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Press Enterprise (Riverside, CA)
Aug 05, 2003
by MIKE SCHWARTZ, THE PRESS-ENTERPRISE
The unkindest cut : More patients and doctors avoid unnecessary surgeryThree years ago, shoulder surgery loomed in Laura McDonald's future.
The Riverside Poly High School swimmer had injured a right rotator-cuff tendon while training for the Olympic trials.
"I couldn't sleep on it, wash my hair or even rest my arm on a steering wheel without pain," recalled McDonald, now a 19-year-old business and sports science major at University of the Pacific in Sacramento. "My dream was kaput."
Four orthopedic specialists advised surgery. That prospect worried McDonald; two of her friends were athletes who had gone under the knife and permanently lost their competitive edge afterward.
But a fifth doctor was more optimistic: He said muscle-strengthening exercises would stabilize the tendon, give it time to heal and make surgery unnecessary.
During the next 2 1/2 years, McDonald underwent rigorous rotator-cuff therapy. By February 2003, she was consistently winning one-mile races for her college team.
"I'm my old self again," she said. "My goal is the Olympic trials next summer in Long Beach."
McDonald's close call with needless surgery poses a longstanding question in medicine: How do patients and their doctors know when surgery is necessary?
It's no small concern if you're battling a competitive sports injury, breast cancer, an enlarged or cancerous prostate, coronary heart disease or other conditions for which surgery is an option.
"It's gotten harder for doctors to make a buck because HMOs have bled them dry," argues Jamie Court, a Los Angeles-based consumer advocate and author of "Making A Killing: HMOs and the Threat To Your Health." "So they've had a tendency to want to do more surgery." Most overdone surgeries, Court said, are "high-ticket items with the biggest price tags for the doctors and chains." His assessment echoes various studies that have reported similar findings.
Yet the pendulum is swinging toward more surgical restraint.
"A lot of unnecessary surgery already has fallen off," said Dr. Ronald Bangasser of Redlands, president of the California Medical Association. "Second opinions and professional peer review are nothing new, but much more of it is going on."
Unless surgery is clearly life-saving, many doctors now are inclined to treat a condition with medication. They monitor an injury with "watchful waiting" or operate with the least amount of cutting possible.
"You always have to define the degree of a disease and what you mean by 'unnecessary,' " said Dr. Ismael Nuno, director of cardiac surgery at Los Angeles County-USC Medical Center. "If a patient has coronary heart disease amenable to medical therapy or balloon angioplasty, we'll try that. If not, the illness must be corrected surgically."
More powerful CT, MRI and ultrasound scanners have given diagnosticians breathtakingly clear views into the body, often eliminating the need for exploratory surgery.
A study last year in the Journal of Nuclear Medicine confirmed the ability of positron emission tomography (PET), another new type of scan, to assist in treatment planning and to reduce ineffective surgeries.
"We see repeated examples where a patient's treatment is changed completely based on the results of that one diagnostic test," said Riverside radiologist Peggy Fritzsche, president of the Radiological Society of North America.
Doctors also can try new "minimally invasive" alternatives such as radiology intervention, which cuts off the blood supply to a tumor and thus starves it to death. This method eliminates the need for open surgery.
An even bigger factor has been growing data that documents overuse of many common operations -- from Caesarean deliveries and tonsillectomies to hernia repairs and even gum surgery.
For example, common throat surgeries used to "cure" snoring and sleep apnea are effective in less than 10 percent of all cases, according to researchers at the Ohio Sleep Medicine Institute in Dublin, Ohio.
More than two years ago, a study published in the Journal of the American Medical Women's Association found that many women who have breasts removed due to cancer don't need such radical surgery.
Studies at Dartmouth College several years ago found wide, "unwarranted variations" in the ordering of mastectomy and several other common elective, or non-emergency, operations.
Too often, demand for surgeries is determined by individual preferences and the practice patterns of local specialists, which aren't always in a patient's best interests.
An orthopedist may veer you into a knee replacement rather than physical therapy. A cardiac surgeon might advise bypass surgery for blocked coronary arteries instead of less-invasive
angioplasty. And a urologist might favor removing a slow-growing prostate cancer over watchful waiting or radiation therapy.
"Clamoring for appearance-enhancing surgery almost always comes from patients," said Los Angeles malpractice attorney Steve Heimberg. "Take away the vanity, and the clamoring comes mostly from the surgeon.
Sometimes patients choose surgery for convenience. For example, Caesarean sections, the most common major operation, appeal to some women seeking control over the childbirth process.
Too much reliance on surgery is a byproduct of financial reimbursement that is only one-fourth what it was 20 years ago, said Dr. Henry Bellaci, a cardiologist and medical staff president-elect at Desert Regional Medical Center in Palm Springs.
"It's a system based on crisis medicine," Bellaci said. "It fails to reward preventive care, but rather encourages doctors to treat as many patients as they possibly can."
If surgeons now perform fewer needless operations, it may be because they must choose between some reimbursement for less invasive, cheaper care or not getting paid. Many health plans no longer will authorize the most overdone procedures without compelling clinical reasons, second opinions or a course of non-surgical therapy first.
But Nuno, president of the American Heart Association, Western States Affiliate, warns that "cheaper" and "non-invasive" aren't always better.
"Consumers must understand that nothing is free," he said. "You can go for a lesser procedure and still wind up dead because of complications. Or you can have surgery and go home safe and sound."
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