Posts Tagged ‘surgery’

Medical Second Opinions: An Under-utilized Option for Patients

Monday, May 2nd, 2011

Today’s medical world is vast with various technologies, treatments and options.  So, if a patient is diagnosed with a medical condition, and doctor A recommends treatment A, what keeps the patient from seeking a second opinion? This is an interesting phenomenon.  After performing intake summaries and client interviews for quite a while now, it still amazes me how many people have bad outcomes from surgery simply because they never requested a second opinion. Second opinions are not simply reserved for surgery, though; cancer treatment options, medical therapies for chronic conditions like rheumatoid arthritis or inflammatory bowel disease, chiropractic care of chronic back or neck pain are some other conditions that, in my mind, scream for a second opinion!

Having practiced medicine for 13 years, working with physicians from all specialties, I can honestly say that doctors are not gods. They are human beings, no different than you or me, and human beings are prone to prejudice and errors. Granted, physicians go through a lot of education and training to perform their daily duties, but location of training, timing of training and educational mentors play a huge role in shaping the decision-making process of these humans.

Inherent limitations that can affect physician recommendations

For example, the latest technology for prostatectomy has been the DaVinci procedure, using minimally invasive robotic technology to surgically remove the prostate.  Operation of the robotics involves manipulation of “joysticks”, much like video-gaming. No offense, but if your particular urologist is 60 years of age or older, what are the chances that this particular surgeon is as adept with these skills or technology as a 30-year-old urologist?  Special training is required for use of these robotics, and not all hospitals even have the technology available. Therefore, one’s choices are automatically limited, and a minimally-invasive robotics-assisted procedure may not even be an option! A second opinion by another urologist at a different facility might be able to provide that option. A similar situation would be the use of gamma knife surgery for removal of brain tumors; it is not always an option available based on the facility or the neurosurgeon providing the consultation.

Can recommendations be limited by specialty?

Another example has to do with medical specialty affiliation. If one is trained as a surgeon, he/she focuses on the technical removal or repair of abnormal body parts. If one is trained in radiation-oncology, the focus would be the various radiation technologies available for treatment of disease. If one is a medical oncologist, chemotherapy protocols for the particular neoplastic condition would be the focus.  So who ties all of this together?  First of all, is the tumor even operable? Is the patient a good candidate for surgery? Should one try radiation first to shrink the tumor, then follow it with an operation? Is chemotherapy the way to go, but which regimen of drugs is really appropriate? These are very technical and complex questions. Should one leave the ultimate recommendation up to one specialty physician?

Suggested approach to the problem

For me, it would be a little more comforting to get the same overall recommendation from two independent physicians. What if the opinions differ?  A third opinion? – or, simply focus on the discrepancies with direct questioning of the two physicians and find out the rationale for the recommendation being made. You do not know how many times I have heard, “I trusted my doctor.” I ask you, if your car was making a rattling noise but seemed to be running okay and a mechanic told you a new transmission was necessary at the cost of $1800, would you get a second opinion?

Don’t let fear or reprisal get in your way

One of the main reasons for fear in seeking second opinions is anticipated disapproval and potential retaliation by the first physician or fear of a change in the patient-physician relationship.  I pose to you the following:  if a physician has done his/her research regarding the condition and is confident is his/her recommendation, then he/she should not fear the opinion of a peer. If that opinion differs, it should be reviewed for accuracy and appropriateness because it might just be a viable option not previously considered. If the physician is “offed” by the patient’s search for a second opinion, that physician thinks way too highly of himself/herself; keep in mind that this is about the patient who has a condition that requires treatment, not the physician’s integrity or ego. It is my firm opinion that physicians should be proud of those patients who advocate so strongly for themselves and seek to be educated about their condition.  Education leads to a better understanding of the disease process, better expectation of the “road ahead,” and better patient compliance with medical therapies. Retaliation is prohibited by the medical code of ethics; if there is a retaliatory action, the state’s Medical Board should be notified and prompted to investigate.

Beware of the on-line second opinion approach!!!

Recently, multiple facilities have offered a “second opinion service” via the internet. A patient submits his/her medical condition along with various lab studies and other diagnostic imaging (CT scans, x-rays, MRI scans, etc.) for review over the internet; an opinion is provided based on these facts!  What this really doesn’t take into consideration is the patient!  Patients are people – human beings with emotions, physical limitations, families (or not), previous histories and other underlying health conditions. One of the things I was taught in PA school was to treat the patient and not the numbers!  Not all patients are surgical candidates.  Not all patients can emotionally or physically tolerate some of the chemotherapy protocols. Someone might look good on paper with great blood parameters, vital signs, etc., but in person, one’s assessment changes dramatically.  These virtual second opinions may have their place in certain situations, but I generally have to question the validity of such an assessment.

A “real-life” story

I leave you with a quick summary of a case:  Mr. B was a 40-something, physically fit male professional, who loved to work out and exercise. He developed some mechanical back pain for which he sought treatment. An MRI scan revealed an incidental finding of small spinal cord glioma in the low back. Clinically, there was no evidence to support that this incidental finding was in any way related to Mr. B’s pain. He sought the advice of a neurosurgeon, who immediately wanted to operate. Well, if research had been done, these particular tumors are 99% benign, very slow-growing and can often be monitored for 10 to 20 years before surgery might even be necessary.

Mr. B followed the advice of the surgeon and underwent a resection of this small tumor. The surgery required resection of the S1 nerve root, which affects sensation in the genital region and anus; Mr B was now impotent and had problems with bowel movements in addition to a chronic burning sensation in his genital region. A second opinion might well have saved Mr. B a lot of pain, permanent erectile dysfunction and money required to undergo alternative methods for conception. He’ll never know now.

Have you or someone you know gotten second opinions before making a decision about an important medical procedure? What’s your approach? Have you ever received different opinions about how to treat a condition? How did you resolve this situation? Any tips for others?

Image: Wellsphere.com

Update: After posting Theresa Neumann’s piece this morning, I came across a somewhat related post on KevinMD.com entitled Marcus Welby and the relentless growth of specialization. The author, Jan Henderson, PhD, raises some very interesting thoughts about what I would call the “over-specialization” of medicine. She provides the following quote of Dr. Welby from very first episode of this TV show of years gone by, which – to me – supports one of the concerns raised by Theresa in her blawg:

… I hope some of you will go into general practice. For if you don’t, where will a patient turn who doesn’t know that he has an orthopedic problem? Or a neurological problem? Or a psychiatric problem? Or a nutritional problem? But who only knows that, in lay terms, he feels lousy.

Just some food for thought you might enjoy.

Brian Nash (editor of “Eye Opener”)

A Surgeon’s Sleep Deprivation and Elective Surgery – Not a good (or safe) combination

Friday, January 14th, 2011

The New England Journal of Medicine published a Perspective on December 30, 2010, that screams common sense and should be embraced as a starting point to implement some new patient-safety standards of practice.

Place yourself in the position of a patient getting ready to undergo an elective (i.e. non-emergency) surgical procedure. You’re wheeled into the operating room for your surgery and are greeted by your surgeon in the process. Your mind is focused on just coming out alive and better than when you went in. What you don’t know, however, is your surgeon has been up all night handling a busy call schedule. If you knew he/she was dead tired as any human being would be under the circumstances, would you really want this surgeon operating on you? If you don’t care, then this post is really of no interest to you. If you do care, then read on.

Well, you’re still reading…so you must have some level of concern for your safety. Good for you because here’s a startling number in terms of adverse incidents when involving sleep deprived surgeons:

Researchers have documented the adverse effects of sleep deprivation and sleep disorders on individual performance. In surgery, there is an 83% increase in the risk of complications (e.g., massive hemorrhage, organ injury, or wound failure) in patients who undergo elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep between procedures during a previous on-call night.

Note that this relates to elective surgery – you elected to have it; it is not an emergency. Sure, if the surgery has to be rescheduled, that’s a major inconvenience and not emotionally satisfying after you have prepared yourself for the “magic hour” when you are to be taken to the operating room. In most surgeries, you have not been allowed to eat since midnight (NPO status) if you are going to be anesthetized during your surgery. But let me ask – would you rather be inconvenienced or suffer from “a massive hemorrhage, organ injury, or wound failure” – to name but a few of the things that could go wrong at the hands of a sleep deprived surgeon?

The NEJM article reports that “most patients would be concerned about their safety if they knew their doctor had been awake for the prior 24 hours.” I really don’t think they needed a survey to reach that conclusion. Do you?

So how is this risky situation supposed to be avoided? Are you supposed to ask your surgeon: “So did you get a good night’s sleep?” Or – “How you feeling today, Doc? Well rested?” While some more assertive patients might take this approach, way too many, I’m afraid, would just “trust” their doctor to know  better than to operate under such a condition and advise the patient now is not a good time for him/her to do the surgery. In an ideal world, that’s what should happen – but we don’t inhabit such a world now do we? For whatever motivation – some good; some not so good, I sincerely doubt this is going to happen and certainly should not be the standard. In fact, the following excerpt from the NEJM piece addresses this very issue – at least in part:

Chronic sleep deprivation degrades one’s ability to recognize the impairments induced by sleep loss.5 Sleep-deprived clinicians are therefore not likely to assess accurately the risks posed when they perform procedures in such a state, and they should not be permitted to decide whether or not to proceed with elective surgery without obtaining the patient’s informed consent.

That’s a start, but frankly, I’m not really a big advocate of this approach. Obtaining my informed consent? So what happens – I’m told as I’m awaiting my surgery that my doctor has been up all night and the prior day. He then asks, “Are you willing to have your surgery anyway?” I then ask: “Well how are you feeling? Are you up to doing this?” If I get an affirmative response, why should the burden be on me (read: YOU in this scenario) to make a decision if it’s alright to proceed?

I much prefer the primary suggestion of the authors:

As a first step, we recommend that institutions implement policies to minimize the likelihood of sleep deprivation before a clinician performs elective surgery and to facilitate priority rescheduling of elective procedures when a clinician is sleep-deprived. In addition, patients should be empowered to inquire about the amount of sleep their clinicians have had the night before such procedures.

While I say I “prefer” this approach of “implementing policies to minimize the likelihood of sleep deprivation,” I would modify this “recommendation” to read – “to implement policies to eradicate the likelihood of sleep deprivation or in those instances where certain “sleep guidelines” have not been met, to mandate the rescheduling of this elective surgery. Note that the latter part of this “first step” recommendation puts the burden back on the patient “to inquire about the amount of sleep their clinicians have had the night before such procedures.” Same issues; same problems. The patient should not be put in this position. The hospitals ought to be protecting the patient in such situations, not empowering them – whatever that means!

This is a problem whose solution is not that complex. It is a problem whose solution is way too long overdue. I would urge the medical profession and hospital  administrators to stop trying to be “balanced” on this issue. Sure it’s an inconvenience for all concerned. No doubt this can wreak havoc in terms of a hospital’s operating room scheduling. Too bad! Figure out ways to deal with “call schedules” then. Don’t place the onus on the patient. The health industry claims it is constantly in search of ways to improve safety. Well isn’t this a pretty simple issue to tackle if that’s the case?

What are your thoughts on this issue? Would you be concerned if the person holding the surgical instrument for your procedure has sleep deprivation? Would you ask the questions about their sleep patterns or how much sleep they got the night before? Should this be a patient’s burden? What policies make sense? Share your thoughts with our readers. Maybe – just maybe – the right people might read your comments and come up with some solid policies to protect all of us in such circumstances.

Image: peoplespharmacy.com

Non-Cardiac Surgery Too Soon After Cardiac Stenting Increases Risk of Complications

Friday, May 14th, 2010

According to a recent study published in Circulation: Cardiovascular Interventions (an American Heart Association journal), patients should attempt to postpone having surgeries for at least six weeks after a coronary angioplasty procedure with stenting.  Researchers found that patients who wait at least six weeks before having another surgery are less likely to develop reduced blood flow to the heart (a.k.a. heart ischemia) and heart attacks.

The study data revealed that 42 % of patients who had other surgeries within the six-week period developed these complications. Only 13 % of patients who had surgeries beyond the six-week period developed the same complications. The study focused 1,953 patients with an average age of 64 who had cardiac angioplasty with stenting between 2003 and 2007.

According to the American Heart Association:

  • Over 70 percent of coronary angioplasty procedures in the United States also include stenting.
  • In 2006, approximately 65 percent of PCI procedures were performed on men, and approximately 50 percent were performed on people age 65 or older.
  • In 2006, an estimated 1,313,000 PCI procedures were performed in the United States.
  • In 2006, approximately 76% of stents implanted during PCI were drug-eluting, compared with 24 percent bare-metal stents.
  • In 2006, there were 652,000 PCI procedures with stents — 425,000 in men, 227,000 in women.

If you recently had cardiac stenting and require another surgery, make sure to ask your doctor about waiting to have the next surgery. This is particularly true if your next surgery is an elective one. If your doctor or surgeon is not a cardiologist, you may want to consider asking your doctor for a referral to a cardiologist.  You may also want to make sure that your physician or surgeon obtains cardiac clearance before proceeding with another surgery.   Don’t assume that your doctor will do these things for you. Be proactive; ask questions.

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Contributing author: Jon Stefanuca