- Consent to a surgery or procedure only if it is relatively clear that there is no alternative, especially if surgery can be delayed while attempting alternatives without obvious costs/tradeoffs/risks
- Get a second opinion from a different physician
- Ask directly about financial benefits to your physician from doing procedures
- Ask your physician if he would do the procedure on his or her mother or his daughter under similar circumstances - or would s/he nudge them towards alternatives, saving surgery as a last resort?
Monday, February 22, 2016
Procedure Meat: How Procedural Lust Imperils Patients
It was about 17 years ago, while I was in training, that an attending accepted a moribund woman from a faraway place in the hinterlands. She had multiple hepatitides and uncontrolled bleeding from esophageal varices. A collective groan among the housestaff met notification of the incoming transfer which would keep everybody up all night with the inevitable death forestalled only briefly, and in a streak of his usual candor, the attending admitted that he accepted her not because he thought there was anything that could be done to help or save her, but because she would serve as good "procedure meat for the interns." And the interns were like:
There are a lot of problems with that entire episode as I reflect upon it, and I won't dissect them all here. I've been thinking about procedure meat because I so often see physicians feasting on it, to the peril of the patients. Ideally, each and every procedure that is done ought to be done because it is in the patient's best interest to have it done. All too often, ulterior motives and unstated goals creep into decision frameworks and lead to unnecessary procedures and therapeutic misadventures. To combat this problem, we need to start nudging physicians to consider and patients to ask directly, "Is this procedure the best thing for me? Are there alternatives? Do the expected benefits outweigh the costs and risks? Where will I be in six days, six weeks, six months, and six years as a result of the proposed procedure? Where will I be at those times without it?"
Several years ago a now deceased surgeon admitted to me that he wanted me to keep alive an octogenarian with dementia, bowel perforation, and sepsis on whom he had operated "at least until day 30. I don't care what happens to him after that." He was interested in his 30-day mortality statistics. When I pressed him on why he operated in the first place, knowing that the outcome was likely to be poor, he confessed: "Look, do you think if this was my own father I would have operated on him? Hell no. But I'm a surgeon. I'm trained to operate. It's what I do." (That link is worth a click.)
As they say, the first step to recovery is overcoming denial. With procedures, physicians often deny that they are doing them only or primarily because they lust to do them or they are compensated in some way for doing them. As I have stated before, this often begins in training programs where trainees are taught to seek out procedures for the experience of doing them. Rather, we should teach trainees judiciousness in their decision making. Later when in practice, coupling of remuneration with procedural volumes reinforces the training effect.
I've insinuated that reimbursement reforms and more honesty and common sense in decision making can combat procedure lust, but I have no illusions that these are coming soon. What, in meantime, is a patient to do? The gold standard, in my mind, is to have a reasoned and careful discussion asking the questions in bold above, as well as others. This is difficult, and I expect it may engender some resentment and frustration if patients (and other physicians) push physicians who may be in denial to answer these detailed questions about expected utility, goals, competing possibilities, and evidence. But there are some heuristics, or rules of thumb that may suffice:
Finally, consider approaching these decisions with an emphasis on cost. The only thing that proceeding with procedures guarantees is cost, an incision, anesthesia and its risks, the risks of complications, etc. Those things are guaranteed. I would consent to a procedure or surgery only if it was abundantly clear that those factors were clearly outweighed by surgery, or if the alternatives (all of them) were not an option or had already failed.