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(generated from captions) is the first play you have written and you were nominated for four awards!Yes, yes! Thanks to God! Where to from here?I'm always writing. You never know - it may take another year or two or three years before a director says, "This is another good play, let me put it on". But I've been working on now Prize Fighter the movie and hopefully in a few years it will come out.Monique Schafter reporter. That's the program for tonight. Tomorrow my special guest will be the legendary musician Tim Finn. Hope you can join me then - goodnight. This program is not captioned.

This program is not captioned.

Hello and welcome to this special
summer edition of The Drum. I'm John Barron. We're gonna go through
our back catalogue to bring you some of our best
episodes from the past year when we focused on
a single major issue rather than just the news of the day. I hope you enjoy the discussion.

PRESENTER: The healthcare system
as we know it is changing. But what does that mean for you? Tonight, we speak to the doctors challenging our ideas
of good medicine.

Joining me on our eminent panel, executive director of the Brain and
Mind Centre, Professor Ian Hickie, orthopaedic surgeon and author of a new book Surgery,
The Ultimate Placebo, Dr Ian Harris and in London,
award-winning science writer and author of
New York Times bestseller Cure: A Journey Into
The Science Of Mind Over Body, Dr Jo Marchant. And you can join us on Twitter
using the hashtag #thedrum. From the second we're born we rely on the health-care system
to keep us well. But what if our elaborate network
of doctors and hospitals is creaking and cumbersome and not actually the best way
to keep people healthy after all? One of our panellists says healthcare
systems are the least well-managed of all modern systems. Professor Ian Hickie, would you like
to own up to that and tell us why? Absolutely
I'd like to own up to that. Walking into
an average health-care clinic is like walking into a 1960s bank. You sit there, you wait, the teller eventually comes around and eventually the bank tells you
what you can do and not do and you're meant to be grateful
for the whole experience. If you've got complex financial
problems it doesn't help you, it just tells you
what it's going to do. In the modern age,
in the 21st century, we really need health systems that
work with you as a genuine partner. So just like you take care
of your banking online or I've just travelled
around the world on airlines without any tickets anymore
or any more nonsense, a system that responds to your needs
as an individual that helps you to deal with
your individual problems, that's what we desperately need -
an efficient system. So medicine's filled
with great robots and great machines but behind that, the organisation
of effective care, getting care, managing chronic problems, arranging the system
to be there when you need it, particularly in areas like mental
health, dental health, aged care, those things outside of hospitals,
it's hopeless. Well, Dr Ian Harris, what have you observed
about our health-care system? Does it work? It works
but it's terribly inefficient.

It's not necessarily
focused on value and I agree with everything
that Ian said. I mean, I can quickly do
anything I want on my smart phone through the Commonwealth Bank but I can't even look
at a patient's X-ray because it's somehow too hard. And the focus
is purely on financial control.

The focus isn't on patient first. Well, Jo Marchant,
I want to bring you in here. How do other medical systems
around the world cope with waste and inefficiency?

I'm really here to talk more about
the scientific research regarding the role of the mind
on physical health. I really think that conventional
medical systems have a blind spot
when it comes to that. We base our medicine on the results
from evidence-based trials which has drugs and physical
interventions against placebo to check that they work. And that's
a really wonderful intervention that's led to many advances
in medicine. But it's also caused us to focus very much on physical drugs
and intervention and not on the other elements
of care, the more human elements of care,
if you like, which research is now showing can have very important outcomes
on patients' physical health. Not just sort of how pleasant
they find the experience of care. So, really what I want to talk about is the idea that we need to look at these aspects of a patient's
mental state, their hopes, their expectations,
their individual attitudes, the kind of care that they receive. We need to treat that
in an evidence-based scientific way and try and incorporate
those elements back into conventional medicine. Well, on conventional medicine,
Dr Ian Harris, you've just released your new book
Surgery, The Ultimate Placebo. Let's take a look
at some of your findings. There's little evidence spinal
fusion for back pain is effective. There's an overuse of C-sections
during childbirth.

A common operation,
knee arthroscopy, you found
that for arthritis and tears it's no better than sham surgery. And we'll get you to explain that
in a moment. Also appendicitis doesn't have to
land you on a hospital gurney.

And in your book, Ian Harris, you admit to performing
unnecessary surgery, which is a very brave admission. How did that happen?
And do you think you're the only one? I'm certainly not the only one. And, interestingly,
I just sort of added that confession after I'd written the book because
otherwise it sounded a bit like, "I'm fine, everyone else
is the problem." And so just to put that
in perspective I've fallen for all of these traps. I've thought that the patient
needed the operation so I'm not saying that I'm
deliberately doing it now I'm saying I did operations
that I thought to be effective and found out later
that they were not. But, unfortunately there's a lot of
operations that are being done today which are also
of questionable benefit.

And how have other surgeons
responded to your book detailing unnecessary surgeries and saying
they don't need to take place? To me, the response
has been surprisingly positive from my colleagues. So all of the correspondence
I've had directly to me has been excellent. I think some of the correspondence
that hasn't gone directly to me hasn't been so good. Right. What do you think
is the problem here? Is it that people, surgeons, aren't aware that some
of the procedures are not effective or is it that surgeons
can't handle the uncertainty so much and they feel they need to recommend
something, even if it's invasive. Yeah. Both. So, there's two problems - one is
where we don't have good evidence. Alright? And that's where there's
uncertainty, there's doubt. And there is this strong temptation to just say,
"Well, let's give it a go," or, "I'm not sure
so at least we tried." And that's even supported
by the legal system. If you treat someone non-operatively
it's seen as somehow neglectful. Whereas if you operate on them
and it doesn't go well, the feeling is,
"Well, at least you tried." So when there isn't much evidence
or there is uncertainty we tend to operate. The other problem is
when there is good evidence, a lot of surgeons don't have the
training in the scientific method to properly pick apart
that evidence. And there's so much evidence
it's very difficult to do. Mmm. Mmm. And so they believe
what they were taught and they have confirmation bias. They only sort of
remember the articles that support what they believe. But all our health systems
do what we pay for. I mean, we pay for
a lot of procedural medicine, we set it up
in the belief that it does good. We don't tend to support a whole lot
of systems that do other things, physiotherapy, physical support and I would say, particularly,
monitoring the response of people to a lot of those other treatments. I think what's often called
the placebo is actually a misunderstanding of
all the other components of care, the non-specific elements, particularly if you've got
orthopaedic injuries, musculoskeletal problems,
being active, attending to sleep/wake cycle,
attending to pain management that may make adding on an operation
not necessary or not necessary
at least in the first instance. But our health-care system
is not organised that way. It doesn't pay
for that sort of care. It doesn't really prioritise
that kind of care. And it doesn't really support people
to have those kind of options. I think the evidence
is pretty clear - when you give people options and you actually say, "Look,
we'll do those sort of things," then neither the surgeon
nor the system is as likely
to go straight for the intervention. Well, I want to...
I want to bring Jo in here because, Jo,
you've written quite a lot about the various kinds of
placebo effects. Tell us about the placebo effects
that you've researched and the various conditions
you can apply it to.

Well, I think Ian's right. The placebo effects encompass a whole range of different
mechanisms that are going on including all the other sort of
elements of care that help people to get better
over time. But what neuroscientists
are also finding is that when people
respond to placebo there are specific biological
changes occurring in the brain that affect our symptoms. So when people receive a placebo
painkiller for example, there's the release of endorphins
in the brain, these are natural
pain-relieving chemicals, and in fact opiate drugs
like morphine and heroin work by mimicking endorphins. So when your pain is reduced
by taking a placebo it's working through exactly
the same biochemical mechanism as when you take a drug. And there are other mechanisms
and other conditions. For example when Parkinson's
patients respond to placebo they get a release in the brain
not of endorphins but of dopamine, which is
the neurotransmitter they need that they would normally get
with their drug. Even in altitude sickness people at the top of the mountain
can breathe fake oxygen and scientists are measuring a reduction in the level
of chemicals in the brain called prostaglandins which are responsible for many of
the symptoms of altitude sickness. So I think we need a bit of a shift
in attitude about placebos. That's not a failure if something
is working through a placebo effect. That's a real biological response. And surgery, it's interesting. You might think, "Well, surgery's
a serious intervention, "you wouldn't get placebo responses
with surgery," but actually invasive interventions
like surgery and many alternative treatments
as well can create
particularly large placebo effects. So there's a paradox there,
if you like. Some of these surgical interventions
may be no better than placebo but they can still be having
quite dramatic benefits, actually, for patients. And we need to think about what is the best way
to deal with that. I would argue that the effects
aren't that dramatic. I think they're probably
smaller than you think and they're probably short-lived. Well, I do want to ask you...
I don't that's true actually. Sorry. Jo, after you. In trials
these effects can be very dramatic. They're not the same in everyone. So, some people respond
very dramatically, some people don't. They are sometimes short-lived, other times in other trials,
particularly for Parkinson's, there are effects
reaching over years in trials. And researchers are also finding out that if you can combine
placebo effects with learning, like, with conditioning techniques. If somebody has learned
by taking a real drug several times what the appropriate
physiological response is, then their body
starts to respond automatically and when you do that
then the responses to placebo can be as large
as the effect of the original drug. That's quite a new finding
that's coming out of the research. So, yes, placebo responses
are inconsistent and their different
in different situations but I think we do need more research to understand
exactly what's going on here, when they work, why they work,
who they work for and how we can best harness
those in patients. Well, there's not just
the placebo effect in surgery, there's also placebo surgery. There's fake surgery. Dr Ian Harris, what is fake surgery? It's a sham surgery. It's a procedure
where you will do enough to make it so that the patient,
when they wake up, doesn't know whether
they had the full procedure or not. Do they pay for that?
It sounds extraordinary. If it's done under
experimental research conditions then that research is funded and they don't have to pay for it. But they do have to sign up for it.
It's a scientific experiment. So they have to consent for it. So the patient knows
that they're going to get either a 50-50 chance of having the real operation
or a placebo operation. And it's necessary because we tend to say, "Oh,
this operation works because..." And then we just attribute some biologically plausible
mechanism to it, without ever sort of
really testing it. And so many times
when we've done the placebo surgery and compared it to the real surgery,
it's come up no better. Now you can argue,
and I agree with Jo to some extent, that patients in both groups
get better, but they don't get any better when you do
the actual physical intervention that you thought made the difference
in the first place. Professor Ian Hickie,
you're a mental health expert. Where do you weigh in on this?
What do you think is going on here? Come back to the earlier point, I think, people think of placebos as
tricks. And that's really unhelpful. You know, sugar pills, as if you just lay at home
and took sugar pills that would be the same as being
involved in active treatment trials. When you get involved in trials,
as Ian was just describing, you're involved in a complex thing. You're coming along for assessment,
you're being reviewed regularly. You may even have a procedure
that resembles a particular issue. Definitely, as Jo said,
you can bet along the way there'll be a set
of physiological responses to that. I disagree with Jo about
the conditioning evidence being new. We've known you can condition
the immune response for 30 years. You know, you can actually
take particular agents that will elicit
a particular physical response and if you learn to do it,
like Pavlov's dogs, you ring the bell, the physiology
will actually take place. And that's
a really powerful set of issues. So, the brain
is a very powerful coordinator of all of the body's
homoeostatic systems, all the systems that put you
right again, your immune system, your stress response system, other neurochemical systems, particularly those
that regulate pain and fatigue and other sets of issues
which you're often try to cure, you know, musculoskeletal
or somewhere in the body. So understanding the whole system, the way the whole system works
towards recovery is really important and manipulating that. In other words, working with it
to achieve that result is something that a lot of procedural medicine
doesn't really do. It tries to just fix the problem
at the mechanical bit. You see a bit hanging out of a knee
so you go and take it out or a bit in your back
and you go, "That's the problem," when it's not really
what is driving, what's causing the person
to come along. I don't think we should forget, people come along
with real problems. People are in pain,
people are disabled. They can't move. Whatever. It's the nature of the solutions. We tend to have a very mechanical,
mechanistic kind of view of that. Well, actually... If we see it on X-ray, we can find
it in a film, we cut it out or we inject it
or we do something to that rather than the experience
the person's having. And, Jo, I know you've written
about how in Western medicine we consider the body
to be purely a machine. Is that a very big mistake?

Well, I think so
and I think it's not something that chimes with
lot of patients' experience but it just comes down to the way
that Western medicine is generally based on the evidence
from clinical trials which, as I said, is a good thing but it doesn't leave us
with a good way to measure and value the effects
of these more human aspects of care and the individual differences
in the mental state of the patient. So in trials on placebo research,
for example, researchers are finding that
the attitude of the practitioner, whether the practitioner is warm
and empathic or cold and polite, makes a difference
to physical outcomes For patients. The length of the consultation time makes a difference
to physical outcomes for patients. And that's mainly in terms
of symptoms that people experience. But there are other examples,
for example during keyhole surgery, where researchers at Harvard,
for example, are using psychological techniques
to reduce anxiety in patients so just communicating with them
in a more empathic way, responding to their request swiftly,
trying to make them feel in control, encouraging them to use
visualisation exercises to relax, for example. And this reduces
not just the anxiety of the patients but their pain, the amount of painkillers they
require, the procedures go faster and these patients have
a lower rate of complications. So just attending to the psychological state
of the patient has a real effect
on these hard physical outcomes. And I think that's what
we're really missing at the moment. How is technology changing
the way we diagnose and treat people? One study showed
that four in five Australians Google search for health information while others
are turning to mobile health apps to connect with fellow sufferers
and research alternative therapies. Reporter Jade Macmillan has more. JADE MACMILLAN: In the digital age,
we're sharing more than ever before. From social media to apps putting us in touch
with an endless stream of services. But would you be prepared
to share your medical history online? Every tiny detail. I was diagnosed with psoriasis. I have Parkinson's disease. Relapsing remitting
multiple sclerosis.

PatientsLikeMe is a website
which was established in 2004 after cofounder James Heywood's
brother Stephen was diagnosed with a rare
motor neuron disease known as ALS. You think about disease,
it takes so much from you. It's so isolating. PatientsLikeMe
is a little bit like Facebook except that rather than
trying to connect to friends the goal is to connect to people
with the same condition or the same state
or the same symptoms. Petra Walsh is one of the website's
400,000 users. She lives with multiple sclerosis and uploads detailed information
about her condition, tracking the severity of her symptoms and measuring
the effectiveness of her treatments. WOMAN: We lived in Papua New Guinea
for four years and had no access
to medical personnel so I needed to know
more about my condition. There are a lot of drugs out for MS and I want to be up-to-date, um, stem cell research,
myelin repair research. It's an absolute minefield. PatientsLikeMe
then analyses the data and sells it to companies
producing drugs, insurance and medical services, a condition of use which is clearly
spelt out on its website. The website argues
the information helps companies to improve their products
for their patients. But it does raise questions
about privacy. And has also prompted concerns that such a large online forum could
push people away from their doctors and towards alternative,
potentially unsafe, therapies. We've done research
with The Institute of Medicine, we've done research on our own
that have shown the exact opposite. In fact, we had a publication where people were using a chemical
to treat their disease. They thought
they were getting better And because we collect
such rigorous outcomes we knew they were getting worse. We published that and hundreds of people stopped doing
something that was making them sick. PatientsLikeMe is just
one of the number of online tools helping people to take their
healthcare into their own hands. So, what role
should doctors be playing, and does traditional medicine
need to change as technology does?

Well, Professor Ian Hickie, you've just returned
from a trip to California where you met with the heads
of Google Life Sciences. Is this the future?
Absolutely. Just think of the way our lives
have changed in the last decade with the arrival of smartphones,
social media, things we wouldn't have imagined
just a decade ago. Healthcare is going the same way. The doctors
will end up being the dinosaurs in this particular kind of scenario because, really,
people will have in their hands not just access to information but actually putting
their own information back through
so-called wearable devices, all sorts of monitoring devices, putting those back into
smart healthcare systems. So you can see
what's actually happening to you. Jo was talking about
clinical trials. We talk about clinical trials versus
placebo. They're group averages. What happens to 100 people with that
condition versus 100 other people? Frankly, you don't really care.
You care what happens to me. So you start to put in
my information into that and get the range of options, including
the traditional medical ones but also share with people
who've got the same condition or people who tried other options. And you then have the option
in your own 'n=1' trial of trying to find out
what actually happens. As people say in the future, you'll then give the doctor some
time to consult with you rather than you having to
line up with them as to whether they might like to get
involved in your care or not. In the developing world, for stacks of people who've never
had access to really expert care they won't just be stuck at the end
of some primary care system that doesn't really know about
their really specific disease or their condition. They'll put in sophisticated
information into Smart systems and whether you like it or not, the future healthcare companies
are Google and Facebook and Amazon and there are people lining up to put Smart systems
back into healthcare rather than you lining up
at the old bank teller agency and be told
what you can do with your money. Well, Jo, what is driving people away
from conventional care? Is it this kind of
one-size-fits-all approach?

I think that is part of it. This idea that people
are just physical machines and whatever average result came out
of the clinical trial, as Ian said, is gonna be right for you. I think people are realising that particularly
for chronic health conditions, so chronic pain, fatigue,
depression, those kind of conditions that aren't well treated
by conventional medicine at the moment, they're realising that that
personalised care you can get with alternative
therapists can be very helpful and I wouldn't necessarily advocate all going out
to use alternative medicine. I think, really,
we need to be understanding why those kinds of therapies
are helping people and incorporate those elements back into
evidence-based conventional care. But I do think
we are going to see a shift towards much more individualised,
personalised care towards patients taking more
responsibly for their health, being more engaged
with their treatment and another perspective
I would add to that is that for conditions
like depression and chronic pain, neuroscientists are finding that when patients are engaged
with their treatment, taking a positive, active role and feeling optimistic
about their treatment, they do tend to respond much better. Whether that's alternative medicine
or conventional. So I think
it's a very important shift that patients start to take
this more active role. Well, Dr Ian Harris,
what do you think of this? Is there such a thing
as googling too much? Are doctors getting exasperated by being second-guessed
by Doctor Google? Yeah, you can. Because even some of the examples that were just used
in that breakout, for multiple sclerosis there are
so many treatments out there which have been shown not to work and yet if you Google it, you'll find an example
of somebody it worked for. That doesn't necessarily mean
it's gonna work for you. And you really need to understand
the science behind it to do it. But those systems are actually
more attractive than that. That's a bit unfair, I think. The big patient systems, in fact, I think it was emphasised
in the take-out there, is rather than saying
one person responded, it's actually collecting data
from large groups of people. So I actually think
it's quite protective against the quackery element.
No, I agree. And that was the other point
I wanted to make. These systems, because we're involved
in a similar kind of project, they're not only good for the
patient, they're also good for.... For us.
For the research, yeah. They're good for us. And you can generate enormous
amounts of data and answer questions that you wouldn't otherwise
be able to answer. What about the ethics around collating such large amounts of data,
though, on people's private health? I mean,
this is the kind of information that could tell you
when someone's actually gonna die. Is there... Are there concerns about that being owned by Google
for example? You bet. Who owns your data?
Currently in healthcare. Because it mainly still it's owned
by the healthcare provider. The big transformation that is gonna
happen in all these systems is your own control over that data
in a particular area. So you decide who to share it with,
where it goes. Now, in deidentified systems it may enter into
bigger data analysis so you can see
how health systems function. But currently if you think
you're in control of your data now, you're not. There's all sorts of systems
that identify you that are sitting
with the healthcare provider that other people can see. And privacy is breached quite often
in our common systems. In fact, you think about the banks. The banks, in fact,
when you move your data around, have much greater privacy protection than your average hospital
or health system and certainly
your average doctor's surgery. Well, so, what is the health system
going to look like in 20 or even 50 years' time? Here's one possible scenario.

What about this?

But, seriously,
the Grattan Institute has found the ineffective management
of chronic diseases like asthma, diabetes and heart disease costs us $320 million a year in avoidable hospital admissions. As our population ages, how do we
address this? Dr Ian Harris. Well, one point I wanted to make was
that not everyone needs treatment. We're saying,
"Well, should we point them here? "Or should they go there
and what are their options?" One of the most effective treatments
that I administer is reassurance. And, so, patients who come in who have, perhaps,
some arthritis in their knee but are coping very well with...
They're walking the dog, they're able to go to work,
they're able to play golf. They might have to use a cart. And I reassure them. I say, "You don't need surgery
at the moment. "You're actually coping very well. "Your disease
will probably progress very slowly "and hopefully you won't
need to see me for many years." And many patients
are very happy with that. And they're happy to go off
and cope on their own. Just knowing, you know, having a little bit more information
about their condition. And the reassurance
gives them the strength to be able to cope on their own. Jo, is that what you found when you
spoke to people for your book? That reassurance was key?

Um, yes. It's very... Like, reassurance, conveying some positive expectations
of the patients, just being there to listen
sometimes, being supported. Sometimes
in stress-related conditions people can just need to feel
as though they've been heard. In the future I do think,
well, I hope anyway, that we will see a bigger emphasis
on preventative medicine, on reducing the risk of disease because that's a lot of research
that's starting to... Well, not starting to,
but increasingly teasing out the links between stress
and the risks of chronic disease, for example and looking at the effects
of treatment such as mindfulness meditation,
for example. There are now hundreds of studies
showing that mindfulness can be effective
at reducing chronic pain, anxiety and fatigue, for example. And we're just starting to see
studies to see whether that feeds through into changes in the immune system,
for example. I think that's gonna be quite
interesting over the next few years. So I hope that we'll see
more of an emphasis on lifestyle and prevention and then also
once we get to treatment it doesn't necessarily have to be
drugs or surgery, there could be
lots of other approaches that help to change patients'
attitude to their disease. I mean, obviously, we still need
chemotherapy for cancer and surgery
for some heart conditions but when it comes to chronic pain,
anxiety, fatigue, these conditions and symptoms that really destroy
a lot of people's lives we're gonna have a bigger range
of approaches that we can rely on. Professor Ian Hickie,
in an ideal world, in 20 years
what would you like to see? A really different health system. It's not just the reassurance
and not just the prevention. Lots of people
live with chronic illnesses and they need much more information
on a daily basis how to manage that illness. That's how you reduce
a lot of the hospital admissions that are unnecessary. By earlier, more strategic and much
more personalised approaches to the risk factors and actually the illnesses
that people are living with. Picking up Ian's point, it's the functionality that arises
that's really critical. If people can stay functional, they tend to stay out of hospital
and that's the system. So much more personal. Where
the person is really what matters. And they get to manage their care alongside all of the other
health professionals and assistance that we can provide. So a bank centred around a person
rather than around the bank. Absolutely. Your money is your
money. You're health is your health. And I said, you don't need a health
system to manage your health. You need to be able
to manage your health with those you live with
in an effective way. That's a huge shift in power,
in attitude. Just think how banks, airlines,
every other industry except health has made
that critical transformation. Instead of telling you what to do
and when to do it, you can be in control. That's what technology
now offers us. We have a long way to go to learn
how to use that very effectively to end up with not just more
efficient health systems but ones that actually assist people
to live with better health because we all want to live
more functional lives. And do that,
particularly as you age.

Well, that's all
for this special edition of The Drum. Thanks to the panel -
Professor Ian Hickie. Dr Ian Harris and in London, Jo Marchant. I'll see you again soon. Captions by Ericsson Access Services Copyright
Australian Broadcasting Corporation

This program is not captioned.

This program is live captioned by Ericsson Access Services. Indonesia suspends military ties with Australia leaving the future of the bilateral operation unclear.

Turkish authorities identify the chief suspect in the deadly New Year's Eve attack in Istanbul. The dangerous online trend that's claimed the life of a Brisbane boy. A century from Peter Handscomb helps Australia strengthen its grip on the third test against Pakistan.

Welcome to ABC News. I'm Natasha Exelby. Those stories in a moment. First to some news just in where an earthquake has reportedly been felt in the Northern Territory near Darwin. The joint Australian tsunami