Professor Ian Harris AM

Professor Ian Harris AM is a Sydney-based orthopaedic surgeon, researcher, and author. In addition to his clinical qualifications, Harris has also completed a Master of Medicine in clinical epidemiology, a PhD, and a Master of Science in Health Data Science. He is interested in trauma care from a clinical perspective, while his diverse research interests primarily relate to surgical outcomes and the appropriateness of medical care. Harris is a national keynote speaker at the upcoming 43rd Annual Scientific Meeting (ASM) of the Australian Pain Society, which will be held in Canberra from April 2-5, 2023. In the lead-up to the ASM, Harris spoke with Lincoln Tracy, a researcher and writer from Melbourne, Australia, about his path to becoming an orthopaedic surgeon, how a teaching job led to a career in research, and his desire to help inform both professionals and the public about how more medicine is not always better. Below is an edited transcript of their conversation.

What was your path to orthopaedic surgery?

I didn’t want to do medicine when I was at school – my interests and talents laid in maths, physics, and science. My parents encouraged me to apply for medicine as my first preference, as it was the hardest course to get into, which made sense to me. I still wasn’t sure about medicine when I got the offer, my parents encouragement continued with “well, you don’t know until you try.” So, off I went. Then when I was doing medicine, I was always interested in the surgical side of things. For me, it was more a matter of what kind of surgery I was going to do. I’ve always had an attraction towards mechanical and architectural things with a lot of structure and function, which orthopaedic surgery offers.

I was also strongly influenced by an elective I did when I was a student, where I worked with a European orthopaedic surgeon in Samoa. This guy was a workaholic, but he was an absolute dynamo. He ran huge clinics and theatres where there was very little equipment in an incredibly creative way, using a hammer and chisel to remove a piece of bone, and then use that as a peg to fix another piece of bone – normally you would need a metal screw and a power saw to do something like that. His skills were quite inspiring to witness, so I was locked into orthopaedics basically as soon as I graduated.

How did you develop an interest in research?

Although I was never formally trained in it, I’ve long been interested in science and the scientific method – how it cuts through the crap and leads to logical and rational conclusions. After I was established as an orthopaedic surgeon, I would attend lectures and see people talk very knowledgeably about publications, critically appraising whether it was a good paper or not. I didn’t have those skills, nor did I know what that was called, as I got virtually no formal training in the scientific method in my medical degree, but I wanted to be one of those people who could do that.

I got a job teaching critical literature appraisal with the College of Surgeons, and quickly found that everyone on the faculty had done, or was doing, a Masters of Clinical Epidemiology. So, I figured that’s what I also needed to do. And doing the Masters was like having the blinkers lifted from my eyes. I realised how poor the evidence was for a lot of what we do, and how good the evidence was that a lot of what we do didn’t work. This just fascinated me, because there was a complete separation between what the science was telling us and what we were doing as doctors. And from that point on, I was hooked.

How did this interest in research lead to you working with clinical registries?

About ten years ago I joined forces with Professor Jacqueline Close to start the Australian and New Zealand Hip Fracture Registry, because I thought that was long overdue. Everywhere I travelled around the world I’d seen how poorly neck of femur fractures were treated. And in Australia, they were always the ones that were bumped, always put off, repeatedly fasted, inconvenienced – and I thought they were the ones that this should be occurring to least. I really felt we needed to do a better job of treating hip fractures, and that’s what started me off there. So, that’s what started me off with the Hip Fracture Registry.

You’ve authored two books (Surgery, the Ultimate Placebo, in 2016 and Hippocrasy: How Doctors Are Betraying Their Oath, in 2021); how did you make the jump from surgeon and researcher to author?

Writing the books came from my awareness that the public perception of medicine was inaccurate. I’d spent a lot of time trying to educate medical practitioners to be more science based. But regardless of what they did, the patients never really had a say in their treatment – what the doctor said went. And the general feeling in the broader community was that medicine is a good thing: we need more medicine, more doctors, and more tests.

But through my studies I came to realise that more medicine wasn’t necessarily better – in many cases it was bad. And it’s very difficult to get such a counterintuitive message like this across. I was fascinated by these huge, randomised trials I’d see from places like Sweden about mammography screening, that showed either no difference or a slight increase in mortality in the screened group compared to the non-screened group, even though they detected more cancers. But they identified more cancers because they were looking for them – it’s then just a question of whether that’s helpful or not. However, no one was reporting this – they were just saying, “Oh look, we’ve diagnosed all these cancers, isn’t it fantastic?”

So, I wanted to put a message about overtreatment out there. And there are a lot of times where modern medicine gets it wrong, and what we do is either ineffective or harmful. The first book had a lot of surgical examples, but I wanted to write something bigger and broader about modern medicine in general. So, for the second book, I got together with Professor Rachelle Buchbinder, a physician, and we wrote it together.

Given much of your research focuses on exploring the true versus perceived effectiveness of different surgical procedures, is there a procedure you’re particularly suspicious of and would like to see investigated further?

I’d really like to take on spinal fusion surgery, particularly for back pain and degenerative conditions – I think that procedure is definitely overdone. In a lot of countries, including Australia, there are significant disparities between rates of surgeries between insurance systems. For example, about two thirds of joint replacement surgeries are done in the private sector and the remainder are done publicly. While this reflects availability, waiting lists, and the like, there is some evidence that people who have a joint replacement in the private sector will have the surgery a little bit sooner and with fewer symptoms than someone in the public sector. So, you could argue there’s a bit of a mismatch in the servicing of the two sectors.

But the rates of spinal fusion surgery are something completely different. There’s something like a tenfold difference between the private sector and the public sector, where it’s rarely offered in the latter. And it’s not like there’s a huge waitlist in the public sector – the surgeons just don’t think it’s a worthwhile procedure in public patients, but they do in private patients. Such an overservicing in the private sector tells me something is wrong. Admittedly, there could also be some underservicing in the public sector, but the evidence for spinal fusion isn’t great. We need to study it further, get more evidence, and be doing fewer of these surgeries in the meantime. But the rates of spinal fusion in the private sector have been increasing steadily over the last 20 years.

It seems that because some surgeons have had experiences where they have operated and people have gotten better – and for what they get paid for it – that it’s worth a go. But for me, that’s a very bad level of evidence. That’s what surgeons, and medicine more broadly, have lived on for thousands of years: “I did something to somebody, they said they felt better afterwards, so therefore what I did to them made them better.” This is the kind of thinking that kept bloodletting going for 2000 years, despite there being no science behind it. It’s a very human, but unscientific, thing.

What’s one of the more interesting research studies you’ve been involved in?

We recently had a paper published in PLoS, looking at the reported treatment effects of pregabalin in clinical trials over time. This paper was somewhat of a follow-up to an earlier paper from the New England Journal of Medicine I had been involved in that showed pregabalin was no better than placebo in the treatment of sciatica. I wanted to investigate the effects of this drug because while it was very commonly prescribed, there were some studies questioning its effectiveness, which led me to question whether it really worked.

I wondered if this was an example of what people called the decline effect. This can occur when a new drug comes along and gets a lot of hype because it seems to work well and have a meaningful effect, but then as time passes there is a change in mindset to ‘it never really worked’ because another new drug comes along. So, we examined the decline effect across a wide range of studies for different conditions using pregabalin and found that irrespective of the condition, irrespective of the dose, irrespective of all the different parameters, that the effectiveness compared to placebo has been steadily decreasing. It was marginal to start with, and now it’s become almost non-existent over a period of 20 years. It’s quite fascinating – I like doing fun things like that.   

If you could offer one piece of advice to a younger you, what would it be?

My path to academia was very slow. Many of my surgical or clinical colleagues would go into academia early and get a PhD during or prior to their specialist training. But I had no idea what I was doing, and it wasn’t until after I had been practicing for several years and graduated from orthopaedics that I started my PhD. And because of this, my advice would be to do it all earlier – study clinical epidemiology, evidence-based medicine, the scientific method – than what I had, which would have probably given me a ten-year head start on where I am now.

Lincoln Tracy is a postdoctoral research fellow at Monash University and freelance writer from Melbourne, Australia. He is a member of the Australian Pain Society and enthusiastic conference attendee. You can follow him on Twitter (@lincolntracy) or check out some of his other writing on his website.

About Australian Pain Society

The Australian Pain Society is a multidisciplinary body aiming to relieve pain and related suffering through leadership in clinical practice, education, research and public advocacy.

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