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New Research Questions Need For Some Common Surgeries
By AMY DOCKSER MARCUS
Staff Reporter of THE WALL STREET JOURNAL
After years of excruciating sinus infections, Susan Doyno decided to have surgery. After two separate procedures, not only did the infections persist but she also developed headaches and blood clots.
So she consulted a third sinus surgeon, who reviewed her case history and offered a startling diagnosis: "Surgery has likely caused much of her problems," says the doctor, Robert Pincus of the New York Sinus Center.
In a development that is significantly changing the medical landscape, research is calling into question the value of a wide variety of common surgeries. Thanks to this research and advanced technology -- as well as concern about higher health costs -- doctors are telling many patients not to go under the knife for conditions that were once routinely treated that way.
In the process, a slew of different surgeries -- for everything from back pain to gum disease -- are being put under the microscope. It used to be, for example, that someone who suffered a liver or kidney injury in a car accident had the organ removed. Now in nearly all cases, the patient is tracked but not operated on -- and most of the time, recovery occurs naturally.
Doctors who used to recommend operations to treat arthritic knees and some kinds of hernias are telling patients either to wait or to skip surgery altogether. There's also concern that some cardiologists may be too quick to resort to bypass operations.
The move away from surgery is being spurred in part by such technology as better ultrasounds and CT scans that let doctors monitor a patient more closely without opening them up. But another, more-striking development is also behind the change in mindset: a growing number of studies that show patients who don't get surgery often fare just as well, if not better, than those who do.
Surgeons now see that "the major side effects and complications of surgery are often worse than the disease itself," says John Parrish, a doctor who is the director of CIMIT, a consortium of institutions that develops new medical technologies.
The results of some of the studies have been startling. Donlin Long, a neurosurgery professor at Johns Hopkins Medical Institutions in Baltimore, followed 3,000 patients with severe back and leg pain for two years during the late 1990s. The longstanding approach to treating that problem has been to give patients two weeks to feel better; if they don't improve, then the doctor operates. But the study pointed out flaws in that approach: In 86% of the cases, the patients got better on their own, but it took between one and three months to get there. "The longer you wait, the better chance the patient will recover without any surgery at all," Dr. Long says.
Health-care insurers, which have been putting stiff pressure on doctors to offer less-costly care, already are beginning to factor this new research into their policies. Health plans in general are moving away from requiring patients and doctors to get preapproval for surgeries. Instead some are starting to create lists of procedures that need prior authorization -- these are typically operations that science suggests are performed too frequently, such as hysterectomies or surgery for lower back pain. Doctors may be more willing to try alternatives to these surgeries if they know it will be a struggle to get reimbursed.
Insurers Revisit Policies
The surgery studies have huge implications because so many of these procedures are commonly performed and routinely covered by insurers. An estimated 650,000 people each year, for example, undergo arthroscopic surgery for arthritic knees -- at a cost of $5,000 for each procedure. But last year, a study on the subject found that people who had a placebo version of the surgery (they believed they were actually getting the operation) were likely to feel just as well as those who had the real thing.
After the study came out, Bruce Moseley, a co-author, says some of his partners at Baylor College of Medicine in Houston received letters from their insurer recommending they take the findings into consideration before doing the operation again; the letter stopped short of saying it would no longer be reimbursed.
The movement toward less-intrusive care has been gaining steam in all corners of the medical world. More people avoid drugs unless absolutely necessary, choose the least-invasive procedures, and get out-patient treatment whenever possible. What is different about the current movement is that it is being driven primarily by the one group that seemingly has the biggest incentive to operate: the surgeons. "Radical surgery is a thing of the past," says Richard Andrassy, chairman and professor of surgery at the University of Texas Medical School in Houston.
Doctors say there is some concern about their own liability for recommending watchful waiting as opposed to surgery. But some experts say it is probably sufficient for the physician to carefully document that all of the possible medical risks have been explained, that the patient understood these risks, and that the patient and doctor agreed on the decision not to operate right away.
The new research is even prompting a reduction in some procedures that were already on the decline. Several decades ago, doctors began rethinking the necessity of taking children's tonsils out. As a result, tonsilectomies have become much less common. While 49,001 in-patient tonsilectomies were done in 1993, that number had fallen to 17,344 by 2000. Now, studies are helping to overturn some other antiquated assumptions.
The tradition of operating immediately on hernias of the groin, for example, is based on information that is about a century old, says Robert J. Fitzgibbons, a surgeon at Creighton University in Omaha, Neb. Back then, doctors believed all such hernias (known as inguinal hernias) should be treated right away because of the potential that the bowel might find its way into the hernia and lead to life-threatening complications. "What was a guess by doctors in the early part of the last century became perceived as fact because it is now referenced all the time," he says.
Patient Objections
Of course, surgery plays a central role in medical care. Trauma patients -- people who have been pulled from the wreckage of car, for example -- often don't have a choice but to be operated on. Surgeons also say other ailments like appendicitis can't be cured other than with surgery.
Not all patients are ready to give up the option, even when presented with some other choices. One nonsurgery alternative to treating sinus problems is twice-daily flushing with nasal wash -- unappealing to many new patients. In other cases, avoiding surgery requires people to change their diets or shed weight.
Vijay Vad, a professor of rehabilitation medicine at the Hospital for Special Surgeries at Cornell University Medical Center in New York City, treats many patients with acute back pain. If they want to avoid surgery, he recommends a special yoga and Pilates program three times a week. "It's a lot of work," he says. "The patient has to want to not get to surgery."
But increasingly, both doctors and their patients are embracing the alternatives -- even when the doctor is the patient.
When Charles Filipi, another Creighton surgeon, found he had a hernia in his groin, he went to see his colleague Dr. Fitzgibbons, assuming he would need an operation to repair it. "That's what we were taught in medical school," Dr. Filipi says.
Instead, Dr. Filipi wound up in a study to examine whether watchful waiting worked just as well. He was in the group that didn't get surgery. Two years later, he says, "I feel fine."
Write to Amy Dockser Marcus at amy.marcus@wsj.com