Jared Powell:
Today's guests are Professors Rachelle Buchbinder and Ian Harris. Rachelle and Ian are icons in the field of medical research. They've published hundreds of influential studies ranging in content from the management of compression vertebral fractures to the efficacy of various orthopedic surgeries to the treatment of plantar faciopathy. Rachelle is a rheumatologist working in research and clinical practice in Melbourne, Australia. Rachelle is not only a trained rheumatologist, but also has advanced training in clinical epidemiology and also a PhD.
Jared Powell:
Rachelle directs the Monash Department of Clinical Epidemiology and has a staggering H index of 142, and her work has been cited nearly 200,000 times. Not only prolific, Rachelle also produces work of the highest quality regularly publishing in high impact medical journals such as jama, the Lancet, and the New England Journal of Medicine. In 2020, Rachelle was made an officer of the order of Australia for distinguished service to medical education in the fields of epidemiology and rheumatology. Rachelle is a true giant of global medical research. Ian Harris is no less distinguished. Ian is an orthopedic surgeon by background, and similarly to Rachelle has a graduate degree in clinical epidemiology and also a PhD. Ian is an academic orthopedic surgeon, meaning he still sees and operates on appropriate patients whilst also holding a professorship at the University of New South Wales, Australia. Ian is a vocal critic of aspects of his own profession, orthopedic surgery, and his research focuses on the true effectiveness of many common orthopedic surgeries such as spinal surgery and knee arthroscopy.
Jared Powell:
To this end, Ian published a book in 2016 titled Surgery the Ultimate Placebo. Ian has also been elected as a member of the Order of Australia. Ian is also a true giant of medical research. I have brought Rachelle and Ian on the podcast to talk broadly about modern medical care, which coincidentally they've written a book on. Their book is titled Hypocrisy How Doctors Are Betraying Their Oath. In this episode, we will discuss some key themes and chapters from the book, and we will also sprinkle in some personal anecdotes from the professors about the personal cost of doing research that goes against the status quo of your peers and your profession. Iwithout any further delay, I bring to you my conversation with Rachelle Buchbinder and Ian Harris. Professors Rachelle Buchbinder and Ian Harris, welcome to the show.
Rachelle Buchbinder:
Thanks. Pleasure.
Jared Powell:
This is a real treasure or treasure. It's a treat and a treasure and a privilege and a pleasure. That's what I was meant to say to to talk to you guys. I've been reading all your research for as long as I've been a physio now, which is 15 or so years. I've read your book, which we're gonna talk about today, which is titled, hypocrisy How Doctors Are Be Portraying Their Oath, which is a beautiful title. But before we get into the nitty gritty of the chat, I want you both to just briefly introduce yourselves professionally. Rachelle, I'll start with you.
Rachelle Buchbinder:
So I'm a rheumatologist and I trained in clinical epidemiology in Toronto at University of Toronto. And I work one day a week as a clinical rheumatologist seeing patients. And the rest of the time I'm a researcher and head of units musculoskeletal health and Wiser Healthcare in the School of Public Health and Preventive Medicine at Monash University.
Jared Powell:
Awesome. Ian?
Ian Harris:
I'm an orthopedic surgeon in practice in Sydney mainly specializing in trauma surgery. But followed a similar path to Rachelle. We didn't realize until we met later that we both started a specialist but then did clinical epidemiology which I studied, and then other degrees in in epidemiology. And I've been an academic now for a fair while, and now most of my time is spent doing research.
Jared Powell:
Awesome. And hobbies, what are you guys into, this is always the most popular question, so bear, bear with me with asking these frivolous questions. What do you like to do for fun when you're not researching or, or seeing patients?
Rachelle Buchbinder:
Want me to go? So two things. So swimming so I've competed in for Australia in two Macca bear game. Oh, wow. And I love swimming. Ian and I have also with our partners have gone on lots of hard long walks. The latest one was the Dolomites, so a 10 day walk in the Dolomites that Ian self-guided us through , which was a lot of fun. Now that we've finished it, .
Jared Powell:
Wow. What an experience. Was there any altitude sickness or anything like that?
Rachelle Buchbinder:
Yeah, no, actually my husband got sick one day. We actually were just talking about it today. We've just come back from a walk that one day that we were climbing the highest part of the dollarmites.
Jared Powell:
Fair enough. And just on swimming Rachelle, are you looking, do you, do you watch the Olympics? Are you looking forward to the Olympics coming up to see how the Aussies go?
Rachelle Buchbinder:
Yeah, I love it. I love I watch them whenever they're I can I watch.
Jared Powell:
Yeah, it's such a seeing how the Australians, and I'm gonna focus on the Australians 'cause we are three Australians. How we perform from such a small country on the international stage in the Olympics and our rivalry with the US it's, it's really an amazing thing to watch. I think last, last Olympics in Tokyo, Emma McKean was the star. She won about a thousand gold medals. And we're hoping to, to do it again. You both looking forward to, to the Olympics on a side note coming up.
Ian Harris:
Cool. Yeah.
Jared Powell:
Good. Ian, what do you like to do, mate?
Ian Harris:
Yeah, well, I do hikes regularly. I only do a couple of year or after the Himalayas in October. And apart from that, I, I just like to do woodworking and fiddling around in the, in the shed.
Jared Powell:
Typical orthopod mate.
Ian Harris:
. Yeah. That's
Jared Powell:
Big cliche. I
Ian Harris:
Took to it late. Yeah, I took, I took to it, but I quite, I quite like it. So I'm just really getting into that as I edge towards retirement.
Jared Powell:
Yeah, that's a good thing to do once you hang up the, hang up the scalpel. On, on walking, is that for both of you, has that been a, a lifelong interest or is it sort of become more, more and more, I guess, easier or better on your joints? I don't, I wanna say it's bad. Running's bad for your joints, but has it been more of an interest that's come through into your, into your midlife or, or what's the, what's the arc of walking?
Ian Harris:
Yeah. Yeah. I, well, I, I run every day now, but I didn't used to, so I only got into this late. And the walking was my wife took me and our family to done probably on average a couple of big, you know, multi-day walks every year.
Rachelle Buchbinder:
And we've always, we we're off to Provence for an eight day walk in October. And I just,
Ian Harris:
I just did a six day walk in,
Rachelle Buchbinder:
Oh, we to talk
Ian Harris:
A few weeks ago from the Alps to the Sea.
Rachelle Buchbinder:
Oh, we're doing we're doing something similar to that. Yeah.
Ian Harris:
Ah, okay.
Rachelle Buchbinder:
We haven't talked for our ages, the two of us. Yeah.
Ian Harris:
Jared Powell:
I'll let you guys catch up. Yeah, I'll go. I'll go and I'll come back in a minute. Come that sounds,
Rachelle Buchbinder:
I actually started running when we were writing the book in Bellagio because I couldn't swim. Mm. So I tried to keep that up as well. So yeah, very similar. Oh, I love it.
Jared Powell:
Yeah. And I like the, I like how you are. Just, just lastly on walking, I like how you're combining holidays with sort of walking trips. That seems like a, a really cool thing to do.
Ian Harris:
Mm-Hmm. It's, I've good way to see the country.
Jared Powell:
Yeah, absolutely. I'm, I'm getting a bit more into cycling, which is, I'm, I'm close to turning 40 and it seems like everyone at this age starts cycling and watching the Tour de France at the moment just feels like I want to get on a bike and ride through the countryside in Europe. But doing a walk would be similar.
Rachelle Buchbinder:
We've both, we've actually done cycling trips as well. We've cycled around the big island of Hawaii. And my husband's a cyclist now 'cause he can't run it. Yeah.
Jared Powell:
Awesome. I love it. All right. We could, we could chat about this all day. Let's get into the nitty gritty. Well, actually, so I want take a minute to talk about your career arc and your career trajectory. So you both trained medical doctors. Rachelle, you're a rheumatologist in, you're an orthopedic surgeon. What I'm more interested in is you both got postgrad degrees in epidemiology and a PhD. So Rachelle, I'll start with you. I wanna know, start, have these postgrad qualifications in epidemiology and a PhD changed your worldview when it comes to medicine? Or did it not move the needle at all?
Rachelle Buchbinder:
You know, it absolutely. I mean, I, I, I went to Toronto because my husband wanted to go overseas. I didn't really wanna go and I didn't like the lab jobs. I started a lab PhD. I did it for a year and I hated it. I was meant to give rats arthritis, and at the end of the year, they still hadn't got arthritis. And then my supervisors finally tweaked that I couldn't inject them , so they were never going to get it anyway. And then I met Claire Bombardier in Toronto and she said, come and see my lab, which was just people and computers. And then I read a couple of books and then it basically changed the whole course of my career. I was just going to be a country, not a country, a city rheumatologist. And this really opened my eyes. We did, we did a similar thing in final your med, but it didn't, it wasn't taught very well, and I didn't really understand it. And I forfeited those questions in the physician's exam. 'cause I thought I'll never understand it. So for me, it was a really big life changing thing. And as soon as I started it, I knew that's what I wanted to do.
Jared Powell:
Yeah. So how, how, how has it changed your life in terms of is it a philosophy of how you approach appraisal of research? Or, or how has it changed your, your life?
Rachelle Buchbinder:
It's, well, it's both. It's, it, it's the basic science of clinical medicine. So for any difficult question or treatment, you should look up, you know, you should understand what the evidence is for that treatment and what the risks are and what would happen if you did nothing. And during the course, it became clear that you chose treatments that you are interested in to see what was the evidence behind the treatment. And often I was studying things and realizing that the evidence was someone saying it was a good idea in a book, you know, that it wasn't, it wasn't trials or, or even case series. It was, it was just someone saying something. So that really sparked my interest. And, and I really liked seeing patients as well. And they often bring out the important clinical questions. So I decided when I came back, I wanted to combine research and seeing patients. And many of my ideas, you know, particularly over time have been really driven by patient questions.
Jared Powell:
Yeah, that's a really, that's a really important point. And I want to touch on that. The, the balance between being a clinician and, and being a researcher and how those two interplay. You mentioned a lot of medicine can be based on what he said or what she said, you know, expert or guru based medicine rather than evidence-based medicine. Ian, do you share a, a similar or, or what's your experience been with your post grad degrees and how has it changed your worldview as a, as a trained orthopedic surgeon?
Ian Harris:
It, it completely changed everything for me. And it, it's interesting that Rachelle and I had sort of parallel journeys. And we didn't realize this until we finished the journey. And I think that's why we get along so well and, and research so well together is because we've had the same path. So I started off as a orthopedic surgeon. I was interested in trauma, I specialized in trauma. I did a fellowship in the US at a big trauma center and came back and I was, you know, operating every day, you know, until late, you know, seeing heaps of patients doing a lot of surgery for years and enjoying it, but always wanted to be a better scientist. And I think even when I was a kid, I was kind of like the nerdy kid. I, I loved the idea of science and the scientific method, but it really wasn't, wasn't much of that in in surgery.
Ian Harris:
And I used to admire the surgeons and there, there were many around who really knew how to interpret the literature and knew how to search it. And they knew what a good study was and what a bad study was. And they understood these principles of critical appraisal. And I wasn't like that. And I really wanted to be. And it took me a while and, and I said, how do you, how do you get that knowledge? I want that knowledge. And realized of course, it was basically what I was talking about was clinical epidemiology. I didn't even know what clinical epidemiology was until I, until I sort of looked for it. And then as soon as I started doing the masters of 10 epi, everything clicked into place and I said, this is it. This is what I've been looking for.
Ian Harris:
This is the science of medicine instead of just the opinion. And even when I was studying for my final exams before I'd gone through that journey, you look for the evidence for things. You wanna justify your answer in an exam situation. And I found that the evidence wasn't there, it's just this sounds like it's something that should work and that's why we do it. And and then I started realizing that not only wasn't there evidence for what we were doing, there was evidence for a lot of what we were doing. And that evidence showed that it didn't work and we were ignoring it. And so it was a much bigger problem than just not good evidence. And so that's what I said, well, I have to start doing these studies myself and helping other people do studies. And, and there needs to be a, a more scientific approach to the way we, the way we do medicine.
Ian Harris:
And people think, I mean, lay people think it's a if you watch TV and things like that, you think that medicine is such a high level science. And it can be, and in some areas it's but in general it's not. It's a very low level science. And I always say in some of my talks you know, if you've got a scientist from NASA or C-S-I-R-I or something to sit down and have a look at what we do and the way we make decisions, they faint. It's just terrible way we do stuff.
Jared Powell:
Awesome. Yeah. No, that's, that's really well said. Both of you, Ian. I was just reading one of your papers the other day that you alluded to in the book where you compared lots of surgical trials for chronic musculoskeletal pain, and you analyzed how many of those trials, you know, have involved a non-surgical comparator. And less than 1% of those surgical trials involve a non-surgical comparator. And when they are done, you know, the surgery is often no more favorable. Most of
Ian Harris:
The, yeah, most of the time surgery is not favorable once we start doing these studies. But it's a classic example of, I think people want to be good scientists and they wanna be researchers, but often they're asking the wrong questions researching the wrong things. That's a classic example where in orthopedics we do lots of RCTs. There's thousands of RCTs being done in knee replacement, for example, but there's only been one CT comparing doing an knee replacement, so not doing an knee replacement. And they're the kinds of studies that we really should be doing first. That should be the first study we do with any surgical procedure. Is it better than not doing it? If it is, then we can do the other thousand RCTs that look at how we do it or what approach we use, or what implant we use or other technical aspects.
Jared Powell:
Yeah. So this is, this is getting perfectly into to the, my favorite chapter. I'm a, I'm a nerd when it comes to science and the philosophy of science and the history of science when applied to healthcare and medicine and physio. And this chapter is chapter two called Science Matters. And it's really brilliantly written. It's, you know, dense enough to satisfy nerds like me, but easy enough to understand where the lay person, I think can understand it as well. So well done to both of you for your clear and concise writing. And Rachelle, I'll start with you. Why does science matter in healthcare? And what are some prime examples from the history of medicine that you could perhaps use to emphasize or illustrate your point?
Rachelle Buchbinder:
So science matters because it gives you the, the right or the best available answer. And if you don't have science, you can do things that are, that not only don't work, but are often can be harmful. And we know that 30% of medical care is of no value, and another 10% is actually harmful. And so unless you do think about medicine as a science then you can be harming your patients which is the opposite of what we want to do. So that's the answer to the first question. Some examples so I can't remember what the examples were in the second chapter, but I guess one example is thalidomide so thalidomide, except it's, it's a bit more complicated than what I'm gonna say. But thalidomide was introduced into clinical care on the basis that it was good for morning sickness.
Rachelle Buchbinder:
And in fact, the, the people that that pushed that knew that it, it wasn't, it was actually originally for sleep. And so they argued that if, if you could make pregnant women go to sleep and they wouldn't be so nauseated. So that's how they justified it. But they actually already knew before they put it on the market that it was harming people because it was harming pregnant women within their own pharmaceutical companies. And then what happened was that they, it was introduced, it, it, they tried to get the American marker, but the head of the, like the FDA type person wasn't happy, so she wouldn't let the drug into the us. So more drug went to Canada, New Zealand, Australia and other parts of the world. And they had a very clever marketing strategy. They gave out free samples to all gps particularly in in the country as well.
Rachelle Buchbinder:
And they had them there for as soon as a pregnant woman walked in, they could offer it to the patient. And in fact, I could easily have been a thalidomide baby 'cause my mom was offered the drug and didn't take it. And so then it, it took actually quite a while for people to realize that, that the drug was causing birth defects. And it it that in Australia though, those babies still haven't been properly compensated, for example. And so that was really how we got the TGA in Australia, which meant that you couldn't bring drugs into the country unless they were proven to be safe. And, and so the TGA is primarily concerned with safety. So we wouldn't dream these days of giving people a drug unless it had been properly tested with, with like lab studies and then onto human studies. So that's one example. But there are plenty of other examples. There's leches that were used and in fact, you know, leches have to do, do secrete and analgesic type thing. But they were obviously doing, using leches for many treatments, that many conditions that it wasn't effective for. There, there's an example of washing your hands in between patients. Mm. So that was an important,
Jared Powell:
That's an interesting, I like the, I like that story. So it's the, it's the, I think he's, is he Hungarian? Is it se wise, the, the doctor who, who
Rachelle Buchbinder:
Went between patient, the whole,
Jared Powell:
The, the whole story is fascinating, right? So there's a, there's two wards, two maternity wards, I think it was in London. One had a far higher rate of child bed fever in postpartum women. And he set out trying to answer this question and, and you can tell us what he did.
Rachelle Buchbinder:
Yeah. So he he just washed his hands. ,
Jared Powell:
Yeah, , who would've thought
Rachelle Buchbinder:
When examining on seeing patients postpartum and that clearly showed, sorry, my, that clearly showed that there was a much lower rate of postpartum sepsis in the people who'd had he been treated. It actually took many years for people to believe him. And in fact, he died in a, in a mental asylum because people just ridiculed it. And, you know, it was really, those sorts of examples are really where the science of medicine first started. The earliest example was scurvy where people were dying on, on boats. And then someone did a trial of giving people oranges or lemons, and then the other half, nothing. And there was a much higher death rate among the people that didn't have the fruit. So that was actually one of the, that's what we people say is the, was the first randomized trial. So those, those examples really tell you why their science of medicine is important. 'cause It, it, if you don't use science, you kill people.
Jared Powell:
Yeah. That's, that's gonna be the name of this episode, Rachelle. Well done actually. . Thank you for that. So the, the, the darling of science and evidence-based medicine is the randomized control trial. I think there's not a lot of controversy in saying that. Ian, I wanna I wanna ask you, has the, the advent or the, the, the more common use of the, of the randomized control trial and maybe even mention the placebo controlled randomized control trial changed orthopedic practice in your, from, from when you graduated to now?
Ian Harris:
Yeah. It's, it's more common that they're performed now, they were being performed before. But it's much more common now because I think it's, it is widely recognized that that's the, you know, the best level of evidence to finding out if things work or not. And so they, they're much more common and more accepted, and they do have impact. And we were chatting before about how sturgeons often will discredit randomized trials if it doesn't fall within their beliefs or if it goes against their practice. But at least they have to discredit it like it's there. It's a powerful thing. It's not like they can ignore it. So when RCTs do get published, they do you know, cause an impact, even if it's an opposite reaction. It's still, they cause an impact and they cause you know, debate and often make people sit up and think. So it has changed things a lot. And, and these are the studies that change practice. They still are. And they, they have been. So they're, they're a very important tool to guide medical practice.
Jared Powell:
If we were to take it back to, to 1 0 1, and this is an open question to both of you. Scientific principles 1 0 1, like why is a randomized control trial better evidence than in my experience or observational evidence? Can, can you gimme a a two minute elevator pitch?
Ian Harris:
Who wants to take that? Anyone you want me to take that? Yeah, they, they well, it's often said they tell us causation. And the reason is because it gives us, in a simple, randomized control trial, it gives us two sets of people who differ in only one respect. And that's whether or not they have the intervention that's under study or the intervention versus the control. Therefore, any differences that occur between those two groups must be due to that single difference between them. And in causation world, it allows us to explore the, the counterfactual. It, it's always the question we wanna know is, what's the difference if I do this to you compared to not doing this to you, for example. And whether that's a a, a minor tweak of a, of something, or it's a pill or it's an operation, it's, there's an intervention and there's not the intervention, the the counterfactual.
Ian Harris:
And you can never know that from an individual because I'm either going to treat you or I'm not. So we'll never know what the opposite is. And by doing an RCT, we build that, we build a, a group of patients who are similar to another group of patients, and then we do the intervention to one of them, don't do it to the other and see what the difference is between those two groups. So that's where you gotta be careful because there's, there's bad RCTs where there's other things that are different between the two groups Yeah. That may influence the outcome. And these are things that are confounders. They might, one group might be getting another treatment as well, or something else, or they may have been a different group to start with. There may have been more smokers in one group than the other group. But the only way to minimize the risk of those differences, or the best way is to randomly allocate the people. And then any differences in age or smoking status or whatever between the two groups is at least gonna be random if not well balanced.
Rachelle Buchbinder:
So what you're talking about, Ian, is the RCT is the best way of reducing the bias in determining the, so we do everything we can to minimize the bias. We randomize to try and make the two groups as equal as possible. We in an ideal world, we blind, so no one knows what treatment the person's received. We blind the person measuring the outcome. We blind the patients. And so there are levels of strength of the trial that the best trial is a well conducted placebo controlled randomized trial. And, and so that's just the way to reduce bias. So if you, if you randomize then the, then the result can be due to the intervention, but it can be due to lots of other things as well. And if you don't blind you can selectively choose, you know, there are classic examples where they choose people who are not as sick to get the control group and the people who were more sick to get the active group or vice versa, to try and gain the system to make their treatment look better.
Rachelle Buchbinder:
So there are people gaining it as well to try and sell, sell product.
Jared Powell:
Yeah. Yeah. There's perverse incentives in science too, isn't there? We might, we might get to, you know, we're, we're sort of seeing the praises of science here, but there are some, there's still humans in science, isn't there? And humans are fallible and, and corrupt, unfortunately. There's
Rachelle Buchbinder:
A, there's a big, big trendy, trendy area of research now called commercial determinants of health.
Jared Powell:
. What I, I, I think I can understand what that means, but is that like, or do, do you mind just explaining that quickly? It's
Rachelle Buchbinder:
The commercial influence on healthcare. It's part of what we talk about in the book, it's medicine, healthcare as a business with, with the outcome being to make as much money as possible. So we know that's occurred a lot in, I mean, occurs often in the US with private medicine. In Australia it's occurring more with privatization of things like radiology groups PET scans and then, and then all for profit. And, and, and they talk openly about taking over radiology companies and, and trying to generate more profit for their share, which isn't the same as trying to maximize patient's health or optimize patient's health. So that's a really big worry that we have. The, the commercial determinants.
Jared Powell:
Yeah, the medical industrial machine is a giant. Yeah. And I think we're gonna, we might speak to that in the overtreatment over diagnosis section. Rachelle, I wanna stay with you for a minute. I want you to recount if it's not too traumatic, your, your vertebroplasty affair. And this is one of my favorite stories in, in the book where you conducted a couple of, at least one or maybe two placebo controlled trials of, of Vertebroplasty. And, you know, it wasn't, wasn't really met too well by the, the giant machine of the, of the medical system. Do you wanna just explain that?
Rachelle Buchbinder:
Yeah. So, so it started off that people were doing this, it's an injection of cement into pe into spines that have got a fracture which occur in people who have thin bones. So they're all often older people more fragile people that, that fracture their back. And there was a new treatment being offered that in, that injected the fracture with the cement and it there. And so I went to look up what the evidence was, and it wasn't based on any evidence really, just case reports. There wasn't, when we started thinking about doing the trial, there wasn't even a control trial. There wasn't any study that had compared one group that had the treatment with another group that didn't have a treatment. You know, sometimes you don't even have to do that in a randomized way, but there wasn't a single study. So we decided that we wanted to do a placebo controlled study.
Rachelle Buchbinder:
And there hadn't been any, you know, there'd been a few case reports of side effects, of adverse effects, but nothing really major. And in America it was well accepted and in Europe and in France and in other parts well accepted. So you almost as soon as you got a fracture, you got the cement. In Australia, it was a little bit different. We were much slower. But people were starting to use it. And I was seeing people in hospital getting adjacent fractures or, you know, I was starting to be a bit worried about, gee, cement in your back's pretty drastic. It sounds pretty drastic. And in fact, in Australia, people, we, we, so we, we ended up so what happened was actually we were going to do a trial, but we weren't going to use placebo. But at that time, the first trial of placebo surgery comparing arthroscopy to placebo was performed.
Rachelle Buchbinder:
And it was sort of on the front page of the papers and, you know, there was an, there was a cartoon that said, oh, well, it looks like I've had an operation, had a big scar. And it was at that point that I thought, I'm sure I can convince people now we can do a placebo controlled trial. So that's how that started. And then people were sort of already telling me it was unethical and I was saying, well, isn't it unethical not to know? So I just dismissed that. We, we had trouble recruiting people because we had to explain every single side effect that was possible. And people were just too scared to go in the trial. So we were having trouble recruiting. And at the same time, there was a placebo trial being performed from the Mayo Clinic in the us.
Rachelle Buchbinder:
They were having trouble recruiting because people knew what worked and they just wanted the treatment. They didn't wanna go into a placebo controlled trial. So we sort of found out about each other and talked about, you know, how we having trouble recruiting for completely different reasons. Anyway, we both ended up having to finish the study early, and we both decided we'd, we'd also combine our data eventually. And we analyzed our results without telling each other. And we submitted our papers without telling each other what the results were. And we were both astonished that the treatment actually didn't work. And like, in retrospect, afterwards, you could probably have predicted that because the size of the benefit in the other studies was such that could all be accounted for by bias. But at the time it was really like unbelievable that it actually had no effect compared to placebo.
Rachelle Buchbinder:
But there were already some in our study actually could look at increased risk and we could look at that at two years. And while none of it was statistically significant, every single analysis we did looking at adjacent fractures, non-adjacent fractures, everything's was a trend towards an increased risk. So I still think that there probably is an increased risk, but I can't prove it. But meanwhile, it can perforate the heart, the cement can go into your lungs and you can die. It can paralyze you by the cement going into the spinal canal. But so as soon as the trial was published, even before the trial was published, I was being yelled at at meetings. So people standing up and yelling at me. And then afterwards it, it was much worse. And I didn't expect the, the abuse, the phone calls, the emails, you know, just being half asleep opening my email and getting, you know, abusive emails about how dare I, and you know, you, you are gonna ruin the lives of people who are no longer going to be able to have the treatment.
Rachelle Buchbinder:
And it was actually much worse for my colleague in the Mayo, 'cause he's actually a radiologist. So he was actually doing the procedures. So it was his own colleagues that were really angry with him. And then when we published our results, combining our results together and found we could look at subgroups then because we had a bigger sample again, showing that no matter how we analyze the data, there was no group that was better off with having the treatment. It, it didn't work for anybody. And then I got an email from someone saying I should a socialist charlatan and I, I should go and work in Cuba or China, but they probably wouldn't have me. And they, and they also wish that that Dave Kma said at the Mayo, and I would one day have a fracture to see how painful it was. so went on and on like that. And you know, it, the abuse hasn't stopped it, it went on for a good 10 years. There are people still who, who hate me because I ruined it for them . So anyway, yeah. How,
Jared Powell:
How dare you, Rachelle, how dare you do some robust science?
Rachelle Buchbinder:
The thing is, I actually thought I was gonna prove that it was, so that's what I, that's what I thought at the beginning. So I was as surprised as they were. But it was just the science. That's the science. And in retrospect if you look at lots of treatments like that, most of them don't work. Like 90% of them probably don't work. And you can tell that when, I mean, a lot of things that we study in the, in the surgical world, there's already evidence that things like sub subacromial decompression for people with rotator cuff symptoms it didn't work better compared to not doing the operation. And now there are trials showing it doesn't work compared to placebo either. But really we shouldn't have had to do the placebo trials because it already didn't work compared to not doing it. But people still want that. So I think there's a lot of waste in, in what we do as well because we have to convince people that we're harming people.
Jared Powell:
Yeah. Yeah. I'm so, I'm sorry you had to endure all those personal attacks. It's, I guess, I guess someone's gotta take it, Rachelle, and, and it looks like you've handled it somewhat okay over the years.
Rachelle Buchbinder:
Well, it's not new. I mean, se wise we think about before he
Jared Powell:
Yeah.
Rachelle Buchbinder:
Had it. And it's, you know, it, it happens not just in our field of science, but, you know, climate change scientists have had it. It's just, I mean, I, it wasn't the first time, the first one was the, we'd study shockwave therapy for heel pain. Mm-Hmm. In the American Journal Journal of American Medical Association in jama the week that it was approved for use in the US . So that was my first I was, my first email was something like, you should put your head in a microwave oven. It was something like that. Oh
Jared Powell:
Yeah. . I don't know how you deal with that. I'm too sensitive. I mean, well done. I think I guess you get, do you get thick skin over time and you just get used to it? Or do you kind of, because your, your science is sound, right, so you know that like, yeah, just, you are not, you're not worried about anything trying to, like, there's nothing that can be dug up in your research that's gonna falsify or invalidate your findings. So you've got solid ground to stand on.
Rachelle Buchbinder:
And that's, and that's how I answer my critics with the science. But it, I mean, I did take a personal toll. I got, I mean, I started having really bad panic attacks and I've bit paranoia thinking there, someone following me and being anxious, turning on my email in the morning. 'cause I didn't know what I was gonna find. So it, it, you know, it hasn't been without personal, you know, I get a bit anxious talking about it, but in an often in the evening I'm a bit anxious. But in the morning I'm just going, well, you know, this is, this is harming people and as long as we're harming people, I'm gonna, I'm gonna talk about it.
Jared Powell:
Yeah. You've got heaps of supporters too, Rachelle, so keep keep it up. We're gonna support you. Ian, I want to, I want to get to the orthopedic problem. You know, orthopedic surgery is, it's, it's seen as the gold standard from patients from the public when it comes to musculoskeletal complaints. And we spoke a moment ago that, about a moment ago, that many of these, of the evidence for common elective orthopedic surgeries haven't been subjected to non-surgical comparators and certainly not placebo controlled comparators. So are there any key trials? I know there's lots out there in the knee, and I'm a, I'm a shoulder, I'm a person with a shoulder interest, so I know the ones in the shoulder. There's a couple of really influential trials that you want to talk about that have challenged orthopedic surgery and what's been the, what's been the fallout and the outcry from that in that inner orthopedic sanctum?
Ian Harris:
Well, probably the biggest example that, that people talk about is knee arthroscopy for degenerative conditions. The degenerative meniscus tears and, and osteoarthritis, which is the number one reason for having an knee arthroscopy. That's what most neo arthroscopies are done for. But there's now been quite a lot of studies, and not just placebo studies, but studies comparing it to non-surgical comparators consistently showing that this kind of treatment, this arthroscopic menisectomy or cleanup of the knee or whatever, doesn't, doesn't work. It's a shame that it's taken so much evidence in so long for the message to get through. But I, I have a staying paraphrasing Martin Luther King Jr. That, that the arc of practice changes long, but it bends towards science. And so science normally wins out in the end, but it sometimes takes a bit of a struggle to get there.
Ian Harris:
And so that's probably one of the biggest examples. And we have seen in many areas when I say areas, I mean geographic regions neo arthroscopy rates fall quite significantly. It's still being commonly done, but for example, you know, half as much as it used to be in, in New South Wales, but probably in America about as much as it used to be, because they tend not to listen to the evidence as much. But certainly in a lot of parts of Europe and Scandinavia, the, the rates have dropped. So that's probably a really good example. I think in shoulder surgery there's a, there's a, there's been some very good studies in there, some coming up. So I mentioned that I did a walk in PI was just at the Nice shoulder course in France, which is a big annual meeting for shoulder surgeons.
Ian Harris:
It's like one of the biggest international shoulder meetings. And I presented there and and I discussed a study that we're doing at the moment. So Rachelle and I both involved in this study comparing rotator cuff repair to no rotator cuff repair with all other things being held equal, though it's actually quite scientifically it's one of the ones I'm most proud of because the two treatment are in every way after treatment is exactly the same. The patients are blinded, they dunno what they had done. The people treating them are blinded. The surgeons that see them afterwards are different to the surgeons that operated on them. And so half of these people have their rotator cuff prepared and half of them don't. And nobody following them up knows which group they're in. And so it's a very, is this the trial? No.
Ian Harris:
So when I no, this is a study we're doing called the ARC Trial. We're still a third of the way through recruitment and it's looking at degenerative meniscus. So these are older people, 45 to 75 because that's the most common group that gets rotator repairs. The accurate trial is a similar study being done in Scandinavia. And the chief investigator, the accurate trial is actually on our study as well. And he'll be, and I caught up with him in Nice. And that's a study, very similar placebo study, but looking at traumatic rotator cuff tears. Now that's interesting because if you really want get into the nitty gritty, most rotator cuff repair are done for degenerative tears. I mean, they're by far the most common reason. I mean, the degenerative chairs are everywhere. Most people over the age of 60 have one.
Ian Harris:
So they're the most common reason. But you do occasionally get traumatic ones. You know, a younger person can have a, you know, dislocated shoulder or an injury or something and to compare the rep repair cuff, he's actually looking at those ones. Now, I, I would've thought, oh gee, I would've been scared studying those ones because I would've thought surgery was really helpful. those ones. But I said to him when he started the study, I said, how come you are looking at traumatic tears? Why don't you do a study like we are looking at degenerative tears? And he said, well, we know surgery doesn't work with degenerative tears, . I said, well, you may know it, but the , the rest of the world doesn't. And Rachelle actually was part of the Cochran review that looked into the evidence that we have so far. Yeah. Showing that there isn't really good evidence for surgery for rotator cuff tears. But the studies that have been done so far are not high quality studies. They're not to the degree of the accurate or the ARC study where everyone's blinded and it's much more controlled. So hopefully that's gonna answer the question for it. But I ran into to Vima who's running the accurate study, and he said they just recruited their last patient. Oh, wow. So they finally finished recruitment. So we've gotta wait another year or two for the results.
Rachelle Buchbinder:
I, I've gotta disagree with you. 'cause The, the, some of the trials were quite good. They were just not compared to placebo, they were compared to non-operative treatment. And even those trials couldn't show a benefit. So an even better trial will show an even smaller benefit. So I we, we can argue about this, but you know, the, this, it's, it, the, the trial, the evidence that there exists is, is might be low quality, but a better quality study will only reduce the effect size. And if the effect size already shows it doesn't work, then it can only get smaller.
Ian Harris:
Mm-Hmm. , I, no, I agree. But, but I also think that that needs to be done, but before people will listen to it. Exactly. That's the, and that, yeah, the thing about these, you know, placebo studies, obvious these high quality studies, they do have significant impact. I mean, when they, when they get published, people really pay attention to them. So I'm, I'm hoping that these two studies will do that for rotator cuff.
Jared Powell:
So did you say you're about a third of the way through recruitment for your study? Yeah.
Ian Harris:
With recruited 36 or 37 odds.
Jared Powell:
And then you're planning on doing like a one year follow up? In terms of ? Yeah. Oh,
Ian Harris:
We'll follow them up for two years, but the primary outcome is six months. Yeah.
Jared Powell:
Cool. Yeah, I it's gonna be landmark studies. So again, well done to both of you for, for, for doing these studies. Seriously, that makes such a difference. And I can imagine that there's gonna be some carry on in the, in the industry. Do you, can you sort of gauge the landscape in the orthopedic and general medical community to, what's the response been to the Seesaw trial in amongst orthopedic surgeons? Because I know in Australia impingement surgery has gone down America, it's unchanged. I think the UK it's gone down 'cause it was a UK based study, certainly in Scandinavia as well. America, I've seen this, the, the prevalence rates and it's unchanged. What's the response been in Australia? It's
Ian Harris:
Typical. Yeah. I, I think the response has been like, it's been to a lot of other studies like that. So there was another recent maybe not that recent big study looking at a surgery versus no surgery for humeral neck fractures sticking to the shoulder. They all have about the same reaction. They do cause a change and they do cause some people to sit up and think, oh, maybe this doesn't work. And, and then you do see practice drop off a little bit. But there's still people that disregard it and don't believe it and find flaws in it and feel that they can pick the patients that will get better, et cetera. And they feel that in their hands it works because they see people get better. This is the problem of people not understanding the science. They don't understand the bias in observational evidence, particularly when they're the observer. They don't understand Yeah. That, that just 'cause they see people get better six months later. It doesn't mean that people got better because of what they did. I mean, those people could have improved anyway, but they just don't see the and that that's the problem. So it's, it's, it hasn't been the study, it's been criticized. They had a session at the next shoulder course where they discussed that specific paper and they have people get up and speak to sort of both sides of
Rachelle Buchbinder:
It. And, but often they, I mean, I've, I've given debates with Ty and, and I lose because people believe it works and, and they, they often write editorials in journals that you can't respond to or that you don't know about that that criticize your trials. So there's a big system trying to, trying to reduce the effect of your work. And on average it takes about 17 years to change practice for, for good or better. And, and that's not just surgery. I mean, we've done, there are over 300 trials of physical therapies, but physiotherapists do for shoulder pain. And the bottom line is that probably nothing that you do works other than your kind reassuring manner and time that you spend with patients. So it's not just surgery, it's, it's lots of things.
Jared Powell:
Yeah. 100%. I want to talk about physio for a moment, if you don't mind. I've just written a critical review on exercise for shoulder pain and basically because it's the number one recommended treatment for the non-surgical management of rotator cuff pain. And when you look at the evidence, it's poor. The effect sizes are tiny against natural history. Maybe it's clinically unimportant. Certainly there's been, there's been a couple of placebo control trials and exercise and manual therapy is no better. Rachelle, I think that was the basis of a, a Cochrane review that you, did you author or were perhaps an author before?
Rachelle Buchbinder:
No, I authored it, but I, we also did one of the trials, we did a placebo control trial with Kim Burnell in, it was Kim.
Jared Powell:
Yeah, yeah, yeah. Kim was my last guest on the podcast. And we, we chatted about that as well. We don't know how exercise works with shoulder pain. So the mechanisms are uncertain. It's hard to do a placebo con like a, you know, like a, like for like placebo control trial on exercise because we don't know the active ingredient in inverted commas of exercise and manual therapy. So the whole thing is, is challenging. I
Rachelle Buchbinder:
Mean, we've, we've done a number of placebo controlled trials of physiotherapy including for frozen shoulder for oa, hip OA knee and rotator cuff shoulder. And we used ultrasound with the machine turned off. So instead of talking about exercise, we talked about physical physiotherapy led treatment. And you'll say you'll have one of two treatments and, and we measured the blindness. And people think that sitting in a room with an ultrasound machine's actually treatment and it's not even on. And we know that even if it was on, it didn't work. But yeah, people were well blinded in all of our trials. So there are there are ways that you can get around the, the blinding, but I agree it's not exactly the same. I guess it is exactly the same. It's everything that you do. And it's, the other thing is it's much harder to study because it's a complex intervention. It's not like a drug. It's, it's this and this and you wanna grade eight the ever, you know, grade eight, the exercise and you wanna do this. Mm-Hmm. So it's quite a complex thing like, like surgery, but probably even more complex that you wanna standardize. And it described the thing it is that you are doing Mm-Hmm. But we've spent a lot of time, you know, developing the treatment, the physi with physios, de you know, working out what they think are the active components and putting it all in. And even that didn't work.
Jared Powell:
Yeah, yeah. Yeah. So we've got a, we've got a lot more work to do, I think using mediation analysis to try and figure out the causal mechanisms of exercise for managing pain. Aiden cine and, and and James McCulley group down in, in Sydney Uni is doing a really good job trying to figure out the causal mechanisms of physiotherapy interventions. I know the, oh, what was his trial? Was it, was it the re No, that was Pete's Restore trial's been
Rachelle Buchbinder:
Back the Mark Henkel Hancock just published. Yeah, that's got Thomas media exercise. Exercise where it doesn't have to be therapy. It can just be exercise being fit. That, that has a big benefit. And it's, so, but the actual more fine tuned exercise, like you know, what is it? Multifidus tra strengthening
Jared Powell:
Portability activation for chronic low back pain or rubbish. Yeah, no, I agree. Like structured specific exercise designed to change something biomechanically, which is then meant to magically reduce pain is completely unproven. And it's a hypothesis that physios have been using for 20, 30 years, which now we've started to scientifically study and has been refuted almost categorically. And that's because of science. So, yeah. So I wanna ask you too, surgery, elective surgery isn't great for musculoskeletal pain compared to placebo surgery or non-surgical management. Non-Surgical management when compared to time or surgery or placebo isn't great either. So what the hell do we do? Do we use shared decision making as our paradigm to, to, to choose treatments? Do we just say, I see how it goes over 12 weeks, or let's just sit down, I'll give you a pat on the back and use my empathy and warmth to help you. What do we do? Ian I'll start with you.
Ian Harris:
We don't have to do anything. There's, there's often an assumption with healthcare providers that doing nothing is failing to, to care. So there's a difference between failing to provide care and to this opinion because of my reputation. And they've, you know, been told they need to have a spine infusion or something, and then they come to see me for a second opinion and I explain to them no. I say, you know, this is not gonna help you. There's, there's no evidence that this is gonna help you. I don't, it's, it's a potential risk. It's gonna cost you a lot and you shouldn't have it done. But then the inevitable question is, okay, what's, what's your alternative? And sometimes they've tried, you know, they've tried exercise medications and other things. There's probably always something else you can try some other kind of program.
Ian Harris:
But often it's explaining to people what, or understanding what their expectations are. Because for some people there's this expectation that all pain is a simply a body's response to a single thing in their back. And once that single thing in their back is somehow corrected or removed, then all their pain will go away. And it's, it's a, it's a hundred percent simple mechanistic understanding of pain and they don't understand why we don't just remove it or use it or do whatever it is that will just remove the pain completely and they'll wake up pain free. And you have to explain it doesn't work like that. And, and they need to understand that everybody gets back pain, back pain's very common. And I tell them, I wake up every morning, I can hardly get out of bed with with back pain. It's, this is something that, that people have.
Ian Harris:
And then you have to go into the explanation of pain versus, you know, distress from the pain. Because a lot of people feel pain and just get on with things and it doesn't worry them. But for some people they get very anxious and distressed because they have, and you know, I'm getting myself tied in knots just trying to explain it because it isn't simple to explain. And I often end up sending to colleagues who people with chronic pain and get them to not, not just sort of put up with it, because that's often what the patients say, oh, you expect me to put up with it. And I kind of said, well, in a way, yes, , you know, because a lot of people do you know, it's, it's, it's probably unreasonable to expect, you know, with your knee or your shoulder or your back or whatever, for you to actually live the rest of your life without any pain, that that's not, that's not a reasonable thing to expect.
Jared Powell:
Yeah. And Ian Rachelle, I'm gonna get to you in a minute with your role as a rheumatologist, but Ian, your role as an orthopedic surgeon is very much entrenched in this body as machine paradigm, right? Where you have degeneration in your knee, you have a meniscal tear, you have a disc bulge in your back, you've got arthritis in your back or spondylosis in your back. We, we can change that with a surgical procedure. We can fixate it, we can nip in a tuck, we can wash out, we can repair whatever you want to do. My perception is, 'cause it's hard enough as a physio, right, where we get a lot of those questions, I reckon it will be so hard as an orthopedic surgeon to embrace the bio-psychosocial model and explain the complexity of pain. How do, how do you go about it? You, I mean, you did mention what you do, but it must be challenging on a day-to-day basis.
Ian Harris:
Yeah. It, it is hard. It, well, it's not hard, it's just that we don't do it. And I think we get trained to think the way you say it. And, and I see terrible patients who have had because the surgeon truly believes that there's something there that they can just fix. And I've, I'm just doing a report on someone at the moment who had hip pain and normal x-ray, normal MRI and then they got a repeat MRI and it showed, oh, possibly there's some vague thing there with the labrum of the hip or something. So they have a hip and they do something vague to the labrum. They don't even repair it because it's not even torn, it's just debrided lightly or something like that. But then the pain continues and then they do another MRI, and then all of a sudden the patient's got the latest fashion of condition is you know, a cam lesion you know, some, some pH acetabular impingement.
Ian Harris:
And so back under the scope again. And they addressed that. But the pain's continuing because clearly when you look at the circumstances of it, this patient was under conditions where it was a, you know, work related incident. There's obviously lots of complex things going on, and they had widespread pain. It wasn't, you know, it wasn't something that was really mechanical in nature. And then that didn't help the pain. And then CT scans and MRIs are repeated six months later and they're all reported as completely normal. But the surgeon says there, I think that there's still must be a little bit of a, a bump there that we still haven't fixed. So I'll do a third operation on you and they'll, they'll clean that out again and do something else. And of course it makes no difference to the pain because nothing ever, nothing mechanical would've ever helped this patient who clearly has issues at work complex chronic pain syndrome with pain at rest that's widespread and not localized to a, a specific mechanical movement of the hip.
Ian Harris:
Which is something that make, would make me think that yes, okay, there is something mechanical or catching in that hip that's causing the problem. But it's just the way we think and we just keep going. And I've seen patients who have had that done and then they target the SI joint. That's the latest fashionable thing. And then the SI joint, I've seen a patient with a left SI joint fused. Yeah. Then they got right hip pain, their right side joint got fused, then they got left hip pain again, they got their left hip replaced. And then they came to see me for an opinion because they now want to get their right hip replaced. Even though the x-rays are normal, the surgeons will just keep doing
Jared Powell:
This. It's not good enough .
Ian Harris:
It's to address the purported mechanical problem that's causing 100% of the pain. And it's rarely the case.
Jared Powell:
Yeah, it's distressing to hear about in, in much less, you know, for the patients going through it. R Rachelle, your role as a rheumatologist? My gut feeling like rheumatology is more, is perceived to be more complex than bones and joints. It's, it, you can tell me if I'm wrong, but like if someone has ankylosing spondylitis, you know, yes, you can look for some sort of serum factor HLAB 27 or whatever that might be associated with that condition. Rheumatoid arthritis, there might be rheumatoid factors, some sort of blood test. You can, you can take. Is rheumatology more sort of empirically based where you might look for some sort of diagnostic, some sort of something that raises your suspicion of someone having a diagnosis. But then in treatment, is it far more complex? Like how do you manage someone with ankylosing spondylitis and, and rheumatoid arthritis? It's not just a drug that fixes them. Right.
Rachelle Buchbinder:
Well, it, it all, over the course of my career, we've actually had rev like game changing treatments for inflammatory arthritis. So when I first started as a rheumatologist, we had gold injections and we had penicillin mean, and we had Plaquenil. But when I was a registrar, we got methotrexate, which was a big breakthrough at the time. But about 20 years ago we started having biologic drugs. So the first thing, I mean, rheumatology isn't all that complicated, but there's inflammatory arthritis, which for which we do have good drugs these days and we can suppress the disease so that the patient is in remission and we can prevent joint damage. And the first thing I should say though is that all of these dis diseases, it's a clinical diagnosis so that the tests can help you. But, but it's really, I mean, rheumatoid especially is a clinical diagnosis and, you know, HLAB 27, you can have it without having the disease and you can have the disease without having the gene.
Rachelle Buchbinder:
So, you know, we never even used to bother doing the test. When we first got the biologics, we had to do the test 'cause you could only get the drugs if you were positive. And then we treat lots of immune diseases like lupus and scleroderma and vasculitis, and they've all got treatments. And again, we test all of those treatments in proper placebo controlled trials. And then we've got the, all the regional pain. So I see a lot of back pain as well. A lot of shoulder pain, heel pain, elbow pain. So that, that, that, and in, in community practice a lot of your, you know, probably 50% of mine would be inflammatory and rare disease and 50% would be back pain, shoulder pain hand away. You know, people come with a bit of pain in their hands due to hand away. So for osteoarthritis, we don't yet have any treatment that can change the disease course that is disease modifying. But for the inflammatory arthritis we do and in general we have good evidence. Yeah, so,
Jared Powell:
Yeah. Yeah. Awesome. And so do you, do you recommend sort of lifestyle interventions in conjunction with medication? Or is it drug-based therapy? Like on the average?
Rachelle Buchbinder:
So we've recently have developed clinical care standards. So what patients with rheumatoid arthritis should expect to receive as treatment. And you know, we, we used to need patients with rheumatoid used to have a terrible outcome. In many cases. They'd need multiple joint replacements, they'd need physio, they'd need ot. And a lot of those things you, they don't need anymore because the drugs are so good, they can completely switch it off. But, you know, we know healthy diet is important in preventing rheumatoid, there's some evidence for vitamin C and rich food being slightly preventive, but in terms of treating the disease there's not much in diet that we know of works. There's starvation, which we know helps inflammation a little bit, but as soon as you stop eating, again, the effects lost. And I think we, everybody, all doctors should, should advocate for healthy lifestyle normal weight exercise physical activity as a, as a matter of course, which I mean, they help everybody.
Jared Powell:
Yeah, absolutely. I'm conscious of time being we're onto the first question, . So I'm gonna ask one more question, guys, and I'm gonna, I'm gonna let you off because as was predicted, we've gone down some really great rabbit holes. So I wanted, I'm gonna skip over treatment because it's, it's a huge question and we'll talk for another hour about it. I want to talk about, I know not chapter, which is chapter five. And again, it's one of my favorite chapters. And Ian, you alluded to it a moment ago when we said, you know, you don't have to intervene when, when people come to see you with common musculoskeletal, non-traumatic musculoskeletal complaints. Why are doctors, and I'll extend this to physiotherapists as well, why are we so reluctant to say, I know not, or I don't know, I know, I know not. Is bode from the Hippocratic oath when diagnosing and, and treating patients, is it just how we're trained? Do we have a proclivity to act? Do we wanna help? Is it just because we're good people? What
Ian Harris:
Do you think? All all of those things. Yeah. all of those things. I mean, we, we, we wanna help. We wanna provide them with a diagnosis, which is why we make up the nearest diagnosis. We can get, you know, so when, when people come to us with non-specific symptoms, if you see a gastroenterologist, it'll be ibs. If you see a neurosurgeon, it'll be migraine. If you see a rheumatologist, it'll be fibromyalgia. If you see a chiropractor, it'll be sublux vertebrae, sublux vertebrae. If you see a physio, it's a muscle problem. And if you see an orthopedic surgeon, it'll be, you know, whatever we find on your, on your MRI. So yeah, there, there's just a tendency. 'cause We, we wanna help it, it doesn't help anyone. It certainly doesn't help our reputation, it doesn't help the patients just when we say, I haven't done know what's going on.
Ian Harris:
But quite often it's the truth. And particularly for back pain, when people don't have a clear cause of back pain, they've just got non-specific back pain. It's the truth just to say we dunno what it's, and, and the patient response is, well, you just gotta keep doing tests until you find it. And that's when we get too over treatment treatment. And you have to explain to them, that's not necessarily good for them. And some, and it's enough just to exclude various pathology. You don't have any of that. You don't have anything that requires surgery because you have chronic pain. You're not gonna benefit from opioids and narcotic drugs. And so, you know, you're best treated with, you know, we can try weight loss, step up your exercise a little bit. Simple analgesics or anti-inflammatory medication may be helpful for you. And other, you know, perhaps psychological measures if there's concerns in that regard as well. And so sometimes we just have to say, look, we, we dunno what it's, but we know that it's not harmful and we know that there are things that can improve your pain even though we don't have a name for it. But unfortunately we don't do that. It's just, it's seen as failure to care. It's seen as just disappointing for everyone. And so we have these, you know, catchall diagnoses that, that happen to be specialty sensitive. It depends on who you see as profession specific. Yeah,
Jared Powell:
Exactly. Rachelle, some
Rachelle Buchbinder:
People, some people practice like that. I'll tell people I don't know. And, and often it's well received. They're like relieved that they can get off the band that the what is the, the wheel of having
Ian Harris:
The treadmill. Yeah.
Jared Powell:
Ael
Rachelle Buchbinder:
And, and so, so many cases, it's actually really helpful. They sort of sigh relief that, okay, so I'll just keep doing what I'm doing. I don't, and you try and just, they, they're just so anxious and so caught up in it. And so internally fixated on it, you just try and get rid of all that. If, if they've got insight, they often do really well. You know, I get about one in a hundred patients that are really angry with me because they, they don't like being told that I don't know what's going on and there's nothing. And I often say that it's been going on for so long now and we haven't found anything serious. It's really unlikely it's gonna be anything serious. And they don't like hearing that. So I have to be careful how I phrase things. But I think there are many people who, who were, who actually want to hear that.
Rachelle Buchbinder:
And they've been, often, I see people they've been to, to author pods and they've been to a neurosurgeon and they've been to three physios and two chiropractors and an osteopath. And they've had, everyone's told them all those different things and they've had all these tests and, and I don't even wanna look at the tests. You know? So I think there's gotta, and I think rheumatologists can do that, but, and, and I think lots of us do do that wrong. But often people then go to pain clinics and, and they get on the cannabis wagon. Don't get me started on cannabis, which we know doesn't work for chronic pain. Yeah,
Ian Harris:
Targeted injections. There's always something else you can inject
Rachelle Buchbinder:
Because I think there must cure that, you know, that there must be a cause and therefore there's a cure and they look into the miracle.
Ian Harris:
Yeah. Simplistic approach.
Jared Powell:
People want an explanation for their pain. I don't think, you know, we're not patronizing patients for, for wanting that at all. That is a, a basic human condition, I imagine. But it's up to that doesn't mean that medical professionals can capitalize and, you know, take advantage of that and just offer all these unproven techniques, you know, and that's where you guys come in with your work and some of the research that I'm trying to do as well that's really trying to change that practice. And I'm gonna begin to, to wind up now, and I just wanna conclude by again, thanking you for all your work and all the personal insults that you've endured over the last 20 years or so since you've been doing all this research. We, we, and I'm gonna speak for the medical community community, really appreciate it. So thank you.
Rachelle Buchbinder:
Pleasure. Thank you.
Jared Powell:
Ian, you mentioned you're working on this, this ARC trial, which you're a third of the way through with, with Rachelle. Is there anything else that's on the horizon that we should look out for that we should just sort of warn our biases that things don't work, that we thought they work?
Ian Harris:
We're also doing a study on spine fusion surgery compared to best operative care. Yeah. But that's, that hasn't started recruiting yet, so that's a few years down the track. But that'll be another good one. Hopefully
Jared Powell:
Rachelle
Rachelle Buchbinder:
Mine work's mainly now trying to implement the evidence into practice because it takes such a long time. So we've been working with the government to we did a trial that was published two years ago looking at low value imaging, musculoskeletal imaging, and we reduced it by 11%. So these are people targeting nationally gps who do a lot of tests compared to their peers. And we are doing, we've just finished another one looking at pathology tests and then we've got some ideas for working with the government for some other ones. And we're hoping we we're also doing quality use of medicine. So these are the taking over from what the NPS used to do. So trying to improve care by educating health professionals and consumers and really just, you know, we know a lot of things, the evidence, we know a lot of the evidence gaps are closed, but there's such a big evidence practice gap that my work's trying to make sure that we implement what we know.
Rachelle Buchbinder:
And we're also doing living guidelines. So guide getting guidelines to the point of care that are up to date based on, you know, incorporating any evidence that's published over time. So not doing it every five years, but doing it in real time for research questions that where there's a lot of research activity and where the, the quest, the answer might actually change over time. So we are working on that as, as a, a big part of it. And we're also trying to reduce opioid use both pre, pre and post joint replacement but prescribing it in primary care and prescribing it in hospitals.
Jared Powell:
So you're busy. Well, , I don't know how you get time for your hikes in your, in your, in your swimming and your cycling. Rachelle. Good. Ian, any last words mate?
Ian Harris:
No, no.
Jared Powell:
All good. Where can people find you guys? So I, are you on socials? Are you just on your official academic platforms? Where can people read your work?
Rachelle Buchbinder:
. Yeah, I
Jared Powell:
Just Googling your name. Yeah, Google.
Ian Harris:
Yeah, just Google on Twitter. But yeah, you can, I think you can find this pretty easily.
Rachelle Buchbinder:
Linkedin. Linkedin. I'm relle bind, really novel .
Jared Powell:
And I'm just gonna give a, a shout out to your book. So I'm gonna show it here even though it's meaningless because this is a podcast that people can't see it. But I'm holding up one of the best books I've ever read in terms of like a, an industry specific book. It's called Hypocrisy. Doctors are betraying their oath, and I'll put a link to it in the show notes. So highly encourage everybody to go out and buy it. It's cheap. 20, 30 bucks. You can get it on Amazon and it'll be you the next day. And it's it's a really good book. So thank you both again.
Ian Harris:
Thanks.
Rachelle Buchbinder:
Pleasure. Thanks Jared.
Jared Powell:
Cheers guys. Have a good one. Bye-Bye
Ian Harris:
Bye.
Jared Powell:
Thank you for listening to this episode of The Shoulder Physio podcast with Rachelle Buchbinder, Ian Harris. If you want more information about today's episode, check out our show [email protected]. If you like what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon.
