Here are more guidelines for avoiding unnecessary surgery and getting only high quality surgery you actually need.
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1. Check out the hospital. In selecting a surgeon, remember that he will usually be tied to one or possibly several hospitals. So make sure both the surgeon and the hospitals where he is admitted to practice deliver quality care. Consumers' Checkbook publishes one of the best rating systems on hospitals: Consumers' Checkbook Guide to Hospitals, with rating of 4,500 hospitals. It rated hospitals in the 71 major Metropolitan Statistical Areas in the nation. Checkbook has a Web site at www.checkbook.org. You can see the ratings on the top 50 hospitals at www.modernmaturity.org.
The Checkbook ratings of 4,500 hospitals are based on medical and surgical mortality, accreditation score from the national organization that rates all hospitals, the opinions of physicians and the training programs available to the hospital's doctors.
The Joint Commission on Accreditation of Healthcare Organizations reviews hospitals against established standards, and after inspections, it rates them. The hospitals studied by Checkbook had ratings of 71 to 100. The commission has a Web site with information on hospitals and how to select them (www.jcao.org) as does the American Hospital Association (www.aha.org). The commission also maintains a site of hospitals out of this country at www.jointcommissioninternational.com. There is also a book on medical tourism (going out of the country to get surgery or other care). It is by Josef Woodman and is entitled Patients Beyond Borders. However, medical tourism is a subject beyond the scope of this guide.
There are many other books and periodicals that rate hospitals. One of the best-known ratings is published by the magazine, U.S. News and World Report.
More and more surgery is now carried out in doctors' offices and outpatient clinics, some of it quite substantial and serious. For example, there are plastic surgeons that do most of their work in their own office. This should be approached with special caution, because unlike a hospital-based or hospital-related facility, the doctors' offices are subject to little or no regulation. These surgeons may be top quality, but make sure they have the emergency-room type capabilities on premises in case something goes wrong.
2. Make your visit to the doctor count. Often the excitement and stress of a visit to a doctor means that the patient remembers little or nothing. So take a long a relative or friend who can perhaps take notes or help you remember what is said. You may want to also take notes or perhaps tape record the entire visit. A doctor should not object to that, as they know better than others how little many patients remember from a visit.
Take a list of questions with you and get answers to all of them. For example, what will the surgery be likely to accomplish and what are the chances of success? What are the other benefits and risks? How long does it take to recover, and what is your situation likely to be during the recovery process? If you don't understand something, ask the doctor to explain it again. If you are in doubt about your understanding, try to restate the doctor's answer and ask whether you got it right.
You want to know how many times the surgeon has performed the operation, and what has his success rate been. The same for the hospital because it is well established that especially for complex operations, practice makes perfect.
Depending on your insurance situation, you may want a clear understanding about fees. This is most important in the case of uninsured surgery, most notably plastic surgery, which is rarely covered. If the fees seem to high, don't hesitate to ask the doctor if some adjustment downward is possible.
3. Get a second opinion. And if you think you need more information or advice, don't hesitate to get a second, a third or whatever it takes. When your life and health are on the line, invest in what it takes to get the right medical outcome. Many insurance companies and HMOs will pay for second opinions and even multiple opinions beyond the second one. In some cases, they may require a second opinion as a condition of paying for the operation.
A second opinion serves multiple functions. It sheds light on whether the initial recommendation makes sense or is the best alternative. It also educates the patient in the process, providing additional understanding, raising questions that need to be answered, and clarifying alternatives and risks. It may also educate the surgeon when he has the benefit of other opinions.
But you have to make sure the second opinion isn't just a rubber stamp of the first opinion. You don't want the surgeon's partner or other associate giving the second opinion. You should try for a totally independent opinion and perhaps another viewpoint. So you may want to go to another office or to a doctor admitted at other hospitals. In some cases, you may want to go out of town.
Keep in mind that doctors are extremely reluctant to criticize a fellow practitioner. So sometimes it is a good idea not to let them know what the recommendation was that you are checking.
But you want that second opinion from a true expert. Many advise going to one of the academic medical centers of excellence. Here in eastern Pennsylvania, you have access to some of the nation's leading surgeons and leading institutions in Philadelphia, Baltimore, New York and even beyond if necessary.
You may want to get opinions from different kinds of specialists. For example, urologists are likely to recommend surgery for prostate cancer. Radiologists and radiation oncologists are most likely to recommend radiation. Other specialists might recommend hormone treatment, perhaps no treatment at all or perhaps some other treatment.
Some hospitals have so-called second opinion services to bring together a large interdisciplinary team of doctors and other health-care providers to render a second opinion (or perhaps multiple opinions if the team doesn't agree). This is an efficient method of getting many different viewpoints from many different experts wrapped into a second opinion. For example, the Lehigh Valley Hospital and Health Network maintains a Urologic Cancer Second Opinion Service. The main drawback of this approach, despite obvious advantages, is that the group usually comes from the same hospital.
Experts agree that second opinions often change the initial thinking of the patient. The Johns Hopkins Family Health Book cites a study showing that the rate of Caesarian sections dipped from 18 to 11 percent when second opinions were required. Even if the second opinion doesn't change the decision, as we've seen, it is still likely to add to the understanding of the medical problem and better equip the patient to make a sound decision and also to carry through with the recommended treatment.
Another kind of second opinion involves the pathology report. Just as doctors often disagree over the need for surgery, there can be dramatic disagreement over a pathology report. One expert may say it's cancer, the other that it is not. So the second opinion on pathology is sometimes as important or even more important than the surgery opinion itself. Whenever findings are ambiguous or otherwise subject to doubt, a second opinion on pathology is a good idea.
When opinions differ, the patient has to make an informed decision, often with the help of the family doctor, other advisers and the doctors whose opinions are in conflict.
4. Be especially on guard if one of the operations most often unnecessarily performed is proposed for you. Among those, according to Charles Inlander of the People's Medical Society, are hysterectomies, Caesarian sections, cataract surgery and prostatectomy (removal of the prostate).
Some critics would add that women should also be especially wary of surgery because of the surgical statistics involving operations performed only on females, which seem to be done in excessive numbers. Laurence and Weinhouse, in their book Outrageous Practices, write, "A list of the country's most common inpatient operations is dominated by surgery performed exclusively on women. ... That the most common operations in the country are procedures for which only half the population is eligible is truly astonishing."
5. The patient, not the doctor or surgeon, is supposed to - and is entitled to - make the decision on whether to have surgery. Listen to the experts. But remember, it's still your decision. You're the one that will have to live the consequences of surgery, whether good or bad. You also want the decision to reflect your values and objectives. You're entitled to have the facts you need and you're entitled to decide whether or not to go ahead with the surgery. As the title of the old television show goes, "This is your life."
Herb Denenberg, a former Pennsylvania insurance commissioner and professor at the Wharton School, is a longtime Philadelphia journalist and consumer advocate. He is also a member of the Institute of Medicine of the National Academy of Sciences. His column appears daily in The Bulletin. You can reach him at advocate@thebulletin.us.
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