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

Christer Mjåset's talk addresses one of the biggest problems in Western medicine: over-treatment. Although doctors rely on standards and recommendations in medicine on all levels, variation in the use of diagnostic tools and treatment is a widespread phenomenon. What can you do as a patient to battle over-treatment and how can you benefit from taking it seriously?

Christer Mjåset is a neurosurgeon and the Vice President of the Norwegian Medical Association. He is also a published author of five books and an experienced lecturer on different medical topics.

This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at https://www.ted.com/tedx

I am a neurosurgeon,

and I'm here to tell you today
that people like me need your help.

And in a few moments, I will tell you how.

But first, let me start off by telling you
about a patient of mine.

This was a woman in her 50s;
she was in generally good shape,

but she had been in and out
of hospital a few times

due to curative breast cancer treatment.

Now, she had gotten a prolapse
from a cervical disc

giving her radiating pain

of an intense kind out into the right arm.

Looking at her MRI before the consultation
I decided to suggest an operation.

Now, neck operations like this
are standardized and they're quick,

but they carry a certain risk.

You make an incision right here,

and you dissect carefully
past the trachea, the esophagus,

and you try not to cut
into the internal carotid artery.

Then you bring in the microscope,

and you carefully remove the disc
and the prolapse in the nerve root canal

without damaging the cord and the nerve
root lying only millimeters underneath.

A worst-case scenario
is a damage to the cord,

which can result in paralysis
from the neck down.

Explaining this to the patient,
she fell silent.

And after a few moments,

she uttered a few very decisive words
for me and for her.

"Doctor, is this really necessary?"

And you know what I realized
right there and then?

It was not.

In fact, when I get patients
like this woman,

I tend to advise not to operate.

So what made me do it this time?

Well, you see, this prolapse
was so delicate

I could practically see myself
pulling it out of the nerve root canal

before she entered the consultation room.

I have to admit it;
I wanted to operate her.

I'd love to operate her.

Operating like this is, after all,
the most fun part of my job.

I think you can relate to this feeling.

My architect neighbor says

he loves just sit and draw
and design houses.

He'd rather do that all day
than talk to the person,

the client paying for the house,

that might even give him
restrictions on what to do.

But like every architect, every surgeon
needs to look the patient in the eye,

and together with the patient,

they need to decide on what is best
for the person having the operation.

And that might sound easy,
but let's look at some statistics.

The tonsils are the two lumps
in the back of your throat;

they can be removed surgically,
and that's called a tonsillectomy.

This chart shows the operation rate
of tonsillectomies in Norway

in different regions.

What might strike you is that
there is twice the chance that your kid -

because this is for only children -

will get the tonsillectomy
in Finnmark than in Trondheim.

The indication in both
regions are the same.

There should be
no difference but there is.

Here's another chart.

The meniscus helps stabilize the knee
and can be torn or fragmented acutely,

typically during sports like soccer.

What you see here is the operation rate

for this condition,

and you see that the operation rate
in Møre og Romsdal

is five times the operation
rate in Stavanger.

Five times.

How can this be?

Did the soccer players
in Møre og Romsdal play dirtier

than anywhere else in the country?

(Laughter)

Probably not.

I've added some information now.

What you see now is the procedures
performed in public hospitals

are light blue.

The one in private clinics is light green.

There is a lot of activity
in the private clinics in Møre og Romsdal,

isn't there?

What does this indicate?

Possible economic motivation
to treat the patients.

And there's more.

Recent research has shown
that the difference of treatment effect

between regular physical therapy
and operations for the knee,

there is no difference.

Meaning that most of the procedures
performed on the chart I've just shown

could have been avoided,
even in Stavanger.

So what am I trying to tell you here?

Even though

most indications for treatments
in the world are standardized,

there is a lot of unnecessary variation
of treatment decisions,

especially in the Western world.

Some people are not getting
the treatment that they need,

but even a greater portion of you
are being overtreated.

"Doctor, is this really necessary?"

I've only heard that question
once in my career.

My colleagues say they never heard
of these words from a patient.

And to turn it the other way around,

how often do you think
you'll get a "no" from a doctor

if you ask such a question?

Researchers have investigated this,

and they come up with
about the same "no" rate wherever they go,

and that is 30 percent.

Meaning, three out of 10 times

your doctor prescribes
or suggests something

that is completely unnecessary.

And you know what they claim
the reason for this is?

Patient pressure.

In other words, you.

You want something to be done.

A friend of mine came to me
for medical advice.

This is a sporty guy,

he does a lot of cross-country
skiing in the wintertime,

he runs in the summertime,

and this time he had gotten
a bad backache whenever he went jogging,

so much that he had to stop doing it.

I did an examination,

I questioned him thoroughly.

What I found out

is that he probably had a degenerated disc
in the lower part of his spine.

Whenever it got strained, it hurt.

He'd already taken up swimming
instead of jogging.

There was really nothing
to do, so I told him,

"You need to be more selective
when it comes to training.

Some activities are good for you,

some are not."

His reply was,

"I want an MRI on my back."

"Why do you want an MRI?"

"I can get it for free
through my insurance at work."

"Come on," I said -
he was also my friend -

"that's not a real reason."

"Well, I think it's going to be good
to see how bad it looks back there."

"When did you start interpreting
MRI scans," I said.

(Laughter)

"Trust me on this,
you're not going to need the scan."

"Well," he said,
and after a while he continued,

"it could be cancer."

(Laughter)

He got the scan, obviously.

And through his insurance at work
he got to see one of my colleagues at work

telling him about the degenerated disc,
that there was nothing to do,

he should keep on swimming
and quit the jogging.

After a while, I met him
again, and he said,

"At least now I know what this is."

But let me ask you a question.

What if all of you in this room
with the same symptoms had an MRI?

And what if all the people
in Norway had an MRI

due to occasional back pain?

The waiting list for an MRI
would quadruple, maybe even more.

And you would all take the spot

on that list from someone
who really had cancer.

So a good doctor sometimes says no,

but the sensible patient also turns down,

sometimes, an opportunity
to get diagnosed or treated.

"Doctor, is this really necessary?"

I know this can be
a difficult question to ask.

In fact, if you go back 50 years,
this was even considered rude.

If the doctor had decided
what to do with you, that's what you did.

A colleague of mine,
now a general practitioner,

was sent to away
on a tuberculosis sanitarium

as a little girl.

For six months.

It was a terrible trauma for her.

She later found out, as a grown-up,

that her tests on tuberculosis
had been negative all along.

The doctor had sent her away
on nothing but wrong suspicion.

No one had dared or even considered
confronting him about it.

Not even her parents.

Today, the Norwegian health minister

talks about the patients'
healthcare service.

The patient is supposed to get advice
from the doctor about what to do.

This is great progress,

but it also puts
more responsibility on you.

You need to get in the front seat
with your doctor

and start sharing decisions
on where to go.

The next time you're in a doctor's office

I want you to ask,

"Doctor, is this really necessary?"

And you might feel in many patients' case
the answer would be "no."

But an operation could also be justified.

So doctors, what are the risks
attached to this operation?

Well, five to 10 percent of patients
will have worsening of pain symptoms.

One to two percent of patients
will have an infection in the wound

or even a re-hemorrhage
that might end up in a re-operation.

0.5 percent of patients
also experience permanent hoarseness,

and a few, but still a few,
will experience reduced function

in the arm or even legs.

"Doctor, are there other options?"

Yes, rest and physical therapy

over some time might get you
perfectly well.

"And what happens if I don't do anything?"

It's not recommended,
but even then there's a slight chance

that you will get well.

Four questions, simple questions.

Consider them your new toolbox

to help us.

Is this really necessary?

What are the risks?

Are there other options?

And what happens if I don't do anything?

Ask them when your doctor
wants to send you to an MRI,

when he prescribes antibiotics
or suggests an operation.

What we know from research
is that one out of five of you,

20 percent,

will change your opinion on what to do.

And by doing that, you will not only
have made your life a whole lot easier

and probably even better,

but the whole healthcare sector

will have benefited from your decision.

Thank you.

(Applause)