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Hippocrasy: How doctors are betraying their oath
Two world-leading doctors reveal the true state of modern medicine and how doctors are letting their patients down. In Hippocrasy, rheumatologist and epidemiologist Rachelle Buchbinder and orthopaedic surgeon Ian Harris argue that the benefits of medical treatments are often wildly overstated and the harms understated. That overtreatment and overdiagnosis are rife. And the medical system is not fit for purpose: designed to deliver health care not health. This powerful exposé reveals the tests, drugs, and treatments that provide little or no benefit for patients and the inherent problem of a medical system based on treating rather than preventing illness. The book also provides tips to empower patients—do I really need this treatment? What are the risks? Are there simpler, safer options? What happens if I do nothing? Plus solutions to help restructure how medicine is delivered to help doctors live up to their Hippocratic Oath.
- GenresNonfictionMedicineHealth
304 pages, Paperback
Published October 1, 2021
35 people are currently reading
227 people want to read
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Displaying 1 - 11 of 11 reviews
February 8, 2022
This easy to read book amongst other things, delves into the medicalisation of the ‘normal’ process of ageing, the over diagnosis, testing and treatment of ailments such as lower back pain, depression, ADHD, high blood pressure and obesity most often with no more benefit to the patient than a placebo or doing nothing.
It emphasises the business models that drive profit in the health care industry that prescribe drugs, treatments and testing that have no good scientific evidence to support them and the reluctance of doctors and hospitals to let go of their own beliefs and practices that may have no scientific backing. It points to helpful resources such as Choosing Wisely Australia and www.decisionaid.ohri.ca that help patients make informed decisions about their own health care. A must read for everyone.
It emphasises the business models that drive profit in the health care industry that prescribe drugs, treatments and testing that have no good scientific evidence to support them and the reluctance of doctors and hospitals to let go of their own beliefs and practices that may have no scientific backing. It points to helpful resources such as Choosing Wisely Australia and www.decisionaid.ohri.ca that help patients make informed decisions about their own health care. A must read for everyone.
September 20, 2024
“Medical care has not universally or consistently improved health or quality of life.”
This is a sobering look at modern health care – which the authors are repeatedly reminding us is not synonymous with health.
Buchbinder is a rheumatologist, and Harris an orthopaedic surgeon and author of another affecting book, Surgery, The Ultimate Placebo: A Surgeon Cuts through the Evidence, which I recently read.
Herein, the critique is broader than just surgery, but it is a firm indictment of modern medicine. At its heart, well-meaning doctors are not scientific enough in their thinking or communication, for a variety of reasons, and this can result in ineffective treatments and waste. Some estimates are 10-40% of all medical treatments are either harmful or simply wasteful.
“A core problem, and the reason behind much of the excess in health care, lies in the mismatch between perceptions of the benefits and harms of medical care and their true effects. There’s considerable evidence that doctors’ estimates of the benefits of what they do aren’t accurate, they’re overestimated; while at the same time their estimates of the harms coming from what they do are also wrong–they’re underestimated.”
Patients are also asking the physician for help, and there is a tremendous deference to the healer, and particularly surgeon. This leads to a bias toward “doing something.”
‘What [people] want is not knowledge but certainty’ (Bertrand Russell)
The modern illness-disease paradigm can also have unintended consequences. The medical establishment bears much of this blame, as do human nature and corporate influence in western (and particularly American) medicine – all conspire to create an increasingly expansive set of diagnostic definitions for any deviation from typical experience. The authors caution us against medicalizing everyday life:
“Medicalisation is the process by which ‘normal’ human conditions, such as sadness and grief, slightly elevated blood pressure, shyness, menopause and ageing, come to be defined (and treated) as medical conditions.”
And in considering the role of a healer in society, even a label can have unintended consequences, so the meting out of diagnoses should be performed with exactitude:
“There are also significant harms in labelling people with a diagnosis–converting them from a healthy person or otherwise healthy person with some complaints, to a person with a disease or disability–even if no treatment is given.”
This book is not really for medical personnel or scientists, but rather any lay person with any stake in medical care. That is to say: everyone. And for those who are more sophisticated, there are brief treatments of scientific principles (regression to the mean, lead time bias in outcomes reporting, subgroup fallacies, the problems with surrogate outcomes, and a number of other statistical topics that have real poignancy because they are easy to understand as explained, and reveal much that goes misunderstood in medical literature).
If there is one overarching theme for us as we seek medical care: be skeptical. Don’t medicalize everyday life. Be wary of overdiagnosis and overtreatment. This can mean getting second opinions. Really probe a doctor’s understanding of their treatment recommendations, especially if invasive. Try to understand the uncertainty in the outcome of a treatment you are considering, and how necessary the treatment really is.
“Studies have found that the public are largely unaware of the concepts of overtesting and overdiagnosis or understand them poorly.”
“The bottom line? If you have low back pain, avoid seeing doctors who declare a special interest in it. This is likely to apply to other healthcare professionals as well.”
And for providers of medical care, like me: embrace the idea that you may not know the answer. You don’t have to slip into “therapeutic nihilism,” and conclude that nothing matters or nothing works. Be open to the possibility that everything you think you know is wrong. Study and think hard, know the literature, and remember "you must not fool yourself, and you are the easiest person to fool” (Feynman). High quality research overrules our own memory of what we think works, based on our fallible, first-person experiences.
“Reliance upon clinical experience has often led us astray and harmed people.”
This is a sobering look at modern health care – which the authors are repeatedly reminding us is not synonymous with health.
Buchbinder is a rheumatologist, and Harris an orthopaedic surgeon and author of another affecting book, Surgery, The Ultimate Placebo: A Surgeon Cuts through the Evidence, which I recently read.
Herein, the critique is broader than just surgery, but it is a firm indictment of modern medicine. At its heart, well-meaning doctors are not scientific enough in their thinking or communication, for a variety of reasons, and this can result in ineffective treatments and waste. Some estimates are 10-40% of all medical treatments are either harmful or simply wasteful.
“A core problem, and the reason behind much of the excess in health care, lies in the mismatch between perceptions of the benefits and harms of medical care and their true effects. There’s considerable evidence that doctors’ estimates of the benefits of what they do aren’t accurate, they’re overestimated; while at the same time their estimates of the harms coming from what they do are also wrong–they’re underestimated.”
Patients are also asking the physician for help, and there is a tremendous deference to the healer, and particularly surgeon. This leads to a bias toward “doing something.”
‘What [people] want is not knowledge but certainty’ (Bertrand Russell)
The modern illness-disease paradigm can also have unintended consequences. The medical establishment bears much of this blame, as do human nature and corporate influence in western (and particularly American) medicine – all conspire to create an increasingly expansive set of diagnostic definitions for any deviation from typical experience. The authors caution us against medicalizing everyday life:
“Medicalisation is the process by which ‘normal’ human conditions, such as sadness and grief, slightly elevated blood pressure, shyness, menopause and ageing, come to be defined (and treated) as medical conditions.”
And in considering the role of a healer in society, even a label can have unintended consequences, so the meting out of diagnoses should be performed with exactitude:
“There are also significant harms in labelling people with a diagnosis–converting them from a healthy person or otherwise healthy person with some complaints, to a person with a disease or disability–even if no treatment is given.”
This book is not really for medical personnel or scientists, but rather any lay person with any stake in medical care. That is to say: everyone. And for those who are more sophisticated, there are brief treatments of scientific principles (regression to the mean, lead time bias in outcomes reporting, subgroup fallacies, the problems with surrogate outcomes, and a number of other statistical topics that have real poignancy because they are easy to understand as explained, and reveal much that goes misunderstood in medical literature).
If there is one overarching theme for us as we seek medical care: be skeptical. Don’t medicalize everyday life. Be wary of overdiagnosis and overtreatment. This can mean getting second opinions. Really probe a doctor’s understanding of their treatment recommendations, especially if invasive. Try to understand the uncertainty in the outcome of a treatment you are considering, and how necessary the treatment really is.
“Studies have found that the public are largely unaware of the concepts of overtesting and overdiagnosis or understand them poorly.”
“The bottom line? If you have low back pain, avoid seeing doctors who declare a special interest in it. This is likely to apply to other healthcare professionals as well.”
And for providers of medical care, like me: embrace the idea that you may not know the answer. You don’t have to slip into “therapeutic nihilism,” and conclude that nothing matters or nothing works. Be open to the possibility that everything you think you know is wrong. Study and think hard, know the literature, and remember "you must not fool yourself, and you are the easiest person to fool” (Feynman). High quality research overrules our own memory of what we think works, based on our fallible, first-person experiences.
“Reliance upon clinical experience has often led us astray and harmed people.”
October 31, 2021
A very readable and fascinating account of ways in which doctors persist with treatments even after good scientific evidence that they don’t work (or don’t work better than placebos). The book discusses the evidence about how and why doctors resist change when new evidence is available, how specialists in some fields are especially susceptible to over treatment, and the more general impact of overdiagnosis and misdiagnosis in terms of the costs to the health system, and unnecessary pain for individual patients. The book includes a range of some of the most common areas of diagnostic work and surgery – knee surgery, breast cancer etc. The writers are both experienced doctors (in different fields – rheumatologist and orthopaedic surgeon) and well-published researchers. It also discusses why patients are often not well-placed to challenge suggested over-treatment, and offers suggestions for questions they could ask. The book is very much written for the general reader: it contains reference lists for each chapter but not footnoting for individual points. I found it better to read in individual chapters rather than as a whole, when it becomes a bit repetitive. Overall (as a researcher myself, but not one who works in these fields) I think this is a much-needed and valuable book.
August 17, 2022
Written by two doctors who have written extensively on the importance of evidence-based medicine, Hippocrasy is a well-informed plea for the reduction of overdiagnosis and misdiagnosis and treatments that lack solid research. Doctors are increasingly under time and financial constraints. Standard treatments, including many surgeries, and prescriptions can be a shortcut when what the patient really needs is empathy and care. They can also be very lucrative for everyone but the patients. In too many cases, they do more harm than good and don't address the important choices concerning quality of life and long-term outcomes.
The book is also a very readable nudge for all of us - medical practitioners, bureaucracies, government, pharmaceutical companies, and the general public - to improve our science literacy. The authors include an extensive reading list, as well as links to important sources of information. The Cochrane Library, for example, publishes extensive reviews of health research and invite ordinary laypeople to join the Cochrane Crowd and become part of the review process. Another example is Australia's Choosing Wisely, whose website identifies it as "an initiative of the ABIM Foundation that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures".
With health care consuming ever greater percentages of national budgets and a looming shortage of doctors, we would all do well to read this book and then do our own part in improving the situation.
The book is also a very readable nudge for all of us - medical practitioners, bureaucracies, government, pharmaceutical companies, and the general public - to improve our science literacy. The authors include an extensive reading list, as well as links to important sources of information. The Cochrane Library, for example, publishes extensive reviews of health research and invite ordinary laypeople to join the Cochrane Crowd and become part of the review process. Another example is Australia's Choosing Wisely, whose website identifies it as "an initiative of the ABIM Foundation that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures".
With health care consuming ever greater percentages of national budgets and a looming shortage of doctors, we would all do well to read this book and then do our own part in improving the situation.
January 11, 2025
Wow. My eyes have been opened. Large takeaway...check Cochrane.org before agreeing to treatment. From their website:
"Cochrane is an international network with headquarters in the UK, a registered not-for-profit organization, and a member of the UK National Council for Voluntary Organizations. Cochrane produces systematic reviews, published in the Cochrane Library, to help people make informed health decisions.
Cochrane is for anyone interested in using high-quality information to make health decisions. Whether you are a clinician, patient or carer, researcher, or policy-maker, Cochrane evidence provides a powerful tool to enhance your healthcare knowledge and decision-making.
Cochrane's members and supporters come from more than 190 countries, worldwide. We are researchers, health professionals, patients, carers, and people passionate about improving health outcomes for everyone, everywhere. Our global independent network gathers and summarizes the best evidence from research to help you make informed choices about treatment and we have been doing this for 30 years.
We do not accept commercial or conflicted funding. This is vital for us to generate authoritative and reliable information, working freely, unconstrained by commercial and financial interests."
"Cochrane is an international network with headquarters in the UK, a registered not-for-profit organization, and a member of the UK National Council for Voluntary Organizations. Cochrane produces systematic reviews, published in the Cochrane Library, to help people make informed health decisions.
Cochrane is for anyone interested in using high-quality information to make health decisions. Whether you are a clinician, patient or carer, researcher, or policy-maker, Cochrane evidence provides a powerful tool to enhance your healthcare knowledge and decision-making.
Cochrane's members and supporters come from more than 190 countries, worldwide. We are researchers, health professionals, patients, carers, and people passionate about improving health outcomes for everyone, everywhere. Our global independent network gathers and summarizes the best evidence from research to help you make informed choices about treatment and we have been doing this for 30 years.
We do not accept commercial or conflicted funding. This is vital for us to generate authoritative and reliable information, working freely, unconstrained by commercial and financial interests."
January 26, 2022
THis book should be required reading for ALL doctors, hospital and GP.....and patients about to have tests or treatment, whether it is for a "preventative" medication or something more major.
It is NOT anti-medicine, it is about the way doctors are trained and the resistance to evidence that show if a treatment has minimal if any benefits.
These are not things that happened in the past, these are things that happen, still, now.
Patients are some of the problem. Doctors however are the "experts" and most people go along with what is recommended. We shouldn't have to read books like this, but sadly we need to.
It shows how a lot of things once considered normal are now labelled as medical conditions and thus to be treated.
It shows how levels have changed, so that more people end up treated, and sometimes damaged, for conditions they don't have and probably won't suffer from, because, mainly, it sells more medications and treatments.
The adage If all you have is a hammer, you treat everything as if it were a nail holds true for medicine.
It is NOT anti-medicine, it is about the way doctors are trained and the resistance to evidence that show if a treatment has minimal if any benefits.
These are not things that happened in the past, these are things that happen, still, now.
Patients are some of the problem. Doctors however are the "experts" and most people go along with what is recommended. We shouldn't have to read books like this, but sadly we need to.
It shows how a lot of things once considered normal are now labelled as medical conditions and thus to be treated.
It shows how levels have changed, so that more people end up treated, and sometimes damaged, for conditions they don't have and probably won't suffer from, because, mainly, it sells more medications and treatments.
The adage If all you have is a hammer, you treat everything as if it were a nail holds true for medicine.
August 19, 2023
I read this book because I have heard both authors speak at conferences. I have already read Surgery, The Ultimate Placebo: A Surgeon Cuts through the Evidence, and work within the healthcare system, although not in a patient-facing role.
The main thing I learned from this book is to be more confident about questioning medical testing, and the medicalisation of normal conditions. This is really important, and it gave me more confidence to be able to have conversations about this with friends and family when it comes up (as it often does!). Why test when you have no solution? The example of how reporting pain led, at least in part, to the opioid epidemic was eye-opening for me. The examples of medicalisation of many normal conditions are also useful, particularly the medicalisation of death. I do disagree with some examples: osteoporosis for example, is not a normal part of ageing (although reduced bone mass is!), and many people have high fracture risk very early in life, which can be treated successfully. Osteopenia and sarcopenia on the other hand are not very helpful. Although they could help someone to be more active, often these diagnoses are disempowering and frightening for patients.
Medicalisation is a moving space. At one stage an autism diagnosis was seen as an unhelpful and stigmatising label, but now it can provide resources to help with managing life in a neurotypical world. I don't think autism or ADHD are dealt with particularly well in this book, but I also don't think there would be space to give a fully nuanced argument about how diagnosis and treatment can and can't be helpful in these circumstances. I would like to read more about this issue in particular.
The main thing I learned from this book is to be more confident about questioning medical testing, and the medicalisation of normal conditions. This is really important, and it gave me more confidence to be able to have conversations about this with friends and family when it comes up (as it often does!). Why test when you have no solution? The example of how reporting pain led, at least in part, to the opioid epidemic was eye-opening for me. The examples of medicalisation of many normal conditions are also useful, particularly the medicalisation of death. I do disagree with some examples: osteoporosis for example, is not a normal part of ageing (although reduced bone mass is!), and many people have high fracture risk very early in life, which can be treated successfully. Osteopenia and sarcopenia on the other hand are not very helpful. Although they could help someone to be more active, often these diagnoses are disempowering and frightening for patients.
Medicalisation is a moving space. At one stage an autism diagnosis was seen as an unhelpful and stigmatising label, but now it can provide resources to help with managing life in a neurotypical world. I don't think autism or ADHD are dealt with particularly well in this book, but I also don't think there would be space to give a fully nuanced argument about how diagnosis and treatment can and can't be helpful in these circumstances. I would like to read more about this issue in particular.
August 28, 2022
A very important truth-telling book that every Australian should read. Australians put too much trust in businesses that are more concerned with making money than with people actually being healthy. This book provides a practical introduction to the problems of a profit based health system and ideas on how to navigate it.
July 5, 2022
This book is a must read for anyone making a healthcare decision. God, how anyone navigates the healthcare system without training in healthcare, epidemiology and science based medicine is really left to chance. This is a great book and healthcare providers should recommend it to everyone.
August 27, 2023
⭐️⭐️⭐️⭐️⭐️
Eye opening and simply brilliant.
Eye opening and simply brilliant.
November 12, 2024
I enjoyed this work and appreciated that it talks about a way of doing the science of medicine better, not a book critical of scientific medicine itself.
I appreciated the comment that orthopaedic surgeons stand on their own painful knees while operating to replace the knees of others. Having seen a friend go through three replacement of the one knee over a couple of years and nearly losing his life in the process, I vowed never to get a joint replacement unless I was crippled by pain.
This is a good book to have on hand to look up particular surgeries and treatments if those options are presented to us.
I appreciated the comment that orthopaedic surgeons stand on their own painful knees while operating to replace the knees of others. Having seen a friend go through three replacement of the one knee over a couple of years and nearly losing his life in the process, I vowed never to get a joint replacement unless I was crippled by pain.
This is a good book to have on hand to look up particular surgeries and treatments if those options are presented to us.
Displaying 1 - 11 of 11 reviews