Do You Need That Surgery? How To Decide, And How To Pick A Surgeon If You Do
So your doctor has told you some of the scariest words you can possibly hear: You need surgery. What do you do next?
If you need an emergency surgery, like an appendectomy or a procedure after an accident, you usually don't have much choice in the matter. You'll likely get it done in the hospital where you went to the emergency room, unless the hospital isn't equipped to do it. If that's the case, you'll get transferred.
But if you've been told you need a less-than-urgent procedure — something like a joint replacement, or surgery to remove cancer — you actually have quite a bit of choice about where you go. That choice can make a big difference to your health.
When my patients come to me, a primary care doctor, and ask for my advice in picking a surgeon, I usually start by asking them a few questions.
Do you need it?
The first and most important step is to figure out if surgery is actually what you need.
Sometimes, surgery is a slam-dunk solution to your medical problem. If you have recurrent pain from gallstones, for example, you almost always need to get your gallbladder removed — and it's usually not safe to try to deal with it without surgery.
But there are plenty of medical problems that aren't easily solved by surgery, like back or shoulder pain. This can be frustrating, and you'll need to make a personal decision if the benefits of the procedure really outweigh the risks.
Unfortunately, you may be told that surgery is a quick fix — even if it isn't. Unnecessary surgeries happen all the time, according to Marty Makary, a pancreatic cancer surgeon at Johns Hopkins and author of the forthcoming book on health care, The Price We Pay.
"If there's one theme in the medical literature in the last five years, it's that we have been overdoing it," Makary says.
A 2017 survey of more than 2,000 U.S. physicians, for example, asked doctors how much medical care in their specialty wasn't needed. Respondents estimated that about 11% of all procedures performed in the U.S. were unnecessary.
Search the medical literature
So do you really need that surgery? Your primary care doctor can help you make that decision.
When I work with my patients, I ask what the reason for the surgery is and the name of the recommended procedure. Sometimes patients don't remember all the medical terminology, so it's a good idea to hang on to copies of your records so you can talk to other doctors about your situation.
I also help patients look at the medical literature. We'll search or for systematic reviews — that's a type of research paper that compiles results from multiple studies — about how well the procedure works for their medical problem. That can help them decide if they want to go ahead with it.
Get a second opinion
Even if the recommendation for surgery seems sensible, I almost always encourage my patients to get a second opinion. It can help you be a more informed patient.
I suggest getting a second opinion from a doctor who works in a different group or hospital system from the surgeon you've already seen, since there's some evidence that doctors who work in the same region have similar practice patterns.
A 2018 paper, for example, studied if and when spinal surgeons around the U.S. performed spinal fusion surgery for a slipped vertebra — a controversial procedure because it doesn't always help with back pain. The authors found that there was significant geographic variation in how frequently patients got the surgery.
Getting a second opinion may not require travel. Many surgical specialists will do telephone or video chat consults for patients looking for an additional opinion.
The surgeon or specialist you consulted with first should encourage you to talk to other doctors, says Shannon Brownlee, senior vice president of the Lown Institute, an organization that fights against profit-driven health care.
If not, it's a red flag.
"Any doctor who objects to you getting a second opinion is a doctor you should not be seeing," Brownlee says.
Find a super specialist
If you decide you're getting the surgery, look for a surgeon who specializes — really, really specializes — in the specific procedure you need.
I send my patients to surgeons who perform the exact surgery they need — and who perform it all the time. If you need a knee replacement, don't just pick an orthopedic surgeon. Go to an orthopedic surgeon who's an expert on knees.
Practice makes perfect when it comes to surgery, it seems. A 2016 paper that compiled results from 32 big studies found that the more surgeries a doctor performs, the better patients tend to do. Of course, it depends on factors like how sick patients are and how frequently the type of surgery is needed.
You can look for specialists online by searching for hospitals that offer the surgery you need. But you should also ask around for personal recommendations from other patients, your primary care doctor or other specialists.
If your surgery isn't straightforward and is related to a complicated medical condition, like cancer, try to go to an academic medical center where you can get care from multiple specialists who work as a team. If my patient has breast cancer, for example, she'll get the best care from seeing a breast surgeon and breast oncologist who work together in a comprehensive cancer center.
Interview your top candidates
The next step is surgeon-shopping. Make appointments with different doctors and interview them.
Ask the doctors how many surgeries they do each month and what their specific areas of expertise are. Makary, the pancreatic cancer surgeon, suggests you should also ask if they use minimally invasive techniques — that's when the incision is smaller and recovery time is usually shorter. There are some surgeries where these approaches aren't appropriate, but if they are, your surgeon should know about them. That's a good sign she stays up to date with new technology.
Also, ask how long your surgeon expects the recovery time to be and about any potential complications from the surgery. It can be tricky to predict exactly what will happen after surgery, but in general, look for surgeons who work with physical therapists and nurses to get you up and moving as quickly as possible after surgery. There's evidence that physical activity and eating meals shortly after a procedure can speed up your recovery.
Watch for red flags
Your surgeon's demeanor also matters. Keep an eye out for a doctor who treats you — and her colleagues — with respect. A recent JAMA study showed that surgeons who behave unprofessionally around their coworkers are likely to have more complications after surgery.
"A surgeon doesn't have to have a great bedside manner in order to be a great surgeon, but you want someone who is responsive, someone who will take an interest when things go wrong," Makary says.
Brownlee, of the Lown Institute, suggests you ask your surgeon if she receives any payments from pharmaceutical companies or surgical device manufacturers. These payments can take the form of consulting fees or payments for speaking on the companies' behalf.
According to Brownlee, these kinds of conflicts of interest may influence your doctor to use a particular type of surgical device — even if it isn't right for you.
"It means that your doctor has a financial interest that may make them make decisions that are not in your best interest," she says. "You kind of don't want your surgeon to be in bed with the device industry."
Brownlee recommends that you look up your surgeon on ProPublica's Dollars for Docs website, which tracks payments to doctors from pharmaceutical and surgical device companies. This site is periodically updated with the latest data.
Use online rating sites with caution
In a perfect world, there would be a way to look up statistics on how different surgeons do with complications and clinical outcomes, just like you can compare safety ratings when you're buying a new car. Such a tool doesn't exist yet, but if you're curious, there are a few places where you can try to get some of that information.
For a handful of very common procedures, one site where you can start your search is ProPublica's Surgeon Scorecard website. It lists doctors' death and complication rates for eight different common surgeries.
Use the scorecard and other physician rating sites you find online with some caution, however.
Comparing doctors head-to-head is a new frontier, and there are limitations to the tools that are out there. Sites may be out of date, since they tend to rely on data from Medicare that can take years to process. And they may not show you the whole picture you need to make an informed decision. A surgeon with higher complication rates may not have worse technical skills — it may mean she operates on more complicated patients with more medical problems.
Take your time
Makary urges patients never to rush into surgery. When you find a surgeon you trust, he says, think it over for a few days before scheduling a procedure.
If you have a chronic problem that's been going on for a while, he says, watch out for doctors who try to rush you.
"If you're told that you have a shoulder problem that's chronic, and that you need surgery, and that, 'We have an opening next week' ... Run for your life," Makary says. "People should see a doctor, think about it, weigh the options, come back for another visit and then schedule surgery."
And if you're meeting with several surgeons, he adds, you can even schedule the surgery just to have it on the books while you continue your research. If you end up feeling better about another doctor, cancel it later, he says.
"Don't worry about the doctor's feelings," Makary says."It's your health."
Mara Gordon is a physician and the 2018-2019 health and media fellow at NPR and Georgetown University. In August, she joins the faculty at Cooper Medical School in Camden, N.J.
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