Why Your Doctor Needs Your Help to Battle Over-Treatment

 Christer Mjåset – Neurosurgeon and the Vice President of the Norwegian Medical Association

I am a neurosurgeon, and I’m here to tell you today that people like me need your help. And in a few moments, I will tell you how.

But first let me start off by telling you about the patient of mine. This was a woman in her 50s. She was in generally good shape but she had been in and out of hospital a few times due to curative breast cancer treatment.

Now she had gotten a prolapse from a cervical disc giving her radiating pain of a tense kind out into the right arm. Looking at her MRI before the consultation I decided to suggest an operation. Now operations like these are standardized and they’re quick but they carry a certain risk. You make an incision right here and you dissect carefully past the trachea, esophagus and you try not to cut into the internal carotid artery.

Then you bring in the microscope and you carefully remove the disc and the prolapse in the nerve root canal without damaging the cord and the nerve root lying only millimeters underneath. A worst-case scenario is the damage to the cord which can result in paralysis from the neck down.

Explaining this to the patient she felt silent and after a few moments she uttered a few very decisive words for me and for her: “Doctor, is this really necessary?”

And you know what I realized right there and then: it was not. In fact, when I get patients like this woman, I tend to advise not to operate.

So what made me do it this time? Well, you see this prolapse was so delicate. I could practically see myself pulling it out of the nerve root canal before she entered the consultation room. I have to admit it I wanted to operate her. I’d love to operate her. Operating like this is after all the most fun part of my job. I think you can relate to this feeling.

My architect neighbor says he loves to just sit and draw and design houses. He’d rather do that all day, then talk to the person, the client paying for the house, that might even give them restrictions on what to do. But like every architect, every surgeon needs to look the patient in the eye and together with the patient they need to decide on what is best for the person having the operation. And that might sound easy but let’s look at some statistics. 

The tonsils are the two lumps in the back of your throat. They can be removed surgically and that’s called a tonsillectomy. This chart shows the operation rate of tonsillectomies in Norway in different regions. What might strike you is that there is twice the chance that your kid — because this is for only children — will get the tonsillectomy in Finnmark than in Trondheim. The indication in both regions are the same. There should be no difference at risks.

Here’s another chart. The meniscus have stabilized the knee and can be torn or fragmented acutely typically during sports like soccer. What you see here is the operation rate for this condition, and you see that the operation rate in Møre og Romsdal is five times the operation rate in Stavanger. Five times?

How can this be? Do the soccer players in Møre og Romsdal play more dirty than elsewhere in the country? Probably not.

I’ve added some information now. What you see now is the procedures performed in public hospitals are light-blue, the one in private clinics is light green there. There is a lot activity on in the private clinics in Møre og Romsdal; isn’t there?

What does this indicate? Possible economic motivation to treat the patients, and there’s more. Recent research has shown that the difference of treatment effect between regular physical therapy and operations for the knee, there is no difference. Meaning, that most of the procedures performed on the chart I’ve just shown could have been avoided even in Stavanger.

So what am I trying to tell you here? Even though most indications for treatments in the world are standardized, there is a lot of unnecessary variation of treatment decisions, especially in the Western world. Some people are not getting the treatment that they need, but an even greater portion of you are being over-treated. Doctor, is this really necessary? I’ve only heard that question once in my career. My colleagues say they never heard these words from a patient.

And to turn it all the way around: how often do you think you’ll get a no from a doctor if you ask such questions? Researchers have investigated this and they come up with about the same no rate where ever they go, and that is 30%. Meaning 3 out of 10 times your doctor prescribes or suggests something that is completely unnecessary. And you know what they claim: the reason for this is patient pressure. In other words, you. You want something to be done.

A friend of mine came to me for medical advice. This is a sporty guy, do a lot of cross-country, skiing in the winter time; he runs in the summertime and this time he had gotten a bad backache whenever he went jogging so much that he had to stop doing it. I did an examination. I questioned him thoroughly. And what I found out is that he probably had degenerated discs in the lower part of his spine. Whenever he got strained it hurt.

He’d already taken up swimming instead of jogging; there was really nothing to do. So I told him you need to be more selective when it comes to training. Some activities are good for you; some are not.

His reply was: “I want an MRI on my back.”

“Why do you want an MRI?”

“I can get it for free through my insurance at work.”

“Come on,” I said, “That’s not the only reason.”

“Well, I think it’s going to be good to see how bad it looks back there.”

“When did you start interpreting MRI scans?”, I said. “Trust me on this: you’re not going to need the scan.”

“Well,” he said, and after a while he continued, “it could be cancer.”

He got the scan obviously and through his insurance at work he got to see one of my colleagues at work telling him about the degenerated discs that there was nothing to do; he should keep on swimming and quit the jogging.

After a while I met him again and he said, “at least now I know what this is.”

But let me ask you a question: what if all of you in this room with the same sentence had an MRI and what if all the people in Norway had an MRI due to occasional back pain? The waiting list for an MRI would quadruple maybe even more and you would all take the spot on that list from someone who really had cancer. So a good doctor sometimes says no but the sensible patient also turned down sometimes an opportunity to get diagnosed or treated: Doctor, is this really necessary?

I know this can be a difficult question to ask. In fact, if you go back 50 years this was even considered rude. If the doctor had decided what to do with you, that’s what you did. A colleague of mine, now a general practitioner, was sent away on a tuberculosis sanatorium as a little girl for six months. It was a terrible trauma for her. She later found out as a grownup that her tests on tuberculosis had been negative all along. The doctor had sent her away on nothing but wrong suspicions. No one had dared or even considered confronting him about it, not even her parents.

 Today the Norwegian Health Minister talks about the patient’s health care service. The patient is supposed to get advice from the doctor about what to do. This is great progress but it also put more responsibility on you. You need to get in the front seat with your doctor and start sharing decisions on where to go.

The next time you’re in the doctor’s office, I want you to ask: Doctor, is this really necessary?

And in my female patient’s case, the answer would be no but an operation could also be justified.

So doctors, what are the risks attached to this operation? Well 5% to 10% of patients will have worsening of pain symptoms. One to 3% of patients will have an infection in the wound or even rehemorrhage that might end up in a re-operation. 0.5% of patients also experience permanent hoarseness but still a few will experience reduced function in the arm or even legs.

Doctor, are there other options? Yes, rest and physical therapy over some time might get you perfectly well.

And what happens if I don’t do anything? It’s not recommended but even then there’s a slight chance that you will get well.

Four questions, simple questions. Consider them your new toolbox to help us.

Is this really necessary?

What are the risks?

Are there other options?

And what happens if I don’t do anything?

Ask them when your doctor wants to send you to an MRI, when he prescribes antibiotics or suggests an operation. What we know from research is that one out of five of you, 20% will change your opinion on what to do. And by doing that, you will not only have made your life a whole lot easier and probably even better that the whole health care sector will have benefited from your decision.

Thank you.