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The Thin Line Between Necessary and Optional Operations in Medical Procedure

In medicine, an operation is considered necessary when the risk of death or a permanent disability resulting from not operating exceeds the risks associated with surgery. Advances in medicine and an aging population have led to rising demand for surgical procedures. For example, hip and knee replacements are now everyday operations among patients who would once have lived with their disabilities. Some doctors argue that this rising demand has led to laxer standards for declaring a procedure medically necessary. It has been suggested that 30 percent or more of inpatient surgeries are unnecessary.

Some Surgeries May or May Not Improve Health Conditions

Some surgical procedures provide a clear benefit to patients, such as surgery to treat cancer or repair a mechanical heart valve. However, many other operations fall into the gray area between necessary and optional treatment.

For example, ileoanal anastomosis for ulcerative colitis neither prolongs nor improves the patient's life expectancy. However, it reduces incontinence and enhances the quality of life by lowering bowel frequency from 12 times daily to 3 times daily.

Gastric banding reduces obesity-related illness, but it is also associated with a high risk of serious complications requiring reoperation. In reviewing the literature on bariatric surgery, investigators have concluded that "there is little evidence of long-term benefits for most patients."

The primary benefit of bariatric surgery was weight loss, which led to improvements in hypertension and diabetes. You can check Dr Ben Dodd Brisbane who is a Bariatric Surgeon who leads many Upper GI and Bariatric Surgery research projects through the HUB Research Group for more details.

Advancement In Technology

The number of operations possible has increased with advances in medical technology. For example, more than 150 types of elective procedures involving the chest, abdomen, and pelvis are now available to physicians. One consequence of this increasing clinical menu is that it is difficult for any individual physician to maintain expertise in all general operations.

Some Surgical Procedures are Experimental

Many surgical procedures are performed at least partly on an experimental basis without previous evidence about their safety or efficacy.

In Britain, some people had experimental heart valve implants. A good percentage received implants of tissue engineered from animals as a treatment for severe burns. Some people were treated with artificial hip joints before these devices had been subject to clinical trials.

Only a tiny percent of the patients given synthetic implants in Britain during this period received approval from an ethics committee to participate in the experimental procedures. These high rates of non approved surgery led officials to call for formal consent procedures.

In other words, many operations are performed on humans without prior testing or formal approval—giving some patients risks that others will not accept even if they have been fully informed about those risks.

Patient Demand

Then there is patient demand. Some patients' needs may be unreasonable because they do not understand their condition or the consequences of an operation.

In Canada, the United Kingdom, and other countries, surveys have shown that patients request surgery for medically questionable reasons.

A percentage of patients desire a hysterectomy, varicose vein stripping, and breast reduction.

In some cases, patient demand is used as an argument for unnecessary operations. For example, there has been a dramatic increase in the number of "vaginal rejuvenation" operations reported within the past decade.

The American College of Obstetricians and Gynecologists has stated that there is little evidence to support these surgeries; yet, more than these procedures are performed in the United States alone.

Many insurance companies will not pay for such surgery because it is considered a medicare coverage and cosmetic surgery with no medical indication.

Increase of Surgical Supply

The supply side of medicine also encourages unnecessary surgical procedures and commercial pressures on hospitals to provide good services. Some surgeons have been accused of overprescribing surgery due to self-referral from their practices or investments.

There are cases where surgeons have been able to increase revenue by increasing the number of operations performed. The income can be even higher for a surgeon who owns a chain of hospitals from performing unnecessary surgery on Medicare patients at one hospital.

Some Surgical Criteria are Inappropriate

One difficulty in assessing the unnecessary surgery literature is that research studies vary widely in their criteria for classifying procedures as "unnecessary" or "appropriate."

For example, one study compared surgical rates between children who died of cancer and those who died of trauma. The researchers determined that some pediatric trauma centers performed operations (e.g., amputation) on these children when more conservative treatment options existed with better outcomes, indicating that the trauma surgeries were medically inappropriate.

To make valid comparisons across studies, one must first decide what criteria to define a procedure as appropriate or necessary.

Increased Free Medical Services

The predominant fee-for-service system in American medicine may encourage more procedures than those used in health care providers were paid according to different methods.

The incentives inherent in this system can lead physicians to overtreat or undertreat their patients not to lose income. This potential conflict of interest has been well established, and Congress is currently considering altering the system to base physician payments on performance rather than procedure.

Patients Opinions

Patients may demand procedures that their physicians do not consider to be in their best interest due to popular media and other social influences. In one study, 86 percent of women with breast cancer reported that they would choose mastectomy even if a doctor suggested only less-extensive surgery, such as lumpectomy.

The bottom line is this: Whether we like it or not —and whether we believe it will make any difference—we all need to be advocates for our health care and take steps to reduce medical errors. There is too much at stake.

We can all avoid mistakes, complications, and overmedication by taking responsibility for our health. Unfortunately, the health care system is not set up to help us become active participants in that process today, except in prevention and wellness.


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