Time for a second opinion? When surgery becomes a ‘placebo’?
In the last few weeks, among other things, I’ve been asked to give my opinion on a patient offered a discectomy for a ‘herniated’ spinal disc that I (and the reporting radiologist) found difficult to call ‘herniated’, a patient offered a three-level spinal instrumentation operation when two levels of instrumentation could readily suffice, a patient whose surgeon wants to do another operation on the same patient’s spine having already done several, and a patient with a permanently implanted spinal device that appears to have no real mechanical merit in the peer-reviewed literature but which may in fact be having an adverse effect on the patient’s spine as time goes on.
In each situation, I asked myself this fundamental question: if this was my spouse, my child, or a first-degree relative of mine, is this what I would recommend for them too?
And then I read this….
In a Sydney Morning Herald article posted on 6 March 2016 and entitled “Confessions of a Sydney surgeon: why your operation may not work”, senior writer Tim Barlass, writes:
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“Orthopaedic surgeon Ian Harris who works at Liverpool, St George and Sutherland Hospitals and the University of NSW, said he had performed “surgery that doesn’t work” but says he now performs much less ineffective surgery than he used to.
“In my career, I have done surgery for ‘ununited’ fractures that have already healed, removed implants that were not causing a problem, fused sore backs and ‘scoped’ sore knees. I have even re-operated on people with ineffective procedures after the first ineffective procedure was, well, ineffective.”
In a new book, Surgery, The Ultimate Placebo, he adds: “I have operated on people that didn’t have anything wrong with them in the first place. This happens because if a patient complains enough to a surgeon, one of the easiest ways of satisfying them is to operate.”
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Although I have not read his book as yet, Professor Harris appears to be making quite a statement. At face value, but in the context of the book’s title and the aforementioned comments by the book’s author as quoted by Tim Barlass, to refer to surgery as an “ultimate placebo” reinforces (to me at least) that questionable patient selection processes exist in the real world, where for instance a surgeon sets his or her ‘decision-to-operate’ bar so low such that carrying out the procedure is more likely than not to have no real therapeutic value (i.e., in essence that particular surgery for that particular patient by that particular surgeon offers nothing above that of a ‘placebo’, e.g., a ‘sugar pill’ or a ‘sham operation’). Then why offer it? Why? (Ian, did you address this further in your book?)
In support of Dr Harris’ comments, New York spinal surgeons Nancy Epstein (http://www.ncbi.nlm.nih.gov/pubmed/24340231) (http://www.ncbi.nlm.nih.gov/pubmed/21776403) and Francis Gamache (http://www.ncbi.nlm.nih.gov/pubmed/23248753) have written about a surprisingly high prevalence of what they deem to be ‘unnecessary’ spinal surgeries, something I’ve heard some luminary colleagues of mine rightfully grumble about. Among the many downsides of this surgical ‘overservicing’ (particularly for the patient and those who foot the bills, and the health system in general), are that it can also degrade the Public’s perception of medical/surgical judgement and integrity, and crystallise terms such as “Failed Back Surgery Syndrome” or the equivalent.
Thus, in general, I believe that:
1. Patients should seek (at the very least) a second opinion before undergoing major surgery, particularly spinal (the variability in the expressed opinions in terms of what, if anything, needs to be done surgically may be surprising to patients seeking additional opinions);
2. Surgeons should maintain a higher threshold to operating on patients, i.e., where there is a clear consistency between the symptoms, clinical/physical signs, and radiological findings AND (wherever possible) the procedure has some reasonable merit supported by the peer-reviewed medical literature.
In the meantime, I will continue to fondly remember the words of a wise old surgical technician telling me and my cohort as we started our training at Mayo…”if it ain’t broke, don’t fix it“.
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