First, do no harm

| October 24, 2023

Professor Rachelle Buchbinder, AO, grew up in Melbourne’s suburban southeast. She went to a high school that never figured in the VCE “high-performing” lists. Her parents – both born in Europe with difficult WWII Holocaust backstories – struggled financially for a long period of time.

Now, she’s one of Australia’s most eminent and awarded medical experts, and has just won the prestigious Australian Academy of Health and Medical Sciences Outstanding Female Researcher Medal. Last year’s winner was Professor Sharon Lewin, of the Doherty Institute.

Buchbinder is a professor in Monash’s School of Public Health and Preventive Medicine, specialising globally in clinical epidemiology and rheumatology. She’s a practising rheumatologist, and the founding director of the Musculoskeletal Health and Wiser Health Care Units established more than 20 years ago.

Her primary field of interest, however, is the medical system itself, a system she says is rife with overtreatment, overdiagnosis, and the medicalisation of normal conditions.

Two years ago she co-wrote a book with Professor Ian Harris, a NSW orthopaedic surgeon, titled Hippocrasy: How Doctors Are Betraying Their Oath, invoking ancient Greek doctor Hippocrates, who famously drew up a code of ethics, the Hippocratic Oath. In another text, he outlined the singular tenet of healthcare – always help a patient, but if no help can be given, do no harm.

“Some things doctors do have no evidence base,” Professor Buchbinder says. “Some have no benefit, and some can harm people.”

This seems an approach that might put the distinguished academic and physician somewhat at odds with the establishment of the industry she belongs to.

“When I talk to clinicians and others about the problems of too much medicine, I frame the issue in terms of what’s in the best interests of patients – are they likely to benefit, and what is the tradeoff between the potential benefits and harms.”

She says it’s estimated that roughly 30% of medical care (which can include tests, diagnoses and treatments) is of no benefit, while another 10% is harmful.

Examples of low-value care in the musculoskeletal field include overuse of imaging for non-specific back pain and other regional pain, and arthroscopic treatment for knee osteoarthritis.

Overdiagnosis and unnecessary treatment can also occur when risk factors such as thin bones (osteopenia) are treated as diseases in their own right.

Overestimating benefits, underestimating harms

Professor Buchbinder says an important factor is that doctors tend to overestimate the benefits of what they do, and underestimate the harms.

The newest angle on all this is that not only does low-value care have the potential to harm patients and deny treatment to those who truly need it, carbon-intensive care also has needless effects on the environment that indirectly harms others.

“I don’t think it’s well-recognised that the healthcare system is responsible for about 7% of the carbon footprint of Australia,” she says, “and the delivery of clinical care accounts for about 70% of the healthcare sector’s total emissions.”

Professor Buchbinder was nominated for the Australian Academy of Health and Medical Sciences medal by the University of Sydney’s Professor Chris Maher, the director of its Institute for Musculoskeletal Health.

“What makes Rachelle a truly exceptional researcher,” he tells Lens, “is that she sees problems in research and practice before others do, and then comes up with creative and innovative ways to understand and then address these problems.

“She really is a couple of steps ahead of her peers. She’s such a caring and genuine person. Monash is very fortunate to have her.”

Where does her courage and her determination come from? Professor Buchbinder’s parents weren’t doctors, medical or scientific.

“My father was born in Brussels and was five when the war came to Belgium,” she says. “He was hidden during the war in various places, including a convent, an attic, and finally an orphanage in Montluel, a small village in France. He was traumatised by the family’s failed attempt to escape to Switzerland and then being separated from his parents. My mother survived the war in Bacău, a small town in Romania.”

A path to medicine

Professor Buchbinder’s parents met in Melbourne and married young. Her father studied accounting and became a state auditor, and her mother was a book-keeper. On family drives to the Dandenongs, her parents would point to Monash University and tell her and her sister that this was where they would go after school.

Her father had premature heart disease, with his first heart attack in his late 20s. Professor Buchbinder says this is probably why she pursued medicine. One of his heart attacks occurred the night before her Year 12 English exam, almost derailing her acceptance into medicine.

Professor Buchbinder is married to medical oncologist Professor Danny Rischin – they met in medical school. Two of their three children are doctors; one, a rheumatologist, has joined her practice.

“We’re often discussing my pet subjects of overdiagnosis and overtreatment. They know the area and my views very well.”

In 2019, Professor Buchbinder participated in a public art exhibition, Women, by Sam Burke and Rebecca Umlauf.

Professor Buchbinder came to Monash from high school, for a Bachelor of Medicine, Bachelor of Surgery. She completed her training and specialisation in rheumatology in Melbourne, then completed a master’s in clinical epidemiology at the University of Toronto.

It was during these early years of her career that she began considering the medical default settings.

“One early rheumatology mentor in particular encouraged me to ask questions rather than simply accept the status quo,” she says.

In Canada, studying clinical epidemiology, “the lightbulb went on – that clinical epidemiology is fundamental to the practice of evidence-informed medicine”.

One of the first things she examined was the supposed efficacy of hydroxychloroquine, a standard treatment for systemic lupus erythematosus, or “lupus”. It’s an anti-malarial falsely touted by former US president Donald Trump as a treatment for COVID-19.

“I found that this had become the standard treatment of lupus based on a small-case series reported in a book about this disease written by the renowned lupus expert, Dr Edmund Dubois, in 1966. He reported that patients with lupus taking this drug had less flare-ups – that was it, that was the sole basis for the treatment.

“So that’s when I thought that maybe not everything we do in medicine is based on robust evidence.

“The more I thought about it, the more questions I had about the scientific basis of other standard treatments.”

Hydroxychloroquine was finally proven to be effective in 1991 – after more rigorous science – in a withdrawal trial that randomised stable lupus patients to either remain on the drug or stop it. Those who stopped it had more flares.

Her focus is always on good evidence to achieve the best outcomes – “using the best currently-available evidence, together with the patient’s values and preferences, to inform clinical decisions, and ensuring my research is answering the most clinically-important questions using the most appropriate research methods”.

“It all started back then, and everything I’ve done since has tried to be true to that principle.”

Back pain

In the 1990s, Professor Buchbinder’s long interest in improving care and outcomes for people with back pain began when she evaluated the world-leading “Back pain: Don’t take it lying down” mass-media campaign developed by the then Victorian WorkCover Authority.

She was able to demonstrate that the campaign resulted in a significant improvement in overall knowledge, or “medical literacy”, about low back pain. This work was recognised internationally when she received the prestigious Volvo Award for work in back pain in 2001.

As Lens reported in 2018, “the campaign also reduced the number of WorkCover claims, the number of days taken off work because of back pain, and significantly reduced medical costs. But then the Victorian government changed at the end of 1999 and the campaign was abandoned – it’s since gone on to inspire similar campaigns in many countries overseas”.

The messages were that resting because of back pain delayed recovery, staying active was important, and most imaging was unnecessary – it wouldn’t pinpoint the exact problem.

In 2018, she led a series in The Lancet written by 31 authors from 12 countries to further spread this message, calling for public education programs aimed at patients, the public and, importantly, health professionals.

Read more: Back pain: We’re treating it all wrong

Now, with an Officer of the Order of Australia (AO) honour, the Royal Society of Victoria 2022 Medal for Excellence in Scientific Research, and the newly-bestowed Australian Academy of Health and Medical Sciences medal, it’s on to new endeavours.

Her current focus is on mentoring the next generation of research leaders within her Monash group, and more broadly in Australia and overseas.

She talks of an ongoing commitment to building research capacity and ensuring the most important research questions are addressed to improve outcomes for people with musculoskeletal conditions.

The vehicle for this is the Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network that she co-founded and currently leads. It has been funded via two consecutive NHMRC Centre of Research Excellence grants.

She’s also a member of Wiser Healthcare, a national research collaboration that involves like-minded researchers from three other universities (University of Sydney, Bond University and University of Woolongong) that’s addressing overdiagnosis and overtreatment.

She chairs the world’s first “living guidelines” in rheumatology that provides clinicians and patients with up-to-date recommendations about treatment for both adults and children with inflammatory arthritis.

“I’m particularly driven to investigate treatments accepted into standard care prior to the robust evidence that confirms their benefit. As we’ve shown with treatments like vertebroplasty to treat osteoporotic fractures, surgery for shoulder impingement, knee arthroscopy, shockwave treatment for tendon problems, and opioids for back pain, accepting these treatments prior to their proper evaluation has resulted in patient harm.

“The most recent example is medical cannabis,” she says. “Our recent synthesis of the available evidence evaluating the effects of medical cannabis for chronic pain found moderate certainty evidence that it provides little to no benefit, but there are harms.

“Yet there’s been a dramatic increase in its use.”