Why do surgeons continue to perform unnecessary surgery?
© The Author(s). 2017
Received: 14 December 2016
Accepted: 14 December 2016
Published: 13 January 2017
Leading causes of death in the United Statesa
1. Heart disease (~614 000 deaths per year)
2. Cancer (~591 000 deaths per year)
3. Medical errors (~440 000 deaths per year)
What do we mean by unnecessary surgery? We define this as any surgical intervention that is either not needed, not indicated, or not in the patient’s best interest when weighed against other available options, including conservative measures [1, 15]. From a historic perspective, the threat of unnecessary surgery has been publicized as far back as the 1950s, when Dr. Paul Hawley, the Director of the American College of Surgeons (ACS), stated that “the public would be shocked if it knew the amount of unnecessary surgery performed (…)” . More than twenty years later, in 1976, the American Medical Association (AMA) called for a congressional hearing on unnecessary surgery, claiming that there were “2.4 million unnecessary operations performed on Americans at a cost of $3.9 billion and that 11,900 patients had died from unneeded operations (…)” .
In 2016, the existence of unnecessary surgery remains a daunting reality that continues to expose our patients to an unjustified surgical risk . For example, multiple clinical trials have shown that spinal fusions for back pain do not lead to improved long-term patient outcomes when compared to non-operative treatment modalities, including physical therapy and core strengthening exercises [19, 20]. In spite of these insights from high-quality trials, spinal fusion rates continue to dramatically increase in the United States . Another relevant example is arthroscopic partial meniscectomy, one of the most commonly performed surgical procedures in the world . This minimally invasive surgery allows treating internal knee damage through small percutaneous skin incisions, with a fast-track postoperative recovery period. In the United States alone, surgeons perform approximately 700,000 arthroscopic partial meniscectomies every year. Strikingly, a recently published prospective randomized controlled trial (“Finnish Degenerative Meniscal Lesion Study”/FIDELITY trial) that assessed patient outcomes after arthroscopic meniscal trimming compared to sham surgery revealed no benefit for patients from the routine surgical procedure at 12 months follow-up . Actually, considering the risk for patients sustaining a severe intra- or postoperative complication, no surgical procedure should be considered “routine” from the patient’s perspective . Yet, until present, a change in practice has not occurred, and arthroscopic meniscectomies continue to be performed on hundreds of thousands of patients in the United States every year [24, 25].
Consider this provocative analogy: If surgery were a pharmaceutical drug, the procedure would be required to undergo scrutiny of testing its safety and feasibility in phase 1 and 2 trials. Subsequently, its efficacy would have to be proven in prospective randomized controlled trials prior to approval by the Food and Drug Administration (FDA) . Yet, the FDA does not regulate surgical procedures. Common sense would impose the expectation that whenever new level 1 evidence disproves a benefit for a certain surgical procedure, the ineffective practice would be called into question and abandoned immediately. This is obviously not the case in the field of surgery.
We perform surgery because we have been trained to do so and because “we have always done it this way” or we simply do not know any better. In German psychology, this behavior is analogous to a historic entity termed “Funktionslust” .
We are incentivized to perform surgical procedures, either for financial gain, renown, or both.
As representatives of the most privileged and rewarding profession on Earth, it is our duty as surgeons to be unwavering patient safety advocates. This mandates that we recognize the common - yet extremely dangerous - incentives of unnecessary surgery and their potentially deleterious effects on our patients. Once these “hidden threats” are recognized and mitigated, surgeons can begin to foster a transparent culture of shared decision-making and thereby form a true partnership with their patients . Under this evolving paradigm, patients are encouraged to participate in the choice of their treatment based on the best available scientific evidence, while surgeons take into consideration and respect their patients’ personal values, fears, and expectations . By embracing patient safety as a core responsibility for surgeons, we have the opportunity of eliminating the “phantom menace” of unnecessary surgery and the associated risk of preventable patient harm.
This responsibility is not negotiable. The onus is on us.
PFS designed the editorial and drafted the first version of the manuscript. TFV and FJK provided critical feedback and input to the final version of the article. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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