Editorial
Open Access

Why do surgeons continue to perform unnecessary surgery?

  • Philip F. Stahel1, 2Email author,
  • Todd F. VanderHeiden1 and
  • Fernando J. Kim3
Patient Safety in Surgery201711:1

https://doi.org/10.1186/s13037-016-0117-6

©  The Author(s). 2017

Received: 14 December 2016

Accepted: 14 December 2016

Published: 13 January 2017

Patient safety in surgery has historically suffered from a lack of physician-driven initiatives aimed at recognizing, preventing and mitigating medical errors and surgical complications [1]. In spite of a multiplicity of global patient safety initiatives, mandatory safety protocols and the introduction of surgical safety checklists, we continue to fall short of protecting our patients from preventable harm [2–6]. This unrecognized problem has escalated so far that medical errors currently rank as the 3rd leading cause of death in the United States [7, 8] (Table 1). Strikingly, in the 21st century, we still have to come to terms with the absurd reality that it is significantly safer to board a commercial airplane, a spacecraft, or a nuclear submarine, than to be admitted to a U.S. hospital [9–14]. What can surgeons do to protect their patients from the hidden dangers of an imperfect health care system? The most intuitive solution is to avoid complications originating from surgical treatment that may not be indicated or beneficial for patients in the first place. In other words, avoiding unnecessary surgery could be considered the most pragmatic approach towards reducing preventable surgical complication rates.
Table 1

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)

 

aSource:

▪ http://www.cdc.gov/

▪ Journal of Patient Safety 2013, 9:122–8

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 (…)” [16]. 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 (…)” [17].

In 2016, the existence of unnecessary surgery remains a daunting reality that continues to expose our patients to an unjustified surgical risk [18]. 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 [18]. Another relevant example is arthroscopic partial meniscectomy, one of the most commonly performed surgical procedures in the world [21]. 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 [22]. 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 [23]. 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) [18]. 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.

The title of this editorial asks, “Why do surgeons continue to perform unnecessary surgery?” To phrase it another way, one might pose the question, “Why would a reasonable surgeon consider performing unneeded surgical procedures?” From a surgeon’s perspective, two distinct answers appear intuitive:
  1. 1.

    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” [1].

     
  2. 2.

    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 [26]. 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 [26]. 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.

Declarations

Authors’ contributions

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.

Competing interests

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.

Authors’ Affiliations

(1)
Department of Orthopaedics, and Department of Neurosurgery, University of Colorado School of Medicine, Denver Health Medical Center
(2)
Department of Neurosurgery, University of Colorado, School of Medicine, Denver Health Medical Center
(3)
Division of Urology, Department of Surgery, University of Colorado, School of Medicine, Denver Health Medical Center

References

  1. Stahel PF. Blood, sweat and tears — becoming a better surgeon. Shropshire, UK: TFM Publishing; 2016. p. 320.Google Scholar
  2. Biffl WL, Gallagher AW, Pieracci FM, Berumen C. Suboptimal compliance with surgical safety checklists in Colorado: a prospective observational study reveals differences between surgical specialties. Patient Saf Surg. 2015;9:5.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Gillespie BM, Withers TK, Lavin J, Gardiner T, Marshall AP. Factors that drive team participation in surgical safety checks: a prospective study. Patient Saf Surg. 2016;10:3.View ArticlePubMedPubMed CentralGoogle Scholar
  4. Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgical never events in the United States. Surgery. 2013;153(4):465–72.View ArticlePubMedGoogle Scholar
  5. Stahel PF, Mauffrey C, Butler N. Current challenges and future perspectives for patient safety in surgery. Patient Saf Surg. 2014;8:9.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Kim FJ, da Silva RD, Gustafson D, Nogueira L, Harlin T, Paul DL. Current issues in patient safety in surgery: a review. Patient Saf Surg. 2015;9:26.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Makary MA, Daniel M. Medical error — the third leading cause of death in the US. BMJ. 2016;353:i2139.View ArticlePubMedGoogle Scholar
  8. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122–8.View ArticlePubMedGoogle Scholar
  9. Stahel PF. NASA’s proven safety culture paradigm. Safe Care. 2015;4:54–7.Google Scholar
  10. Kim KO. A first step toward understanding patient safety. Kor J Anesthesiol. 2016;69(5):429–34.View ArticleGoogle Scholar
  11. Ross J. Aviation tools to improve patient safety. J Perianesth Nurs. 2014;29(6):508–10.View ArticlePubMedGoogle Scholar
  12. Renz B, Angele MK, Jauch KW, Kasparek MS, Kreis M, Müller MH. Learning from aviation-how to increase patient safety in surgery. Zentralbl Chir. 2012;137(2):149–54.View ArticlePubMedGoogle Scholar
  13. Prabhakar H, Cooper JB, Sabel A, Weckbach S, Mehler PS, Stahel PF. Introducing standardized”readbacks” to improve patient safety in surgery: a prospective survey in 92 providers at a public safety-net hospital. BMC Surg. 2012;12:8.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Stahel PF. Learning from aviation safety: a call for formal”readbacks” in surgery. Patient Saf Surg. 2008;2:21.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Klaidman S. Coronary - a true story of medicine gone awry. New York: Scribner; 2007. p. 303.Google Scholar
  16. Unneeded operating charged to surgeons. The New York Times, February 17, 1953.Google Scholar
  17. A.M.A. scores ‘unneeded surgery’ report. The New York Times, May 12, 1976.Google Scholar
  18. Why ‘useless surgery’ is still popular. The New York Times, August 3, 2016.Google Scholar
  19. Raabe A, Beck J, Ulrich C. Necessary or unnecessary? a critical glance on spine surgery [German]. Ther Umsch. 2014;71:701–5.View ArticlePubMedGoogle Scholar
  20. Srinivas SV, Deyo RA, Berger ZD. Application of “less is more” to low back pain. Arch Intern Med. 2012;172:1016–20.View ArticlePubMedGoogle Scholar
  21. Jarvinen TL, Guyatt GH. Arthroscopic surgery for knee pain. BMJ. 2016;354:i3934.View ArticlePubMedGoogle Scholar
  22. Sihvonen R, Paavola M, Malmivaara A, Itala A, Joukainen A, Nurmi H, Kalske J, Jarvinen TL. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013;369:2515–24.View ArticlePubMedGoogle Scholar
  23. Grelsamer RP. A patient guide to unnecessary knee surgery. AuthorHouse, 2015, pp.150.Google Scholar
  24. Lyu SR. Why arthroscopic partial meniscectomy? Ann Transl Med. 2015;3:217.PubMedPubMed CentralGoogle Scholar
  25. Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. Br J Sports Med. 2015;49:1229–35.View ArticlePubMedPubMed CentralGoogle Scholar
  26. Page AE. Safety in surgery: the role of shared decision-making. Patient Saf Surg. 2015;9:24.View ArticlePubMedPubMed CentralGoogle Scholar

Copyright

© The Author(s). 2017

Advertisement