Unnecessary surgery: Let's cut that!

(photo:Dr. Brian Goldman)

(photo:Dr. Brian Goldman)

This week on White Coat Black Art, we explore the surprisingly deep and broad problem of unnecessary surgery.  The central argument of the book 'Overdiagnosed: Making People Sick in the Pursuit of Health' by Gilbert Welch, Lisa Schwartz and Steve Woloshin is that diagnosis of 'pre-conditions' -- think 'pre-diabetes' - inevitably leads to over-investigation and over-treatment of more and more patients. What's disturbing is that over-surgery seems to be a growing problem as well.

You'd be amazed at the kinds of operations that make the list. Just last month, a study by the Institute for Clinical Evaluative Sciences in Toronto found nearly a third of angioplasties and heart bypass surgery done in Ontario is either borderline or completely unnecessary. A 2010 report by the Canadian Institute for Health Information found orthopaedic surgeons do more than 3,600 unnecessary arthroscopic knee surgeries a year across Canada for people with osteoarthritis. That's despite research showing the procedure fails to reduce pain or improve function.  

Like your car mechanic, a surgeon knows a lot more about the operation than you do.   Evening up the odds takes up a lot of time and effort. It also helps if you have a personal stake in the matter.

Holly Bridges has both - in spades.  In 2007, the author and journalist was having heavy bleeding due to uterine fibroids. Her then-gynecologist recommended a total abdominal hysterectomy.  This was hardly a radical piece of medical advice. After caesarean section, total abdominal hysterectomy is the second most common operation that women undergo in North America. This year alone, an estimated 700,000 North American women will have the operation. 

Here's the thing.  An influential paper published in the Journal of Obstetrics and Gynecology concluded that a whopping 70  percent of hysterectomies did not meet criteria set by the American College of Obstetrics and Gynecology.

The 2010 CIHI report I cited previously found wide variations across Canada in the rate of hysterectomy.  In that report, rates of hysterectomies varied by more than 60 per cent from one province to the next.  Prince Edward Island led the pack at a rate of 512 hysterectomies per 100,000 women.  At 311 per 100,000, British Columbia lost a provincial race for most hysterectomies for which I think it should be quite proud.  While CIHI did not come right out and call many of those operations unnecessary, it did concede the obvious: when you get wide variations in rates of hysterectomy such as these, it suggests that some are being done unnecessarily.

It took the tragic death of her sister in a car accident to make Bridges question her desire to have a hysterectomy and to look for alternatives. In her book, 'The UNHysterectomy. Solving Your Painful, Heavy Bleeding Without Major Surgery', Bridges aims to teach other women what she learned the hard way.

Using her journalistic research skills, it didn't take her too long for her to find them, including ten minimally-invasive procedures as well as medications and other treatment strategies.

Knowing there are alternatives to a hysterectomy is one thing; finding someone who offers those alternatives is another. Bridges soon bumped up against a sclerotic culture of medicine that is slow to embrace change.

"Gynecology by its own admission in most of the cases is very slow to embrace the new technologies and the new methodologies," she told WCBA.  "You have very well-meaning, well-intentioned (for the most part) gynaecologists. Waiting lists are long.  They're trying to keep up.They're trying to do their best. "

"You have these gynaecologists who are looking for the fastest solution possible with the fewest complications that they know of. So it's (abdominal hysterectomy) sort of the devil they know."

In cringe-inducing detail, Bridges counts the factors and the forces aligned against woman avoiding unnecessary surgery. For the gynaecologist in practice, though the fee for doing minimally-invasive surgery may be higher, the surgeon makes more money doing things the old-fashioned way because her or she can do abdominal hysterectomies much quicker.

Worse still, the well-entrenched culture of modern health care actively discourages young physicians and surgeons from embracing new techniques. In her book, Bridges has a disturbing interview with a young gynaecologist who learned the new techniques in residency, only to be discouraged from using them once out in practice.

Bridges' story has a happy ending. Her search led her to the doorstep of one of the first mavens of minimally-invasive gynecology surgery to set up shop in the nation's capital. 

Author and patient Holly Bridges makes a lot of sense. It bothers me that gynaecologists are sticking with the old-fashioned abdominal hysterectomy because that's all they know and because it's faster to do them - and because it means doctors can keep their wait lists down by cranking them out. Sounds to me like the system serves gynaecologists more than their patients. That needs to change.

One place that is embracing an entirely new way of thinking is the Sunnybrook's Holland Orthpaedic & Arthritic Centre located in downtown Toronto.  There, the people who replace worn out hips and knees are cutting back on needless operations by embracing change.

I visited the clinic where they assess patients for possible hip and/or knee replacement surgery.  As I looked around, the clinic was bursting with patients, each seen - history, physical, six-minute walk test, x-ray - with binding efficiency.  Almost all of them were seen - not by an orthopaedic surgeon - but by an advanced practice physiotherapist. I counted just one orthopod in the entire clinic.

Advanced practice physiotherapists (APPs) are like a physio on steroids. They receive extra training in doing assessments, ordering x-rays and other tests, doing procedures and prescribing medications.  They've been an unqualified success in the United Kingdom, Australia and New Zealand. They're becoming a new success story in Canada as well. 

Mary Elia
has arthritis in her hips.  She's already had surgery on the right one. On the day I attended the clinic, Elia came to find out if it's time for surgery on the left side. Putting Elia through her paces was APP Susan Robarts. 

Robarts is the  the all-powerful gatekeeper of hip and knee replacements. Mary doesn't get a new hip unless she gets to see the orthopaedic surgeon.  And she won't see one unless Susan Robarts says so.

Turning APPs like Susan Robarts into gatekeepers was a change born of necessity. At the time, Ontario had one of the longest wait times for joint replacement surgery. The bottlenecks?  Time spent waiting to see the orthopaedic surgeon and even more time spent waiting for surgery once patients actually got to see the surgeon. When they looked at the system, they discovered an elemental problem: the wait lists were clogged with people who didn't need a new hip or knee. 

That happened for two reasons. First, family doctors - the people who made those referrals - weren't good at determining who needed a new joint and who didn't. Second, and this may surprise you, but orthopaedic surgeons were likewise not so good at making the call based on a five-minute appointment.

Enter the APP. Susan Robarts has the time, the knowledge and the skill to decide who needs to see the orthopaedic surgeon and who doesn't.  She and fellow APPs triage each and every one of the sixty or so referrals per week that the hospital receives for joint replacement. 

"That change up front made a big difference," Robarts told WCBA.  "We were (now) triaging referrals on a daily basis, and then patients are seen within two to three weeks as opposed to a year or eighteen months."

In the beginning, patients were worried about seeing an APP instead of the surgeon. But, she charmed them by offering to answer any question they wanted to put to the orthopod and to be judged by the answers she gave.

"We're not to be a barrier to see the surgeon," says Robarts. "We're just trying to maximize patients' function and prepare them to visit the surgeon when they need it." In addition to shortening wait times, installing APPs as gatekeepers has had another profound effect:  they've reduced unnecessary hip and knee replacements.

"We do get patients coming in that say 'my doctor told me I need a knee replacement'," says Robarts.  "And sometimes that doctor is an orthopaedic surgeon. And, their x-rays are terrible; they have bone on bone degenerative changes. But we've done a six minute walk test and they're at the 75th percentile.  So, we'll turn to the patient and say 'what do you think?'"

You might think all this talk about avoiding surgery is bad for orthopaedic surgeons like Dr. Jeff Gollish - who works alongside APP Susan Robarts - guess again. "Patients get great comfort knowing that with the advanced practice physiotherapist, they've had a good assessment.  Someone has listened to them and explained their options.  And they've had time to think about it before seeing the surgeon," he told WCBA.

Hip and knee replacements are just the beginning. Installing APPs as gatekeepers also promises to cut down on unnecessary back operations. Beyond orthopaedics, the province of Saskatchewan is looking at cutting down on prostate surgery by having non-surgeons do the initial triage of men with elevated PSA tests.

Smart people are trying to put the right people with the right skills into the right place at the right time to cut down on unnecessary surgery.

They're onto something big.
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