Surgical Consultation — when is the right time?

Hhammerwithnailow to make a surgeon cry:  “I don’t want surgery.  What should I do about my hip pain?”  Surgeons are faced with this question every day.  Most of the time the answer is “well, when you are ready you can always come back.”  To be blunt, surgeons are trained to do surgery and surgeons lose money when they spend time doing something else.  In fact, they often don’t have much experience with the “non-operative” management of many conditions.

Think about the problem.   Would you ask a butcher what he would recommend for a vegetarian meal?  Would you ask a home builder about the best apartment to rent?  Would you ask a car mechanic about where to drive your car for a vacation?  It is possible the butcher, home builder or car mechanic will have a good answer but chances are not too great.  So why would this be different with surgeons or other specialists?

The general rule is to ask someone a medical questions who does not have a vested interest in the answer.  Or to do a good job of investigating symptoms on the Internet before getting a consultation so you can ask good questions and be “a little” skeptical.  A primary care doctor’s office is the first place to pose the question.   If the primary care office in uncertain about a diagnosis then a higher level consultation is in order — the question to primary care should be “who would best be able to guide me to the next step?”  Like, “I am having some mild hip pain.  I don’t want to consider surgery yet.  What non-operative treatment is available?”

Recently a friend was having knee pain.  She saw her primary care provider who suggested cutting back on hiking.  That did not seem very high tech so she saw a surgeon who recommended surgery.  Since the knee MRI was normal she was skeptical.  She took some Tylenol and a few weeks later the pain was gone.  The old saying “if you have a hammer then everything looks like a nail” is very true in the procedural world.

Another example comes from gastroenterology.  If a patient has gas and bloating which do you think a gastroenterologist will do first:  a $1000 colonoscopy or trial of a dietary change?  — you guessed it, often the colonoscopy!  Worse,  if the colonoscopy is normal you will likely be sent to primary care to try some dietary changes and some lab tests.  The appropriate route to take is to let primary care suggest the diet changes, get some lab tests and simple x-rays.  Then, if the problem is still not solved go for the colonoscopy.

In health care systems where physicians have a  financial incentive to provide quality and follow evidence-based guidelines the number of unnecessary procedures declines.  Surgical complications are probably higher than you realize.  Taking time to seek answers before getting that surgical consultation is very important.

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