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← 4 questions you should always ask your doctor

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Showing Revision 7 created 09/19/2019 by Brian Greene.

  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,
  6. she was in generally good shape,
  7. but she had been in and out
    of hospital a few times
  8. due to curative breast cancer treatment.
  9. Now she had gotten a prolapse
    from a cervical disc,
  10. giving her radiating pain of a tense kind,
  11. out into the right arm.
  12. Looking at her MRI
    before the consultation,
  13. I decided to suggest an operation.
  14. Now, neck operations like these
    are standardized, and they're quick.
  15. But they carry a certain risk.
  16. You make an incision right here,
  17. and you dissect carefully
    past the trachea,
  18. the esophagus,
  19. and you try not to cut
    into the internal carotid artery.
  20. (Laughter)

  21. Then you bring in the microscope,

  22. and you carefully remove
    the disc and the prolapse
  23. in the nerve root canal,
  24. without damaging the cord
    and the nerve root
  25. lying only millimeters underneath.
  26. The worst case scenario
    is the damage to the cord,
  27. which can result in paralysis
    from the neck down.
  28. Explaining this to the patient,
    she fell silent.

  29. And after a few moments,
  30. she uttered a few very decisive words
    for me and for her.
  31. "Doctor, is this really necessary?"
  32. (Laughter)

  33. And you know what I realized,
    right there and then?

  34. It was not.
  35. In fact, when I get patients
    like this woman,
  36. I tend to advise not to operate.
  37. So what made me do it this time?
  38. Well, you see,
  39. this prolapse was so delicate,
  40. I could practically see myself
    pulling it out of the nerve root canal
  41. before she entered the consultation room.
  42. I have to admit it,
    I wanted to operate on her.
  43. I'd love to operate on her.
  44. Operating, after all,
    is the most fun part of my job.
  45. (Laughter)

  46. I think you can relate to this feeling.

  47. My architect neighbor says
    he loves to just sit and draw
  48. and design houses.
  49. He'd rather do that all day
  50. than talk to the client
    paying for the house
  51. that might even give him
    restrictions on what to do.
  52. But like every architect,
  53. every surgeon needs
    to look their patient in the eye
  54. and together with the patient,
  55. they need to decide on what is best
    for the person having the operation.
  56. And that might sound easy.
  57. But let's look at some statistics.
  58. The tonsils are the two lumps
    in the back of your throat.

  59. They can be removed surgically,
  60. and that's called a tonsillectomy.
  61. This chart shows the operation rate
    of tonsillectomies in Norway
  62. in different regions.
  63. What might strike you
    is that there is twice the chance
  64. that your kid --
    because this is for children --
  65. will get a tonsillectomy in Finnmark
    than in Trondheim.
  66. The indications
    in both regions are the same.
  67. There should be
    no difference, but there is.
  68. Here's another chart.

  69. The meniscus helps stabilize the knee
  70. and can be torn or fragmented acutely,
  71. topically during sports like soccer.
  72. What you see here is the operation rate
    for this condition.
  73. And you see that the operation
    rate in Møre og Romsdal
  74. is five times the operation
    rate in Stavanger.
  75. Five times.
  76. How can this be?
  77. Did the soccer players in Møre og Romsdal
  78. play more dirty
    than elsewhere in the country?
  79. (Laughter)

  80. Probably not.

  81. I added some information now.
  82. What you see now
    is the procedures performed
  83. in public hospitals, in light blue,
  84. the ones in private clinics
    are light green.
  85. There is a lot of activity
    in the private clinics
  86. in Møre og Romsdal, isn't there?
  87. What does this indicate?
  88. A possible economic motivation
    to treat the patients.
  89. And there's more.
  90. Recent research has shown
    that the difference of treatment effect

  91. between regular physical therapy
    and operations for the knee --
  92. there is no difference.
  93. Meaning that most
    of the procedures performed
  94. on the chart I've just shown
  95. could have been avoided,
    even in Stavanger.
  96. So what am I trying to tell you here?
  97. Even though most indications
    for treatments in the world
  98. are standardized,
  99. there is a lot of unnecessary variation
    of treatment decisions,
  100. especially in the Western world.
  101. Some people are not getting
    the treatment that they need,
  102. but an even greater portion of you
  103. are being overtreated.
  104. "Doctor, is this really necessary?"

  105. I've only heard that question
    once in my career.
  106. My colleagues say they never heard
    these words from a patient.
  107. And to turn it the other way around,
  108. how often do you think
    you'll get a "no" from a doctor
  109. if you ask such a question?
  110. Researchers have investigated this,
  111. and they come up
    with about the same "no" rate
  112. wherever they go.
  113. And that is 30 percent.
  114. Meaning, three out of 10 times,
  115. your doctor prescribes
    or suggests something
  116. that is completely unnecessary.
  117. And you know what they claim
    the reason for this is?
  118. Patient pressure.
  119. In other words, you.
  120. You want something to be done.
  121. A friend of mine came to me
    for medical advice.

  122. This is a sporty guy,
  123. he does a lot of cross-country skiing
    in the winter time,
  124. he runs in the summer time.
  125. And this time, he'd gotten a bad back ache
    whenever he went jogging.
  126. So much that he had to stop doing it.
  127. I did an examination,
    I questioned him thoroughly,
  128. and what I found out is
    that he probably had a degenerated disc
  129. in the lower part of his spine.
  130. Whenever it got strained, it hurt.
  131. He'd already taken up
    swimming instead of jogging,
  132. there was really nothing to do,
  133. so I told him, "You need
    to be more selective
  134. when it comes to training.
  135. Some activities are good for you,
  136. some are not."
  137. His reply was,
  138. "I want an MRI of my back."
  139. "Why do you want an MRI?"
  140. "I can get it for free
    through my insurance at work."
  141. "Come on," I said --
    he was also, after all, my friend.
  142. "That's not the real reason."
  143. "Well, I think it's going to be good
    to see how bad it looks back there."
  144. "When did you start interpreting
    MRI scans?" I said.
  145. (Laughter)

  146. "Trust me on this.

  147. You're not going to need the scan."
  148. "Well," he said,
  149. and after a while, he continued,
    "It could be cancer."
  150. (Laughter)

  151. He got the scan, obviously.

  152. And through his insurance at work,
  153. he got to see one
    of my colleagues at work,
  154. telling him about the degenerated disc,
  155. that there was nothing to do,
  156. and that he should keep on swimming
    and quit the jogging.
  157. After a while,
    I met him again and he said,
  158. "At least now I know what this is."
  159. But let me ask you a question.

  160. What if all of you in this room
    with the same symptoms had an MRI?
  161. And what if all the people in Norway
  162. had an MRI due to occasional back pain?
  163. The waiting list for an MRI
    would quadruple, maybe even more.
  164. And you would all take
    the spot on that list
  165. from someone who really had cancer.
  166. So a good doctor sometimes says no,
  167. but the sensible patient
    also turns down, sometimes,
  168. an opportunity
    to get diagnosed or treated.
  169. "Doctor, is this really necessary?"

  170. I know this can be
    a difficult question to ask.
  171. In fact, if you go back 50 years,
  172. this was even considered rude.
  173. (Laughter)

  174. If the doctor had decided
    what to do with you,

  175. that's what you did.
  176. A colleague of mine,
    now a general practitioner,
  177. was sent away to a tuberculosis
    sanatorium as a little girl,
  178. for six months.
  179. It was a terrible trauma for her.
  180. She later found out, as a grown-up,
  181. that her tests on tuberculosis
    had been negative all along.
  182. The doctor had sent her away
    on nothing but wrong suspicion.
  183. No one had dared or even considered
    confronting him about it.
  184. Not even her parents.
  185. Today, the Norwegian health minister

  186. talks about the patient
    health care service.
  187. The patient is supposed to get advice
    from the doctor about what to do.
  188. This is great progress.
  189. But it also puts more
    responsibility on you.
  190. You need to get in the front seat
    with your doctor
  191. and start sharing
    decisions on where to go.
  192. So, the next time
    you're in a doctor's office,

  193. I want you to ask,
  194. "Doctor, is this really necessary?"
  195. And in my female patient's case,
  196. the answer would be no,
  197. but an operation could also be justified.
  198. "So doctors, what are the risks
    attached to this operation?"

  199. Well, five to ten percent of patients
    will have worsening of pain symptoms.
  200. One to two percent of patients
  201. will have an infection in the wound
    or even a rehemorrhage
  202. that might end up in a re-operation.
  203. 0.5 percent of patients
    also experience permanent hoarseness
  204. and a few, but still a few,
  205. will experience reduced function
    in the arms or even legs.
  206. "Doctor, are there other options?"

  207. Yes, rest and physical therapy
    over some time
  208. might get you perfectly well.
  209. "And what happens if I don't do anything?"

  210. It's not recommended,
  211. but even then, there's a slight chance
    that you will get well.
  212. Four questions.
  213. Simple questions.
  214. Consider them your new toolbox to help us.
  215. Is this really necessary?
  216. What are the risks?
  217. Are there other options?
  218. And what happens if I don't do anything?
  219. Ask them when your doctor
    wants to send you to an MRI,
  220. when he prescribes antibiotics
  221. or suggests an operation.
  222. What we know from research

  223. is that one out of five
    of you, 20 percent,
  224. will change your opinion on what to do.
  225. And by doing that, you will
    not only have made your life
  226. a whole lot easier,
    and probably even better,
  227. but the whole health care sector
  228. will have benefited from your decision.
  229. Thank you.

  230. (Applause)