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To Go Under the Knife--or Not?


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 Institute of Medicine of the National Academies 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


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