Thursday, December 26, 2013

Harms, Benefits and Unknowns in Surgery

“If you are a surgeon, think like an internist, and if you are an internist, act like a surgeon.”
“Never give a patient with a medical illness to the surgeons.”
                                                     Robert Whitlock, MD

When I was a medical student at the Columbia University College of Physicians and Surgeons, Dr. Robert Whitlock was an attending who inspired me to focus on gastroenterology.  Dr. Whitlock was a southerner in a prestigious New York medical school – a private practitioner who taught and believed patient care and teaching were the two noblest activities that anyone could ever take part in, and a purveyor to medical students of “Whitlock’s Rules of Medicine,” always given in a southern drawl that made them seem so much more important.  The two quotes above may not have originated with Dr. Whitlock, but they will be forever associated with him in my mind.  I thought of these rules as I read several articles in the December 26, 2013 Wall Street Journal

It is striking that in today’s premier financial newspaper, there are three articles related to healthcare -- only one of which is related to health insurance.  The other two are related to surgery – and the Wall Street Journal isn't the place where one expects to see the latest surgical studies to be published.  As is my routine, I went back to the original medical journal sources of the articles after reading the news articles.  They both make it clear that the wisdom of Dr. Whitlock holds today, just as it did back in the 1970s. 

The first article was about a study from Finland reported in the New England Journal of Medicine this week. The study used the technique of “sham surgery” to determine if people with partial meniscal tears that are not the result of acute injury, benefit from arthroscopic surgery to remove the torn part of the meniscus.  Sham surgery is surgery in which someone is taken to the operating room and put under anesthesia; a small cut is often made —and then nothing else is done.  Patients wake up thinking that they have had the surgery, but it is a fake.  Based on this study, it appears that arthroscopic surgery has no benefit for someone with a torn meniscus not due to an acute injury.  In any surgery, if there is no benefit, then there is only the risk of harm from the anesthesia and the surgery itself, and of course, the $4 billion in annual direct medical costs in the United States that make the study worthy of the Wall Street Journal.  The unknown in all of this is whether specific patients have certain characteristics that would make them likely to benefit from the surgery.  The authors of this study specifically excluded certain people (as any good study would), but in those exclusions there may be others who would benefit.  I make this point because the study does not say that all arthroscopic knee surgery is unnecessary.
Sometimes we don’t realize a surgery is harmful until the surgery has been performed for some time.  The other Wall Street Journal article focuses on a 2012 study, entitled “Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms.”  In morcellation, a uterine benign tumor is removed via hysteroscopy —which involves only a very small incision and quick recovery time –after the tumor is basically smashed into small pieces.  The problem: If the tumor is cancerous, then the small pieces can get lodged in the abdominal cavity and cause the cancerous cells to spread.  This was originally believed to be an exceedingly small potential harm, but has turned out to be more common (though still very unlikely) than previously thought.  Since the harm fits into the category of the “small probability but devastating outcome,” the procedure has come into question.

In a world of big data, my voice on this blog has been, and will continue to be, about relating studies and data to individuals in need. What does all this mean to the individual and how does that relate to the wisdom of Robert Whitlock?

  • Surgeons believe in surgery.  In order to be a surgeon, you have to believe that the work you do is effective and helps people, so that creates a bias toward operating.  My wife’s uncle was an orthopaedist.  He called himself an orthopaedist, as he believed that the term orthopaedic surgeon was too limiting -- and it pushed physicians to think that all solutions were to be found in the operating room.  If you don’t need surgery, don’t go to a surgeon.
  • If you go to a surgeon, make sure you go to one who “thinks like an internist,” meaning he or she will evaluate all the various solutions, understand the potential harms of surgery, and are willing to walk away from operating if the risk of harm is larger than the potential benefit. 
  • Be wary of the procedure that is “new” and promises to be easier for the patient.  The risks may be only partially understood and the potential harm may be greater than it appears.  When I was practicing gastroenterology and nutrition, it was popular to treat obesity by placing a balloon in the stomach to limit the amount of food that could be eaten – until the complications of the balloon perforating the stomach and esophagus became apparent. 
  • Don’t assume all surgery is unnecessary.  Some surgeries are lifesaving, and the same type of bias that may cause unnecessary surgeries can also cause people to avoid having the surgery that they need.  

A decision to have surgery should be thoughtful and made with complete information and the help of trusted family, doctors and other knowledgeable health professionals.  It should be based on the specific facts of the individual patient at that point in time informed by the medical evidence that best defines the potential benefits, harms and alternatives available.  It is never a decision to be taken lightly.