01:04:47,720 is this harder used to be ligated and by 1439 01:04:52,570 --> 01:04:50,270 ligating this artery and not having any 1440 01:04:54,730 --> 01:04:52,580 blood going down your chest wall it 1441 01:04:57,160 --> 01:04:54,740 would divert the blood and an extent to 1442 01:05:00,640 --> 01:04:57,170 your heart so more blood will be going 1443 01:05:02,180 --> 01:05:00,650 to the to the cardiac vessels rather 1444 01:05:04,090 --> 01:05:02,190 than to this other fairly useless 1445 01:05:06,890 --> 01:05:04,100 thistle and so they would like eight the 1446 01:05:08,870 --> 01:05:06,900 internal memory artery and was great 1447 01:05:12,560 --> 01:05:08,880 procedure it worked very well and was 1448 01:05:14,540 --> 01:05:12,570 accepted and widely used because her 1449 01:05:15,890 --> 01:05:14,550 biological plausibility and then they 1450 01:05:18,170 --> 01:05:15,900 did a randomized control trial where 1451 01:05:19,940 --> 01:05:18,180 they located the artery and half of them 1452 01:05:22,220 --> 01:05:19,950 and didn't locate in the other half and 1453 01:05:24,710 --> 01:05:22,230 they found no difference that's amazing 1454 01:05:27,260 --> 01:05:24,720 so when they say they didn't like gate I 1455 01:05:30,500 --> 01:05:27,270 know for example in certain treatments 1456 01:05:33,380 --> 01:05:30,510 for example certain types of infection 1457 01:05:35,840 --> 01:05:33,390 of fungal infections what you would do 1458 01:05:38,450 --> 01:05:35,850 is my wife used to work in clinical 1459 01:05:41,060 --> 01:05:38,460 studies and she worked in this study 1460 01:05:47,000 --> 01:05:41,070 where they compared a new treatment new 1461 01:05:50,510 --> 01:05:47,010 drug for fungal infections that the 1462 01:05:52,670 --> 01:05:50,520 control was not was not placebo the 1463 01:05:55,100 --> 01:05:52,680 control was this standard best treatment 1464 01:05:56,420 --> 01:05:55,110 of the day I'm just wondering about 1465 01:05:57,980 --> 01:05:56,430 something like this whether it's quite 1466 01:05:59,930 --> 01:05:57,990 radical you opened the chest cavity 1467 01:06:03,620 --> 01:05:59,940 those it's an into significant injury 1468 01:06:05,300 --> 01:06:03,630 which takes a long time to heal do you 1469 01:06:06,770 --> 01:06:05,310 actually then do something else so you 1470 01:06:10,880 --> 01:06:06,780 just opened the chest cavity and then 1471 01:06:12,950 --> 01:06:10,890 dunno that's it that's it don't do 1472 01:06:14,510 --> 01:06:12,960 anything else you got to be careful of 1473 01:06:17,390 --> 01:06:14,520 using the gold standard there's a kind 1474 01:06:19,820 --> 01:06:17,400 of a creeping error that gets into this 1475 01:06:21,290 --> 01:06:19,830 because something gets tested and or 1476 01:06:23,660 --> 01:06:21,300 doesn't get tested it's just standard 1477 01:06:25,160 --> 01:06:23,670 practice and then something else gets 1478 01:06:27,320 --> 01:06:25,170 tested against that because it's the 1479 01:06:29,840 --> 01:06:27,330 gold standard and it's found to be just 1480 01:06:31,220 --> 01:06:29,850 as good or slightly better and then 1481 01:06:32,960 --> 01:06:31,230 something else gets tested against that 1482 01:06:34,820 --> 01:06:32,970 new gold standard more sudden we've got 1483 01:06:36,200 --> 01:06:34,830 something that's absolutely fantastic 1484 01:06:40,330 --> 01:06:36,210 but probably if you tested against the 1485 01:06:44,120 --> 01:06:40,340 share it may not be that beneficial but 1486 01:06:47,570 --> 01:06:44,130 in you don't have to do a sham trial 1487 01:06:50,450 --> 01:06:47,580 recently they did a great study in 1488 01:06:52,430 --> 01:06:50,460 surgery looking at appendicectomy and 1489 01:06:56,270 --> 01:06:52,440 still today if you present to a hospital 1490 01:06:58,790 --> 01:06:56,280 in Sydney with pain and signs consistent 1491 01:07:00,530 --> 01:06:58,800 with appendicitis you will have your 1492 01:07:02,180 --> 01:07:00,540 appendix removed and you will have it 1493 01:07:05,720 --> 01:07:02,190 removed as a matter of some degree of 1494 01:07:07,070 --> 01:07:05,730 urgency and yet a randomized control 1495 01:07:09,830 --> 01:07:07,080 trial published in the British general 1496 01:07:12,390 --> 01:07:09,840 surgery this year randomizing patients 1497 01:07:16,600 --> 01:07:12,400 to surgery or antibiotics 1498 01:07:18,790 --> 01:07:16,610 showed in no difference in the treatment 1499 01:07:20,740 --> 01:07:18,800 between the two groups except that the 1500 01:07:22,300 --> 01:07:20,750 complication rate was higher in the 1501 01:07:23,920 --> 01:07:22,310 surgically treated group as you would 1502 01:07:25,660 --> 01:07:23,930 probably expect yeah because they get 1503 01:07:27,190 --> 01:07:25,670 adhesions all sorts of late 1504 01:07:28,840 --> 01:07:27,200 complications from having an operation 1505 01:07:31,150 --> 01:07:28,850 so you want to try and avoid so do as 1506 01:07:33,760 --> 01:07:31,160 much as possible there's so many areas 1507 01:07:35,410 --> 01:07:33,770 where surgery is just not done anymore 1508 01:07:37,840 --> 01:07:35,420 where it used to be done before is 1509 01:07:40,420 --> 01:07:37,850 standard as a trauma surgeon when I came 1510 01:07:43,000 --> 01:07:40,430 here every trauma patient that came in 1511 01:07:44,680 --> 01:07:43,010 that had a bleeding abdomen had their 1512 01:07:46,030 --> 01:07:44,690 abdomen open and had their spleen taken 1513 01:07:48,460 --> 01:07:46,040 out and their liver packed and 1514 01:07:50,710 --> 01:07:48,470 everything else done in now it's really 1515 01:07:52,360 --> 01:07:50,720 done you just leave them alone and they 1516 01:07:54,520 --> 01:07:52,370 tend to do fairly well and he sounds to 1517 01:07:55,780 --> 01:07:54,530 me like you like that optional you like 1518 01:07:57,130 --> 01:07:55,790 the fact that that's odee it's 1519 01:07:58,990 --> 01:07:57,140 progressing yeah well it's just 1520 01:08:03,370 --> 01:07:59,000 consistently I'm still waiting to be 1521 01:08:04,720 --> 01:08:03,380 shown the the study that shows oh this 1522 01:08:07,390 --> 01:08:04,730 operation we were doing actually was 1523 01:08:10,360 --> 01:08:07,400 good and I still haven't seen that study 1524 01:08:12,940 --> 01:08:10,370 I just keep seeing operations fall by 1525 01:08:14,710 --> 01:08:12,950 the wayside but then as new technology 1526 01:08:16,120 --> 01:08:14,720 come along new operations get introduced 1527 01:08:19,090 --> 01:08:16,130 without necessarily going through the 1528 01:08:21,220 --> 01:08:19,100 same oops but could that be because the 1529 01:08:22,510 --> 01:08:21,230 studies are conducted conducted in those 1530 01:08:24,970 --> 01:08:22,520 areas where there's a level of 1531 01:08:26,410 --> 01:08:24,980 uncertainty amongst the surgeons could 1532 01:08:27,610 --> 01:08:26,420 it be there's a certain bias down the 1533 01:08:29,560 --> 01:08:27,620 results you're saying you haven't seen a 1534 01:08:32,020 --> 01:08:29,570 successful trial but perhaps it's 1535 01:08:34,990 --> 01:08:32,030 because those miles that where it's 1536 01:08:38,320 --> 01:08:35,000 quite clear that to everybody involved 1537 01:08:40,240 --> 01:08:38,330 there's benefits not just too few best 1538 01:08:43,420 --> 01:08:40,250 you just possibly I think that's a good 1539 01:08:45,100 --> 01:08:43,430 point but gee you know appendicitis 1540 01:08:46,960 --> 01:08:45,110 that's something where there's just no 1541 01:08:48,310 --> 01:08:46,970 argument I mean you ask any surgeon you 1542 01:08:51,460 --> 01:08:48,320 got a pen oh so take your pen Excel i 1543 01:08:53,530 --> 01:08:51,470 mean it's infected it will get worse and 1544 01:08:56,890 --> 01:08:53,540 it will rupture and it will mean it's 1545 01:09:02,050 --> 01:08:56,900 biological with you can't argue against 1546 01:09:03,370 --> 01:09:02,060 that and yet apparently you can but no I 1547 01:09:05,470 --> 01:09:03,380 don't think there's much uncertainty and 1548 01:09:10,000 --> 01:09:05,480 even with studies that show that surgery 1549 01:09:12,220 --> 01:09:10,010 is not necessarily required they're 1550 01:09:15,390 --> 01:09:12,230 still operate on them is the honda 1551 01:09:17,380 --> 01:09:15,400 studies done there's no uncertainty I 1552 01:09:18,880 --> 01:09:17,390 don't know it's something about being a 1553 01:09:20,890 --> 01:09:18,890 surgeon you have to be fairly certain 1554 01:09:21,990 --> 01:09:20,900 I've got things and you have to make 1555 01:09:25,200 --> 01:09:22,000 decisions as to 1556 01:09:30,570 --> 01:09:25,210 your hand must not shiver sure has not 1557 01:09:32,160 --> 01:09:30,580 steak we have to to end now in thank you 1558 01:09:36,390 --> 01:09:32,170 very much for being on the skeptic zone 1559 01:09:38,280 --> 01:09:36,400 and hopefully we'll have time to ask you 1560 01:09:41,820 --> 01:09:38,290 some more questions some other time what 1561 01:09:43,140 --> 01:09:41,830 does it thanks very much thank you after 1562 01:09:45,210 --> 01:09:43,150 listening to the interview while editing 1563 01:09:47,039 --> 01:09:45,220 it I realized that some issues that 1564 01:09:49,710 --> 01:09:47,049 would be important to most skeptics were 1565 01:09:51,120 --> 01:09:49,720 not covered so I contacted en again by 1566 01:09:54,510 --> 01:09:51,130 email and ask him to the following 1567 01:09:56,370 --> 01:09:54,520 questions one since you dispute that 1568 01:09:58,560 --> 01:09:56,380 scientific medicine is responsible for 1569 01:10:02,120 --> 01:09:58,570 the increase in life expectancy what 1570 01:10:05,370 --> 01:10:02,130 benefits has it provided to society to 1571 01:10:07,830 --> 01:10:05,380 similarly for antibiotics we saw it had 1572 01:10:09,540 --> 01:10:07,840 no effect on the decline in TB yet it is 1573 01:10:11,670 --> 01:10:09,550 common knowledge that antibiotics have 1574 01:10:14,160 --> 01:10:11,680 saved millions of lives is this common 1575 01:10:17,850 --> 01:10:14,170 knowledge wrong if it is what benefits 1576 01:10:20,550 --> 01:10:17,860 has antibiotics provided three we have 1577 01:10:21,930 --> 01:10:20,560 not discussed vaccines per se so could 1578 01:10:23,370 --> 01:10:21,940 you tell me what you think of the debate 1579 01:10:27,210 --> 01:10:23,380 about the efficacy and safety of 1580 01:10:29,070 --> 01:10:27,220 vaccines this was Ian's response the 1581 01:10:30,510 --> 01:10:29,080 benefit of society from medicine is an 1582 01:10:32,340 --> 01:10:30,520 interesting question taking out the 1583 01:10:34,020 --> 01:10:32,350 question of mortality the knee-jerk 1584 01:10:36,510 --> 01:10:34,030 response would be relief of suffering 1585 01:10:38,610 --> 01:10:36,520 from things such as joint replacement 1586 01:10:41,310 --> 01:10:38,620 surgery and even simple things like 1587 01:10:43,230 --> 01:10:41,320 painkillers and antidepressants it with 1588 01:10:44,490 --> 01:10:43,240 recent research showing the twenty-five 1589 01:10:46,830 --> 01:10:44,500 percent of Australian and knee 1590 01:10:48,270 --> 01:10:46,840 replacement recipients stating that they 1591 01:10:50,880 --> 01:10:48,280 would not have had the procedure given 1592 01:10:52,770 --> 01:10:50,890 their time over with now narcotic 1593 01:10:54,780 --> 01:10:52,780 analgesic complications and addiction 1594 01:10:56,430 --> 01:10:54,790 being such a problem and with recent 1595 01:10:58,440 --> 01:10:56,440 questions over the effectiveness of 1596 01:11:00,060 --> 01:10:58,450 antidepressants not to mention the 1597 01:11:02,130 --> 01:11:00,070 increase in suicide rates in younger 1598 01:11:05,040 --> 01:11:02,140 patients I am not sure how to answer 1599 01:11:06,830 --> 01:11:05,050 that question as always it comes down to 1600 01:11:09,180 --> 01:11:06,840 the balance between benefit and harm I 1601 01:11:11,610 --> 01:11:09,190 think their areas in medicine where 1602 01:11:13,470 --> 01:11:11,620 there is clear benefit examples would be 1603 01:11:15,600 --> 01:11:13,480 antibiotics for simple infections 1604 01:11:17,550 --> 01:11:15,610 anesthesia and simple analgesics and 1605 01:11:20,310 --> 01:11:17,560 immunization programs for conditions 1606 01:11:22,800 --> 01:11:20,320 like smallpox now eradicated polio and 1607 01:11:24,540 --> 01:11:22,810 measles but we must also accept that 1608 01:11:26,850 --> 01:11:24,550 their areas where medicine does little 1609 01:11:28,680 --> 01:11:26,860 good and actually does harm particularly 1610 01:11:31,380 --> 01:11:28,690 in my field of surgery as we discussed 1611 01:11:32,820 --> 01:11:31,390 an interesting perspective on this is 1612 01:11:35,090 --> 01:11:32,830 given by the Nobel Prize winning 1613 01:11:37,130 --> 01:11:35,100 economist Amartya Sen 1614 01:11:40,250 --> 01:11:37,140 his 2002 article in the british medical 1615 01:11:42,860 --> 01:11:40,260 journal titled health perception versus 1616 01:11:44,930 --> 01:11:42,870 observation he noted that the quality of 1617 01:11:47,240 --> 01:11:44,940 life is relative to what you are used to 1618 01:11:49,310 --> 01:11:47,250 and that people in the poorest parts of 1619 01:11:51,260 --> 01:11:49,320 india actually write their quality of 1620 01:11:53,810 --> 01:11:51,270 life as similar to those in better off 1621 01:11:56,030 --> 01:11:53,820 areas Carl Sagan asked a similar 1622 01:11:58,640 --> 01:11:56,040 question when you asked if we the human 1623 01:12:01,370 --> 01:11:58,650 race were any happier because of science 1624 01:12:03,260 --> 01:12:01,380 not just medicine are people happier 1625 01:12:05,270 --> 01:12:03,270 less stressed or more satisfied with 1626 01:12:08,990 --> 01:12:05,280 their lot than the average person 100 1627 01:12:12,260 --> 01:12:09,000 200 or 1000 years ago probably not is my 1628 01:12:13,940 --> 01:12:12,270 answer specifically about immunization I 1629 01:12:15,680 --> 01:12:13,950 think that this is one of those areas 1630 01:12:17,090 --> 01:12:15,690 where there is a perplexing and 1631 01:12:19,880 --> 01:12:17,100 disproportionate response to the 1632 01:12:21,770 --> 01:12:19,890 question of harm common immunisations of 1633 01:12:23,810 --> 01:12:21,780 children have a high benefit to risk 1634 01:12:26,180 --> 01:12:23,820 ratio but there is a strong reaction 1635 01:12:28,190 --> 01:12:26,190 against the potential harm at the cost 1636 01:12:30,530 --> 01:12:28,200 of ignoring the benefit this is 1637 01:12:32,690 --> 01:12:30,540 perplexing because if I raise the same 1638 01:12:34,820 --> 01:12:32,700 questions of something else topical like 1639 01:12:36,530 --> 01:12:34,830 cancer screening or surgery where there 1640 01:12:38,450 --> 01:12:36,540 is a real possibility of the harm while 1641 01:12:42,200 --> 01:12:38,460 wearing the benefits nobody wants to 1642 01:12:43,850 --> 01:12:42,210 know so this was Ian's response and I'd 1643 01:12:45,830 --> 01:12:43,860 like to thank Ian very much for the 1644 01:12:47,420 --> 01:12:45,840 extensive interview and for the amount 1645 01:12:50,420 --> 01:12:47,430 of time and thought he had given for the 1646 01:13:03,939 --> 01:12:59,310 you 1647 01:13:05,530 --> 01:13:03,949 episode of the skeptic zone don't forget 1648 01:13:07,959 --> 01:13:05,540 if you found that interview interesting 1649 01:13:11,140 --> 01:13:07,969 and I sure did please come to skeptics 1650 01:13:13,390 --> 01:13:11,150 own TV and let us know your comments 1651 01:13:16,120 --> 01:13:13,400 next week the full shows back again with 1652 01:13:19,060 --> 01:13:16,130 Stefan dr. Richie reports a grain of 1653 01:13:24,879 --> 01:13:19,070 salt and the think tank until then it's 1654 01:13:27,310 --> 01:13:24,889 goodbye from Richard Saunders you've 1655 01:13:31,930 --> 01:13:27,320 been listening to the skeptic zone visit 1656 01:13:34,390 --> 01:13:31,940 our website at wwc a petting zoo TV for 1657 01:13:36,710 --> 01:13:34,400 comments contacts and extra video 1658 01:13:51,090 --> 01:13:36,720 reports