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HEALTH
To Go Under the Knife--or Not?
Deciding whether a surgical operation
recommended by your doctor is right for you
Are surgeons too quick to put patients under the
knife? That's an important question for anyone considering a coronary
bypass, hysterectomy, prostate removal, or a long list of other common
elective operations. Studies recently released by Dartmouth College
researchers show tremendous "unwarranted variations" in the
numbers of invasive procedures performed in the U.S. In other words, the
likelihood of your having surgery depends more on the doctor you see than
whether you really need an operation.
Avoiding unnecessary surgery requires a proactive
patient willing to challenge opinions and research options. "One of the
biggest problems with our health-care system is that patients are way too
passive," says Dr. Robert Brook, director of health policy research at
the RAND Corp.
Doctors have biases that may conflict with your
best interest. A urologist is more inclined to recommend surgery for
prostate cancer, while a radiotherapist is likely to tell you to have
radiation. An orthopedic surgeon will lean toward back surgery for disk
compression, while a sports medicine doctor will more often advise physical
therapy.
Not surprisingly, money often comes into the
equation. "The system does not reward doctors for talking. It rewards
them for doing," says Megan Cooper, editor of the Dartmouth Atlas
project, which tracks health-care expenditures across the nation. Patient
advocates say it's no coincidence that the most commonly performed
procedures are also the most expensive. "If coronary bypass surgery
cost $500, you can bet doctors wouldn't be doing so many of them," says
Charles Inlander, president of the People's Medical Society, a consumer
group in Allentown, Pa. A typical bypass operation runs $39,000 to $123,000,
with the surgeon's fee ranging from $5,000 to $20,000.
Indeed, Gerald Hines, chairman of Hines Interests,
a real estate development firm in Houston, weighed the monetary motive when
he decided years ago against two cardiac surgeons' recommendations that he
get a triple bypass. "You have to be reflective when the cost is such a
large amount," he says. Besides, "I didn't want someone opening up
my chest." Instead, under the supervision of his internist, he followed
a strict low-fat diet, started an exercise regime, and practiced yoga and
meditation. He also took a beta-blocker drug, which reduces the rate and
force of heart contractions. That was more than 20 years ago. Now 78, Hines
is orchestrating his company's overseas expansion. "I feel great,"
he says.
GET MULTIPLE OPINIONS. With this in mind,
never accept one doctor's word that you need an invasive procedure. Be
especially wary if it's one of the "big-ticket" operations that
insurance investigators and patient advocates say are overdone (table). You
should also check the Dartmouth Atlas project's Web site (www.dartmouthatlas.org)
to see if it is a procedure that is performed in your area at a rate far
higher than the national average. By clicking on "Custom Reports"
and entering your state under "Community Profile Reports," you can
find, for example, that there are suspiciously high numbers of back
surgeries in Boise, Idaho, and of bypass surgeries in Redding, Calif.
Get a second, third, or even fourth opinion. Most
insurance companies cover and encourage multiple consultations. Any doctor
who takes offense that you want to seek another's advice is not truly
concerned for your welfare. Also, don't pester your doctor into more
aggressive treatment. Be careful what you ask for because you'll likely get
it whether you need it or not.
EDUCATE YOURSELF. Make sure you
obtain opinions from different kinds of relevant specialists, and don't go
to doctors who are professionally associated with the doctor you saw first.
If possible, consult with doctors at the nearest teaching hospital. As
academic institutions, they're at the forefront of medical research. Also,
the doctors there are more often salaried rather than paid by the procedure,
so they don't have a financial interest in your surgery. Since physicians
are usually loath to contradict each other, give only your medical history
and test results. Don't divulge your diagnosis or the treatment
recommendation you already have. That way you won't prejudice the consulting
doctor's judgment. "Ideally, you want to get at least three doctors in
agreement on what needs to be done," says Inlander
You also want to educate yourself about your condition so you know your
options and can question your doctor intelligently. Don't rely on the
ubiquitous pamphlets offered at medical offices which are essentially
marketing brochures. Get on the Internet, where you can find some helpful
new resources such as YourSurgery.com, which exhaustively details various
procedures (table). For example, the site's section on carpal tunnel surgery
tells you the preliminary diagnostic tests you should have. It also gives a
detailed description and animated depiction of the operation. In addition to
the success rate and possible complications, you'll learn that thyroid
dysfunction can often cause carpal tunnel syndrome, in which case it may be
resolved with medication.
Medical school libraries are another valuable
resource because they can give you access to the latest research on surgical
outcomes and alternatives. Many medical libraries now have consumer sections
with librarians devoted to helping the general public find information.
"Look at the statistics on medical errors," says Dartmouth's
Cooper, alluding to a 1999 National Institutes of Health study that
estimates 98,000 people admitted to hospitals die annually from medical
errors. "You don't want to have surgery without exploring other
options."
Most surgeries are discretionary -- meaning
they're at your discretion, not your doctor's. You may decide that the
benefits of an invasive procedure outweigh the risks and are preferable to
more conservative treatments. But it should be your informed decision. Find
out what the potential complications are, and think about what's best for
your body, your mind-set, and your lifestyle. The kindest cut may be no cut
at all. - By Kate Murphy Business
Week
7 July 2003
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