Decisions about surgery: The rock and the hard place

Dr Mary Wyatt

Successful surgery starts with the best decision about whether surgery should be performed.
A reason to worry

Jane, a 46 year old store manager, had surgery for tennis elbow that had not improved after six months. She developed the condition from repeatedly hanging clothes in her role managing a fashion outlet. Focused on her work, she felt uncomfortable handing over tasks to her two part-time staff when the condition initially developed.

Despite a number of treatments, Jane’s tennis elbow didn't improve. Frustrated, she pressured her doctor for further treatment. In response, he referred her to a surgeon who suggested an operation. At six months Jane decided to go ahead with surgery.

Unfortunately Jane’s elbow surgery was complicated by development of non-specific pain and a frozen shoulder. While the frozen shoulder improved over 12 months, she suffered considerably with the shoulder pain. Jane’s arm pain also continued.

This pain was lessened with medication, but at 16 months post-surgery it was still giving Jane significant bother. It stopped her from doing a number of home-based activities. She was back at work part time but not able to do much around the store other than serve customers.

At 18 months post injury, Jane thought her chance of returning to her normal job was low.

Surgery for tennis elbow doesn't have a great reputation and there's little scientific evidence to say it helps. Tennis elbow surgery is generally reserved for cases that don't improve after a prolonged period such as 12-18 months.

So, how did Jane end up having surgery?

First and foremost, Jane felt under pressure to get better. Surgery was presented as a potential solution. Her surgeon gave her what I would consider an overly optimistic estimate of the likely chance of success. There was little discussion about the potential downsides.

A frustrated and demoralised Jane, limited at home and at work, was 'over' being in pain. She felt guilty and couldn't be the person she wanted to be at home and work, and grasped at the opportunity to fix the condition. 

So Jane went ahead with surgery: hopeful, expecting, and in some ways desperate for a solution.

Expectations versus reality

In situations like this, we often see people make decisions about surgery based on hope, rather than a balanced understanding of the pros and cons of an operation. 

In many instances, surgery is straightforward and is clearly needed.

  • A cartilage tear in the knee can cause significant pain and limits function. In this situation, a person isn’t likely to get better without surgery. Done early and appropriately, surgery for a cartilage tear generally produces a good result.
  • A disc prolapse in the back that presses on the nerves to the bladder and bowel can cause long-term incontinence. Surgery for this condition needs to be done urgently.
  • Surgery for classic carpal tunnel symptoms also generally produces a good outcome.

In other cases, the benefits from surgery are less clear cut.

  •  A 62 year old with a worn rotator cuff who has shoulder surgery for a full thickness rotator cuff tear does not have a high chance of success. The likelihood of them being able to return to a manual job is low.  
  • Surgery for someone who has back pain with diffuse leg pain and much distress has a poor chance of resolving the pain and making a difference in return to work.
Why does unnecessary surgery occur?

Surgeons focus on surgery

It's the way they help people, and it's the way they earn their income.  

My 85-year-old father had hip pain and his x-ray showed moderate hip osteoarthritis. However the type of pain he experienced and the pattern of his symptoms didn't sound like hip osteoarthritis.

An opinion was sought from two well-respected surgeons.  Both advised a hip replacement without conducting a physical examination. Under pressure, a scan was done. This was followed up with a cortisone injection into the local bursa at the hip and that resolved his pain. Hip surgery in someone of his age group is a major undertaking and would have been unnecessary.

This was not a complicated medical condition; it was an everyday problem that resulted in the advice to operate based on inadequate assessment of the patient.  Advice to undergo a major procedure with a one year recovery (not a sneeze for someone in their 80s) with what I would say was a cursory review of his condition.   

Patients often feel that they should do as they are told. Their specialist tells them to get an operation and they feel they should do as is recommended. They may have some concerns, but the surgeon is busy so the patient doesn't press them with their questions. 

Most people don't have doctor daughter in the background grumbling about surgery recommendations.   

Or, the patient believes that their employer or claims manager will consider them not motivated if they don't go ahead with surgery.  But being a 'good' patient doesn't always produce a good outcome.

Surgeons think they get better outcomes than research tells us

We often hear what we want to hear, and surgeons are not different.

People feel they should be positive when they return to the surgeon after their operation. They may not complain, as the surgeon is busy and there is not time. It's common to see a patient tell you they are not happy about the results of the surgery, yet receive a letter from the surgeon saying there has been a good outcome.

A surgeon I worked with closely developed his own case of carpal tunnel syndrome. He had operated on hundreds of patients with this condition. After his own surgery, he was surprised about the amount of post-operative pain he had and complained bitterly. Yet it was the type and amount of pain we usually see after carpal tunnel surgery.  

As a surgeon, he was great at making sensible diagnoses and getting good outcomes. One can only assume either he just didn't listen to his patient's post-operative complaints, or his patients didn't complain that much when they went to their post-operative reviews.  He was a great surgeon, perhaps his patients didn't want to respond to him negatively. 

The helping profession feels the need to help

Doctors and surgeons aim to help. Faced with a distressed patient, doctors feel they have to 'do' something. The pressure to provide treatment often outweighs concerns about lack of effectiveness from treatment. At least something is being done for the patient.  

We see this in many areas - overuse of investigations, overuse of opiates or strong pain medicine, ongoing physio that isn't making a significant difference.  And we see it in some cases of surgery.  

Scientific evidence

As with medicine generally, research on the outcome of various operations is not well used. Good quality research still needs to be done for some operations. For other operations, research is available but is ignored. There are a number of initiatives to improve the use of available evidence, but we are a long way from best practice.  

Advice and explanation takes time, and sometime lots of time

In Jane's case, letting her know about the natural history of tennis elbow was key. The condition generally gets better, but often takes up to a year.  

Sorting out the work concerns so she was ok about handing over tasks would have made a difference. Teaching her how to do things in a different way, such as using different clothes hangers, may well have sorted out the problem. After all, tennis players with tennis elbow often change their technique. They avoid prolonged rest and generally avoid surgery.

Ensuring Jane's workplace knew she was still a keen employee, and arming her with tools to manage her condition - as well as reassurance the problem would settle with time - would likely have avoided her having surgery - and all of the post surgery suffering. These approaches may have helped her stay in the job she now considered she would lose.  

How can you assist someone in this situation?

It's important to be aware of the influence of expectations and assumptions when considering surgery. Even in straightforward operations, there is not a guaranteed outcome.  

It's vital patients are given realistic information about surgery - the benefits and the risks.  

Stay tuned for a two-part series on how to help ensure people make the best decision they can about proceeding with surgery.