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

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    I am a neurosurgeon,
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    and I'm here to tell you today
    that people like me need your help.
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    And in a few moments, I will tell you how.
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    But first, let me start off by telling you
    about a patient of mine.
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    This was a woman in her 50s;
    she was in generally good shape,
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    but she had been in and out
    of hospital a few times
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    due to curative breast cancer treatment.
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    Now, she had gotten a prolapse
    from a cervical disc
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    giving her radiating pain
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    of an intense kind out into the right arm.
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    Looking at her MRI before the consultation
    I decided to suggest an operation.
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    Now, neck operations like this
    are standardized and they're quick,
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    but they carry a certain risk.
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    You make an incision right here,
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    and you dissect carefully
    past the trachea, the esophagus,
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    and you try not to cut
    into the internal carotid artery.
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    Then you bring in the microscope,
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    and you carefully remove the disc
    and the prolapse in the nerve root canal
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    without damaging the cord and the nerve
    root lying only millimeters underneath.
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    A worst-case scenario
    is a damage to the cord,
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    which can result in paralysis
    from the neck down.
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    Explaining this to the patient,
    she fell silent.
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    And after a few moments,
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    she uttered a few very decisive words
    for me and for her.
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    "Doctor, is this really necessary?"
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    And you know what I realized
    right there and then?
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    It was not.
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    In fact, when I get patients
    like this woman,
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    I tend to advise not to operate.
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    So what made me do it this time?
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    Well, you see, this prolapse
    was so delicate
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    I could practically see myself
    pulling it out of the nerve root canal
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    before she entered the consultation room.
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    I have to admit it;
    I wanted to operate her.
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    I'd love to operate her.
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    Operating like this is, after all,
    the most fun part of my job.
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    I think you can relate to this feeling.
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    My architect neighbor says
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    he loves just sit and draw
    and design houses.
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    He'd rather do that all day
    than talk to the person,
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    the client paying for the house,
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    that might even give him
    restrictions on what to do.
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    But like every architect, every surgeon
    needs to look the patient in the eye,
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    and together with the patient,
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    they need to decide on what is best
    for the person having the operation.
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    And that might sound easy,
    but let's look at some statistics.
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    The tonsils are the two lumps
    in the back of your throat;
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    they can be removed surgically,
    and that's called a tonsillectomy.
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    This chart shows the operation rate
    of tonsillectomies in Norway
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    in different regions.
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    What might strike you is that
    there is twice the chance that your kid -
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    because this is for only children -
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    will get the tonsillectomy
    in Finnmark than in Trondheim.
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    The indication in both
    regions are the same.
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    There should be
    no difference but there is.
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    Here's another chart.
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    The meniscus helps stabilize the knee
    and can be torn or fragmented acutely,
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    typically during sports like soccer.
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    What you see here is the operation rate
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    for this condition,
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    and you see that the operation rate
    in Møre og Romsdal
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    is five times the operation
    rate in Stavanger.
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    Five times.
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    How can this be?
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    Did the soccer players
    in Møre og Romsdal play dirtier
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    than anywhere else in the country?
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    (Laughter)
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    Probably not.
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    I've added some information now.
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    What you see now is the procedures
    performed in public hospitals
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    are light blue.
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    The one in private clinics is light green.
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    There is a lot of activity
    in the private clinics in Møre og Romsdal,
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    isn't there?
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    What does this indicate?
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    Possible economic motivation
    to treat the patients.
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    And there's more.
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    Recent research has shown
    that the difference of treatment effect
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    between regular physical therapy
    and operations for the knee,
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    there is no difference.
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    Meaning that most of the procedures
    performed on the chart I've just shown
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    could have been avoided,
    even in Stavanger.
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    So what am I trying to tell you here?
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    Even though
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    most indications for treatments
    in the world are standardized,
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    there is a lot of unnecessary variation
    of treatment decisions,
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    especially in the Western world.
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    Some people are not getting
    the treatment that they need,
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    but even a greater portion of you
    are being overtreated.
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    "Doctor, is this really necessary?"
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    I've only heard that question
    once in my career.
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    My colleagues say they never heard
    of these words from a patient.
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    And to turn it the other way around,
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    how often do you think
    you'll get a "no" from a doctor
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    if you ask such a question?
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    Researchers have investigated this,
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    and they come up with
    about the same "no" rate wherever they go,
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    and that is 30 percent.
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    Meaning, three out of 10 times
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    your doctor prescribes
    or suggests something
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    that is completely unnecessary.
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    And you know what they claim
    the reason for this is?
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    Patient pressure.
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    In other words, you.
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    You want something to be done.
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    A friend of mine came to me
    for medical advice.
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    This is a sporty guy,
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    he does a lot of cross-country
    skiing in the wintertime,
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    he runs in the summertime,
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    and this time he had gotten
    a bad backache whenever he went jogging,
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    so much that he had to stop doing it.
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    I did an examination,
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    I questioned him thoroughly.
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    What I found out
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    is that he probably had a degenerated disc
    in the lower part of his spine.
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    Whenever it got strained, it hurt.
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    He'd already taken up swimming
    instead of jogging.
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    There was really nothing
    to do, so I told him,
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    "You need to be more selective
    when it comes to training.
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    Some activities are good for you,
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    some are not."
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    His reply was,
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    "I want an MRI on my back."
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    "Why do you want an MRI?"
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    "I can get it for free
    through my insurance at work."
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    "Come on," I said -
    he was also my friend -
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    "that's not a real reason."
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    "Well, I think it's going to be good
    to see how bad it looks back there."
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    "When did you start interpreting
    MRI scans," I said.
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    (Laughter)
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    "Trust me on this,
    you're not going to need the scan."
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    "Well," he said,
    and after a while he continued,
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    "it could be cancer."
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    (Laughter)
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    He got the scan, obviously.
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    And through his insurance at work
    he got to see one of my colleagues at work
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    telling him about the degenerated disc,
    that there was nothing to do,
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    he should keep on swimming
    and quit the jogging.
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    After a while, I met him
    again, and he said,
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    "At least now I know what this is."
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    But let me ask you a question.
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    What if all of you in this room
    with the same symptoms had an MRI?
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    And what if all the people
    in Norway had an MRI
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    due to occasional back pain?
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    The waiting list for an MRI
    would quadruple, maybe even more.
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    And you would all take the spot
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    on that list from someone
    who really had cancer.
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    So a good doctor sometimes says no,
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    but the sensible patient also turns down,
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    sometimes, an opportunity
    to get diagnosed or treated.
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    "Doctor, is this really necessary?"
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    I know this can be
    a difficult question to ask.
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    In fact, if you go back 50 years,
    this was even considered rude.
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    If the doctor had decided
    what to do with you, that's what you did.
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    A colleague of mine,
    now a general practitioner,
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    was sent to away
    on a tuberculosis sanitarium
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    as a little girl.
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    For six months.
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    It was a terrible trauma for her.
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    She later found out, as a grown-up,
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    that her tests on tuberculosis
    had been negative all along.
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    The doctor had sent her away
    on nothing but wrong suspicion.
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    No one had dared or even considered
    confronting him about it.
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    Not even her parents.
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    Today, the Norwegian health minister
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    talks about the patients'
    healthcare service.
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    The patient is supposed to get advice
    from the doctor about what to do.
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    This is great progress,
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    but it also puts
    more responsibility on you.
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    You need to get in the front seat
    with your doctor
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    and start sharing decisions
    on where to go.
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    The next time you're in a doctor's office
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    I want you to ask,
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    "Doctor, is this really necessary?"
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    And you might feel in many patients' case
    the answer would be "no."
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    But an operation could also be justified.
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    So doctors, what are the risks
    attached to this operation?
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    Well, five to 10 percent of patients
    will have worsening of pain symptoms.
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    One to two percent of patients
    will have an infection in the wound
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    or even a re-hemorrhage
    that might end up in a re-operation.
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    0.5 percent of patients
    also experience permanent hoarseness,
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    and a few, but still a few,
    will experience reduced function
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    in the arm or even legs.
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    "Doctor, are there other options?"
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    Yes, rest and physical therapy
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    over some time might get you
    perfectly well.
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    "And what happens if I don't do anything?"
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    It's not recommended,
    but even then there's a slight chance
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    that you will get well.
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    Four questions, simple questions.
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    Consider them your new toolbox
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    to help us.
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    Is this really necessary?
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    What are the risks?
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    Are there other options?
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    And what happens if I don't do anything?
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    Ask them when your doctor
    wants to send you to an MRI,
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    when he prescribes antibiotics
    or suggests an operation.
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    What we know from research
    is that one out of five of you,
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    20 percent,
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    will change your opinion on what to do.
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    And by doing that, you will not only
    have made your life a whole lot easier
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    and probably even better,
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    but the whole healthcare sector
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    will have benefited from your decision.
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    Thank you.
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    (Applause)
Title:
Why your doctor needs your help to battle over-treatment | Christer Mjåset | TEDxOslo
Description:

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

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Video Language:
English
Team:
TED
Project:
TEDxTalks
Duration:
11:06

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