Unnecessary Surgery

During the summer of  09, I travel to Austin Texas to visit my mom.  On walking in, I see that her left eye is drooping and red.  Calling the nurses in at her assisted living home, they insisted that I take her to emergency room to check what might be in their opinion a possible stroke.  The emergency room doctor was almost scornful as he was just adamantly clear that it was not a stroke and he also seemed to imply that she should have never been given such a diagnosis.  I also understand that the nurses want to be cautious. The doctor gave her some drops for what he saw as pink eye.
I asked my brother to look after her and take her to the eye doctor.  The eye doctor referred her to an eyelid specialist. Not being there, I’m not sure what happened, but between the three of them, they became convinced that my mom needed eyelid surgery to repair the drooping eyelid. The surgery is supposedly minor.  I come to Austin to help her with this surgery.  Fast forward to the surgery room.  I’m already beginning to have some funny feelings that maybe this is more of a reconstructive surgery rather than a necessary surgery.  The surgeon came in pre-op to meet with us and said it could take up to a year to heal completely.  I’m beginning to feel super uncomfortable.  Then the nurse came in for us to sign a release form and look at all the specific conditions/complications that could happen from the surgery. I am becoming increasingly uncomfortable, for gods sake, my mom is 83, lies around all day, watches TV, and eats cakes and cookies all day.  Her immune system is already taxed.   THen I directly asked the nurse why are we doing this this surgery  to raise a  slightly drooping upper eyelid. The nurse brought the surgeon back in.  I asked if this was a cosmetic surgery.   The supposed reason she was to have the surgery  was because of  “blocked vision” in that eye.  They left and gave us some time alone and I covered my mom’s questionable eye and she could read fine.  Of course, the surgeron was pissed (even though she tried not to show it, it came through in her voice).  I’m sure they talked my mom into the idea that she had blocked vision. I’ll trust that it was probably accidental.  My mom isn’t capable of understanding and would agree to anything that she was repeatedly asked.  ANyway, it took alot of nerve for me to do this, but I actually wouldn’t sign the forms and said I didn’t think she needed the surgery.   I  know that I made the right decision.  I feel deep inside that her immune system would be stressed trying to heal that injury and that it wasn’t neccessary at this time. As a final note, I often go to the teachers at the Austin acupuncture college for treatment when I’m here.  I took my mom in for her first acupuncture treatment and the first thing he said, the surgery wasn’t necessary at her age.
Following are a couple of articles on unnecessary surgery.  The controversy around this has been around for a long time and  statistics are hard to determine accurately.  Of course, emergency surgeries in life threatening conditions are absolutely necessary.  When you can please get a 2nd opinion and if possible  get an opinion from someone in the alternative health care field.

Health Services ResearchVolume 24(3) August 1989

The extent of unnecessary surgery has been the object of considerable speculation and occasional wild accusation in recent years. Most evidence of the existence of unnecessary surgery, such as information from studies of geographic variations and the results of second surgical opinion programs, is circumstantial. However, results from the few studies that have measured unnecessary surgery directly indicate that for some highly controversial operations the fraction that are unwarranted could be as high as 30 percent. Most unnecessary surgery results from physician uncertainty about the effectiveness of an operation. Elimination of this uncertainty requires more efficient production and dissemination of scientific information about clinical effectiveness. In the absence of adequate data from scientific studies, the use of a consensus of expert opinion, disseminated by means of comprehensive practice guidelines, offers the best opportunity to identify and eliminate unnecessary surgery.

Unnecessary Surgery

By James Barron; James Barron is a New York Times reporter.

Published: Sunday, April 16, 1989


Recurrent dizziness. Patient is terrified that he might be having a heart attack. Doctor had ordered a 24-hour ambulatory electrocardiogram, taken with a small portable device that keeps track of the heartbeat. When the patient returned to the office the next day for evaluation, the electrocardiogram showed dramatic fluctuations of the heartbeat: 130 beats a minute during activity, only 40 beats a minute when the patient ia asleep. During the time he’s been monitored, the patient has not experienced any dizziness. THE DOCTOR RECOMMENDATION:

”You need a pacemaker.”

A pacemaker is, in fact, implanted the next day and the patient becomes a statistic: one of millions of Americans who have undergone unnecessary elective surgery – nonemergency procedures performed as alternatives to more conservative treatment. In recent years, researchers have called into question the need for hundreds of thousands of operations, including pacemaker implants, coronary bypass surgery, hysterectomies and Caesarean section, to name only a few procedures that seem to be performed too frequently. A review team headed by Dr. Allan M. Greenspan of Albert Einstein Medical Center in Philadelphia estimated that 20 percent of pacemaker operations may be unnecessary, including the one done on the man with the fluctuating heartbeat. Dr. Greenspan maintains that the fluctuations were normal, and that the patient’s dizziness had nothing to do with his heart.

The surgery rate in the United States grew more than twice as fast as the population between 1979 and 1987. By most accounts, it’s the highest in the world. For example, studies cited by Lynn Payer in her recent book, ”Medicine and Culture,” show that American women are two to three times more likely to undergo a hysterectomy than women in England. Heart patients here are six times more likely to have a coronary bypass. Yet our more aggressive style of medicine doesn’t buy us longer lives: According to the World Health Organization, life expectancy is about the same in the United States as in Western Europe, and Americans are somewhat more likely to die of heart disease than people living in England.

Despite the dramatic increase in surgery, experts can’t say precisely how much of it is unnecessary. Only in recent years have researchers begun to review hospital records to document the problem, and they have been hampered by a lack of consensus among doctors concerning the proper indications for various operations. In addition, records on surgical procedures vary from hospital to hospital, making it difficult for researchers to conduct large studies assessing the appropriateness of operations.

Another way to document the extent of unnecessary surgery is to follow patients who have undergone operations like coronary bypass and compare them with patients who have been treated with more conservative approaches, such as drug therapy. So far, however, studies have been done for only a limited number of procedures. As a result, doctors who recommend an operation over drugs often have ”a basic lack of knowledge of which works better,” says John E. Wennberg, an epidemiologist at Dartmouth Medical School.

Even so, evidence is accumulating that unnecessary surgery is a widespread problem. In Dr. Greenspan’s study, specialists reviewed the charts of 380 patients who had received pacemakers at 30 hospitals in the Philadelphia area. One-fifth of those implants were judged to be totally unnecessary. One reason was that some physicians had failed to evaluate patients’ symptoms correctly, even at university hospitals with sophisticated diagnostic equipment.

The continuing increase in the number of coronary bypass operations performed each year has also come under scrutiny. Dr. Thomas B. Graboys, a cardiologist at Harvard Medical School, estimates that as many as 350,000 bypass procedures will be performed this year – nearly twice as many as in 1983. ”Doctors and their patients tend to view heart disease as a plumbing problem,” he says. Their attitude is that damaged coronary arteries are like corroded pipes -they simply must be replaced. But a major study published by Dr. Graboys in 1987 suggests that this aggressive approach is often unwarranted.

Eighty-eight patients who had been advised by their doctors to undergo coronary bypass surgery received second opinions from specialists working under Dr. Graboys. The bypass operations had been recommended on the basis of a diagnostic test called cardiac catheterization, which had found blockages in the patients’ coronary arteries. The specialists judged that, despite the blockages, 74 of the patients could be effectively managed with drugs instead of surgery. Most of them took the specialists’ advice, and two and a half years after the study began, none of them had died.

A skyrocketing rate of diagnostic cardiac catheterizations is partly to blame for the upsurge in bypass operations, says Dr. Graboys. In this procedure, a catheter is inserted through the skin near the elbow or in the groin area and threaded through blood vessels into the coronary arteries. A dye is injected through the catheter, and X-rays are then taken of the coronary arteries in order to find blockages. According to Dr. Graboys, 800,000 cardiac catheterizations were performed in 1987; by the end of this year, the number may exceed a million. A study he is now working on suggests that even these procedures – which are often done when patients complain of chest pains or when there are abnormal EKG or stress-test results -are frequently unnecessary. When the specialists working under Dr. Graboys gave second opinions to 150 patients whose doctors had recommended cardiac catheterization, they found that the diagnostic procedure was unnecessary in a majority of cases. According to the specialists, the patients were medically stable and their condition could be controlled by life-style changes or medication.

Balloon angioplasty, a procedure in which a tiny balloon is inflated inside a coronary artery to flatten a blockage, has also come in for criticism. A study published in March by scientists at the National Heart, Lung and Blood Institute in Bethesda, Md., suggested that 40 percent of the angioplasty procedures performed on heart attack patients may be unnecessary.

Of course, the heart isn’t the only part of the body vulnerable to unnecessary surgical tampering. In 1988, the Rand Corporation, a research organization in Santa Monica, Calif., completed a study of 1,302 Medicare patients who had undergone carotid endarterectomies -an operation in which blockages in the neck arteries supplying blood to the brain are removed. A panel of physicians found that 32 percent of the operations were unjustified.

Dr. Wennberg at Dartmouth recently helped conduct a study that followed the cases of 263 men who had undergone surgery to repair enlarged prostates. Many doctors recommend this surgery to prevent more serious problems, such as kidney damage, that can shorten a person’s life. But Dr. Wennberg found that because of postoperative complications, the surgery actually caused a slight decrease in life expectancy.

Where a person lives can affect the chances of being operated on unnecessarily. For example, according to a 1985 report by the Senate Special Committee on Aging, hysterectomies are performed 80 percent more often in the South than in the Northeast. Within the state of Massachusetts, the rate of hernia repair surgery varies by as much as 380 percent, while pacemaker surgery varies by as much as 1,250 percent. And, in a study by Dr. Wennberg, carotid endarterectomies were found to be twice as common in Boston as in New Haven. Meanwhile, people in New Haven were twice as likely to undergo bypass surgery as people in Boston.

According to Dr. Wennberg, these geographical variations, or ”surgical signatures,” are seen year in and year out and are independent of rates of illness. There appears to be a correlation between the number of surgeons in a particular area and the number of operations, with more surgeons generally resulting in more operations. The variations may also be indicative of differences in prevailing medical wisdom. In any case, they clearly suggest that something other than hard medical data often underlies the judgment of surgeons.

UNNECESSARY SURGERY means unnecessary risk of complications and even death. In testimony before a Senate subcommittee in 1985, Dr. Wennberg estimated that 5,000 deaths could be avoided each year if all doctors used the most conservative indications for doing prostate surgery. Unnecessary surgery also comes at great financial cost – and not just the cost of the operations themselves. Unnecessary surgery usually means unnecessary tests, drugs and hospitalization. No one knows for sure what the bill is, but even back in the mid-1970’s, Congress concluded that it was unacceptably high. A House investigation found that in 1975, 2 million unjustified operations had been performed in the Medicaid and Medicare programs – at a cost of $4 billion.

Experts cite a glut of surgeons as one of the major causes of needless operations. According to Dr. Eugene G. McCarthy, director of the Health Benefits Research Center at New York Hospital-Cornell Medical Center, the Federal Government began to help finance medical education in the 1960’s to counter what was then a shortage of doctors. One of the results was a 30 percent increase in the number of surgeons.

The fear of malpractice lawsuits is prompting many surgeons to perform operations they might otherwise pass up. Arthur L. Caplan, director of the Center for Biomedical Ethics at the University of Minnesota, says that in the past 20 years, rulings in malpractice cases have changed the way doctors are judged in court. Legal standards of reasonable medical care were once based on the judgment of physicians in the community. ”Today, juries make their own judgments based on what a reasonable patient would want done,” says Caplan. ”Generally speaking, in our society doing something is preferred to doing nothing.” A doctor being sued for malpractice stands a better chance of winning the case if he tried an operation and failed than if he recommended more conservative treatment. As a result, the approach of many surgeons is, ” ‘When in doubt, take it out,’ ” he says.

The lack of studies on the effectiveness of many surgical procedures gives malpractice lawyers a potent weapon in court. ”Malpractice litigation flourishes in this information vacuum, because no one knows what legal standard of reasonableness to apply,” Caplan says.

Ironically, improvements in medical care are also contributing to the problem of unnecessary surgery. Many operations are done more quickly and easily these days. For example, a lumpectomy, a 20-minute procedure in which a breast tumor is removed, is now often done as an alternative to a radical mastectomy, an operation that can take up to three hours in which the entire breast is removed. Kidney stones and polyps in the colon can now be eliminated without surgery. Many surgeons find themselves spending fewer hours in the operating room and collecting fewer or smaller fees, says Dr. Anthony P. Monaco, a professor of surgery at Harvard Medical School. As a result, some of them recommend surgery to their patients when a conservative method might be equally effective.

Hospitals are hurting, too, because operations for such relatively common conditions as cataracts are increasingly being done on an outpatient basis or in doctors’ offices. Consequently, surgeons are being pressured by their hospitals to schedule big-ticket procedures to fill the empty beds.

According to Caplan, the reimbursement policies of many health insurance plans inadvertently encourage surgeons to operate unnecessarily. In recent years, Medicare and some private insurance companies have placed limits on the amounts they will pay for particular operations. A cap on payments for procedures that are highly profitable for hospitals as well as doctors, such as coronary bypass operations, reduces profitability but doesn’t eliminate it. This may encourage surgeons to do more of these operations to make up for the decreased profits.

Sometimes patients must share the blame for unnecessary surgery. ”It’s very easy for the doctor to be lured by a patient’s demand for a quick fix,” says Dr. Peter D. McCann, an assistant professor of orthopedic surgery at Columbia University’s College of Physicians & Surgeons. This is particularly true of weekend athletes who are injured and want to make a rapid comeback. A common source of shoulder pain, for example, can be problems with the rotator cuff, a group of tendons and muscles that helps stabilize the shoulder joint. Patients who elect physical therapy may find the results every bit as satisfactory as those who insist on surgery.

ONE OF THE BEST ways to curb unnecessary surgery is to require that all patients get second medical opinions. ”We surmise that doctors who are subject to the review of their peers are less inclined to prescribe unnecessary surgery,” says Dr. McCarthy.

The first second-opinion program in the country, insti-tuted by New York Hospital-Cornell Medical Center in 1972, required that patients consult a second physician before undergoing elective surgery. Since then, second-opinion programs for both hospitals and insurance plans have multiplied. Virtually all insurance plans in New York State require second opinions for elective surgery, according to Dr. McCarthy. If a patient fails to get a second opinion, his insurance company will typically reimburse him for less than 50 percent of the cost of the operation.

Such mandatory programs have been established in other states as well, and they have had a substantial impact. The hysterectomy rate in New York State is only a third of what it is in states where few or no second-opinion programs exist, says Dr. McCarthy. And, according to the 1985 report of the Senate Special Committee on Aging, back-surgery rates in the Wisconsin Medicaid program plummeted 36 percent when second opinions began to be required.

Attitudes don’t change overnight, but Dr. Greenspan, who did the pacemaker study, says that ”many doctors have become aware that they must abide by a more stringent set of rules. And many patients are now aware that they must ask questions and get second opinions.” As a result, rates of increase for some surgical procedures may have peaked, he says, and the rate of pacemaker implants is actually starting to come down. Thanks to a growing awareness that carotid endarterectomies are often unnecessary, fewer of these procedures are being performed today than in the past.

But much more still needs to be done. In testimony before the Senate Finance Committee’s subcommittee on health last year, Dr. Wennberg pointed out that the Government requires extensive studies to evaluate new drugs, yet surgical procedures rarely get the same scrutiny. ”This double standard for truth in clinical medicine compromises the rationality of medical decisions,” he said. And it threatens the health of both the national economy and countless patients. Dr. Wennberg is pushing for Federal funding of a program to measure the effectiveness of a large number of surgical procedures.

But perhaps the best guardians against unnecessary operations are patients themselves. If a doctor recommends that you have surgery, don’t hesitate to get a second opinion. Get as much information from both doctors as you can, and explore carefully all the alternatives to surgery. Ask whether drug therapy or changes in diet and exercise have proved effective for your condition. You should also ask the doctors specifically what they think an operation could accomplish: a cure, or simply relief from symptoms? Is a relapse likely? What are the possible complications of surgery and what are the chances that they will occur? Have any studies been done about the procedure, and what do they say?

In the end, it’s up to you to decide what’s necessary. For example, Dr. Graboys says it’s reasonable for heart patients who are extremely anxious about their condition to choose bypass surgery even if drug therapy would be sufficient treatment. If, on the other hand, you value medical care that is as noninvasive as possible, it behooves you to find a physician who shares your philosophy. Collaborating with your doctor in making the decision whether to operate or not is probably the best way to avoid becoming another statistic in the annals of unnecessary surgery.

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