English subtitles

← Why your doctor needs your help to battle over-treatment | Christer Mjåset | TEDxOslo

Get Embed Code
10 Languages

Showing Revision 27 created 01/15/2020 by Rhonda Jacobs.

  1. I am a neurosurgeon,
  2. and I'm here to tell you today
    that people like me need your help.

  3. And in a few moments, I will tell you how.
  4. But first, let me start off by telling you
    about a patient of mine.
  5. This was a woman in her 50s;
    she was in generally good shape,
  6. but she had been in and out
    of hospital a few times
  7. due to curative breast cancer treatment.
  8. Now, she had gotten a prolapse
    from a cervical disc
  9. giving her radiating pain
  10. of an intense kind out into the right arm.
  11. Looking at her MRI before the consultation
    I decided to suggest an operation.
  12. Now, neck operations like this
    are standardized and they're quick,
  13. but they carry a certain risk.
  14. You make an incision right here,
  15. and you dissect carefully
    past the trachea, the esophagus,
  16. and you try not to cut
    into the internal carotid artery.
  17. Then you bring in the microscope,
  18. and you carefully remove the disc
    and the prolapse in the nerve root canal
  19. without damaging the cord and the nerve
    root lying only millimeters underneath.
  20. A worst-case scenario
    is a damage to the cord,
  21. which can result in paralysis
    from the neck down.
  22. Explaining this to the patient,
    she fell silent.
  23. And after a few moments,
  24. she uttered a few very decisive words
    for me and for her.
  25. "Doctor, is this really necessary?"
  26. And you know what I realized
    right there and then?
  27. It was not.
  28. In fact, when I get patients
    like this woman,
  29. I tend to advise not to operate.
  30. So what made me do it this time?
  31. Well, you see, this prolapse
    was so delicate
  32. I could practically see myself
    pulling it out of the nerve root canal

  33. before she entered the consultation room.
  34. I have to admit it;
    I wanted to operate her.
  35. I'd love to operate her.
  36. Operating like this is, after all,
    the most fun part of my job.
  37. I think you can relate to this feeling.
  38. My architect neighbor says
  39. he loves just sit and draw
    and design houses.
  40. He'd rather do that all day
    than talk to the person,
  41. the client paying for the house,
  42. that might even give him
    restrictions on what to do.
  43. But like every architect, every surgeon
    needs to look the patient in the eye,
  44. and together with the patient,
  45. they need to decide on what is best
    for the person having the operation.
  46. And that might sound easy,
    but let's look at some statistics.
  47. The tonsils are the two lumps
    in the back of your throat;
  48. they can be removed surgically,
    and that's called a tonsillectomy.
  49. This chart shows the operation rate
    of tonsillectomies in Norway
  50. in different regions.
  51. What might strike you is that
    there is twice the chance that your kid -
  52. because this is for only children -
  53. will get the tonsillectomy
    in Finnmark than in Trondheim.
  54. The indication in both
    regions are the same.
  55. There should be
    no difference but there is.
  56. Here's another chart.
  57. The meniscus helps stabilize the knee
    and can be torn or fragmented acutely,
  58. typically during sports like soccer.
  59. What you see here is the operation rate
  60. for this condition,
  61. and you see that the operation rate
    in Møre og Romsdal
  62. is five times the operation
    rate in Stavanger.
  63. Five times.
  64. How can this be?
  65. Did the soccer players
    in Møre og Romsdal play dirtier
  66. than anywhere else in the country?
  67. (Laughter)
  68. Probably not.
  69. I've added some information now.
  70. What you see now is the procedures
    performed in public hospitals
  71. are light blue.
  72. The one in private clinics is light green.
  73. There is a lot of activity
    in the private clinics in Møre og Romsdal,
  74. isn't there?
  75. What does this indicate?
  76. Possible economic motivation
    to treat the patients.
  77. And there's more.
  78. Recent research has shown
    that the difference of treatment effect
  79. between regular physical therapy
    and operations for the knee,
  80. there is no difference.
  81. Meaning that most of the procedures
    performed on the chart I've just shown
  82. could have been avoided,
    even in Stavanger.
  83. So what am I trying to tell you here?
  84. Even though
  85. most indications for treatments
    in the world are standardized,
  86. there is a lot of unnecessary variation
    of treatment decisions,
  87. especially in the Western world.
  88. Some people are not getting
    the treatment that they need,
  89. but even a greater portion of you
    are being overtreated.
  90. "Doctor, is this really necessary?"
  91. I've only heard that question
    once in my career.
  92. My colleagues say they never heard
    of these words from a patient.
  93. And to turn it the other way around,
  94. how often do you think
    you'll get a "no" from a doctor
  95. if you ask such a question?
  96. Researchers have investigated this,
  97. and they come up with
    about the same "no" rate wherever they go,
  98. and that is 30 percent.
  99. Meaning, three out of 10 times
  100. your doctor prescribes
    or suggests something
  101. that is completely unnecessary.
  102. And you know what they claim
    the reason for this is?
  103. Patient pressure.
  104. In other words, you.
  105. You want something to be done.
  106. A friend of mine came to me
    for medical advice.
  107. This is a sporty guy,
  108. he does a lot of cross-country
    skiing in the wintertime,
  109. he runs in the summertime,
  110. and this time he had gotten
    a bad backache whenever he went jogging,

  111. so much that he had to stop doing it.
  112. I did an examination,
  113. I questioned him thoroughly.
  114. What I found out
  115. is that he probably had a degenerated disc
    in the lower part of his spine.
  116. Whenever it got strained, it hurt.
  117. He'd already taken up swimming
    instead of jogging.
  118. There was really nothing
    to do, so I told him,
  119. "You need to be more selective
    when it comes to training.
  120. Some activities are good for you,
  121. some are not."
  122. His reply was,
  123. "I want an MRI on my back."
  124. "Why do you want an MRI?"
  125. "I can get it for free
    through my insurance at work."
  126. "Come on," I said -
    he was also my friend -

  127. "that's not a real reason."
  128. "Well, I think it's going to be good
    to see how bad it looks back there."
  129. "When did you start interpreting
    MRI scans," I said.
  130. (Laughter)
  131. "Trust me on this,
    you're not going to need the scan."
  132. "Well," he said,
    and after a while he continued,
  133. "it could be cancer."
  134. (Laughter)
  135. He got the scan, obviously.
  136. And through his insurance at work
    he got to see one of my colleagues at work
  137. telling him about the degenerated disc,
    that there was nothing to do,
  138. he should keep on swimming
    and quit the jogging.
  139. After a while, I met him
    again, and he said,
  140. "At least now I know what this is."
  141. But let me ask you a question.
  142. What if all of you in this room
    with the same symptoms had an MRI?
  143. And what if all the people
    in Norway had an MRI
  144. due to occasional back pain?
  145. The waiting list for an MRI
    would quadruple, maybe even more.
  146. And you would all take the spot
  147. on that list from someone
    who really had cancer.
  148. So a good doctor sometimes says no,
  149. but the sensible patient also turns down,
  150. sometimes, an opportunity
    to get diagnosed or treated.
  151. "Doctor, is this really necessary?"
  152. I know this can be
    a difficult question to ask.
  153. In fact, if you go back 50 years,
    this was even considered rude.
  154. If the doctor had decided
    what to do with you, that's what you did.
  155. A colleague of mine,
    now a general practitioner,
  156. was sent to away
    on a tuberculosis sanitarium
  157. as a little girl.
  158. For six months.
  159. It was a terrible trauma for her.
  160. She later found out, as a grown-up,
  161. that her tests on tuberculosis
    had been negative all along.
  162. The doctor had sent her away
    on nothing but wrong suspicion.
  163. No one had dared or even considered
    confronting him about it.
  164. Not even her parents.
  165. Today, the Norwegian health minister
  166. talks about the patients'
    healthcare service.
  167. The patient is supposed to get advice
    from the doctor about what to do.
  168. This is great progress,
  169. but it also puts
    more responsibility on you.
  170. You need to get in the front seat
    with your doctor
  171. and start sharing decisions
    on where to go.
  172. The next time you're in a doctor's office
  173. I want you to ask,
  174. "Doctor, is this really necessary?"
  175. And you might feel in many patients' case
    the answer would be "no."
  176. But an operation could also be justified.
  177. So doctors, what are the risks
    attached to this operation?
  178. Well, five to 10 percent of patients
    will have worsening of pain symptoms.
  179. One to two percent of patients
    will have an infection in the wound
  180. or even a re-hemorrhage
    that might end up in a re-operation.
  181. 0.5 percent of patients
    also experience permanent hoarseness,

  182. and a few, but still a few,
    will experience reduced function
  183. in the arm or even legs.
  184. "Doctor, are there other options?"
  185. Yes, rest and physical therapy
  186. over some time might get you
    perfectly well.
  187. "And what happens if I don't do anything?"
  188. It's not recommended,
    but even then there's a slight chance
  189. that you will get well.
  190. Four questions, simple questions.
  191. Consider them your new toolbox
  192. to help us.
  193. Is this really necessary?
  194. What are the risks?
  195. Are there other options?
  196. And what happens if I don't do anything?
  197. Ask them when your doctor
    wants to send you to an MRI,
  198. when he prescribes antibiotics
    or suggests an operation.
  199. What we know from research
    is that one out of five of you,
  200. 20 percent,
  201. will change your opinion on what to do.
  202. And by doing that, you will not only
    have made your life a whole lot easier
  203. and probably even better,
  204. but the whole healthcare sector
  205. will have benefited from your decision.
  206. Thank you.
  207. (Applause)