Medicine and surgery exist to increase the quality of life of the patients. In my opinion, this is the goal of every treatment, which increases life expectancy in many times. To do this, surgeons must know when to operate based on leges artis, but also when not to operate, which is many times based on clinical evaluation, common sense, conscience, and humanity. This is something harder to achieve and that many will never fulfill.
Unnecessary surgery is a common issue which has been discussed by several authors. In general, unnecessary surgery is surgery that brings no benefit to the patient, or surgery in which the benefits it may promote are outweighed by the risks, morbidity, disability, and pain. This topic is discussed by Prof. Dr. Alberto Ferreres from the University of Buenos Aires, Argentina, and former President of the “Academia Argentina de Cirugía”, in a recent article published in “Cirugía Española”. According to this author, unnecessary surgery is useless and ineffective, and its existence undermines the surgeon-patient relationship because patients have no scientific knowledge to evaluate surgical indications. Patients must trust surgeons as we must trust other professionals when we ask for help. The author states that unnecessary surgery results from ignorance, incorrect clinical evaluation with bad indications, and dishonesty (operating to earn money).
Surgeons must know to put the correct indications for surgery, but also be able to decide if the procedure they are willing to do although indicated will bring the patient more disability, pain, and risks than benefit. Sometimes the correct decision is to do nothing and resist other doctors' (non-surgeons) pressures to go for surgery. Pressures from the family and the patient are also to be fought back. Surgeons must support the decision to operate in science and leges artis, but also in their conscience and humanity. Surgery is not only books and guidelines, the reason why some will always be better than others. Some very well-scientifically prepared surgeons have a natural aptitude for surgery – I call it “a natural feeling” – that makes them great.
According to Prof. Dr. Alberto Ferreres, this topic is not recent. In 1894 William Stokes talked about unnecessary surgery with doubtful outcomes for oncological diseases. In 1922 Haggard published “Unnecessary Surgery”, and Paul Hawley (director of the American College of Surgery) stated that the “population would be in shock if they knew how many unnecessary surgeries are performed”. In 1974 in the USA McCarthy and Wicimer concluded from the Second Opinion Program that 17.6% of surgeries had no indication. From that study they estimated that 2.4 million unnecessary surgeries were performed in the USA each year, causing 11900 deaths/year. Unbelievable I must say. Following these data, a committee presented a list of unnecessary surgery categories from which I highlight three:
Surgeries with doubtful indications.
Surgeries to relieve tolerable and not-threatening symptoms.
Surgeries not supported by clinical evaluation, and/or complementary exams.
Unfortunately, in our daily practice is common to see patients being operated on in these circumstances. Some surgeons do not know how to stop and keep trying everything to keep a patient alive while inflicting pain and suffering without any benefit because the patient has an untreatable or terminal disease. Some would say – “it is a young patient” – to justify an unnecessary surgery and the associated dysthanasia. Age alone must not be a factor in deciding whether to operate or not to operate. The surgeon must tailor the decision according to the patient's comorbidities, and the risk/benefit of performing surgery in that specific patient. Is it an easy decision? No, it is not. That is why presenting critical cases in periodic reunions of a Surgery Department is crucial to promoting good surgical practice and outcomes. Additionally, according to Prof. Dr. Alberto Ferreres, in the presence of unnecessary surgeries, Surgery Departments and Institutions must stop surgical practice, and evaluate indications and outcomes. Audits and presentation of results are crucial points to know who is working well and who needs to improve. Patients always come first.
I would like to finalize with two ideas:
A very well-performed surgery for which there was no indication, is still a bad surgery.
The best surgeon is the one who knows when not to operate.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon