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The Right Choice? When surgery is not the right choice


 

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“A chance to cut is a chance to cure.” This common saying summarizes much of the philosophy of surgery. If we have an opportunity to do an operation and fix something, surgeons find it easy to recommend surgery. There is an immediacy about surgery and a surgical cure that is appealing to most surgeons.

As I think back to medical school, I remember that my decision to become a surgeon was greatly influenced by my subinternship in medicine. Whenever one of my patients needed an operation, I was always anxious to know what the surgeons were finding in the operating room. Having been a surgeon for many years now, I never tire of the opportunity to do something in the operating room that solves a patient’s problem. It is not surprising that when there is a surgical option for a problem, many surgeons find themselves recommending surgery. While it may be true that there is often an economic incentive for surgeons to recommend surgery, there are also many situations in which thoughtful surgeons recommend against surgery.

Dr. Peter Angelos

Dr. Peter Angelos

There are many cases in which the risks of the operation outweigh the benefits. If, for example, a patient with widely metastatic colon cancer presents for surgical evaluation, the recommendation will most commonly be against surgery. In such a case, the goal of cure or increased longevity may not be met by an operation to remove a portion of the colon when there will be a significant burden of disease that cannot be removed. In addition to cases of unresectable cancer, there are many situations in which the patient’s comorbidities make the risks of surgery far higher than the benefits. In such cases, surgeons commonly recommend against surgery or, in some cases, actually do not offer surgery as an option. Most often in such situations, the surgeon is consulted for an opinion and once surgery is deemed not to be an option, the surgeon generally steps aside to allow other doctors to provide care for the patient whether it be medical therapies, palliative care, or a combination of both.

In recent years, surgeons have increasingly been involved in nonoperative management strategies. For example, some thyroid cancer patients with small, presumed indolent cancers are entered into clinical trials where observation is one of the arms of the trial. Perhaps most well established is the recommendation that patients with early stage (Gleason 6) prostate cancer consider “active surveillance” as an option to be considered along with surgery and radiation. What is particularly notable in the case of prostate cancer is that even when the recommendation is made for active surveillance, most of these patients continue to follow up with the urologist. In this scenario, even though surgery may not have been recommended by the urologist or chosen by the patient, it is the urologist who maintains the ongoing surveillance with the patient.

In an era in which surgeons often complain about being treated purely as technicians, the role of surgeons in active surveillance should be seen as a breath of fresh air. Here, the surgeons are recommending a course of action that is much less financially beneficial than an operation. Having surgeons involved in such nonoperative strategies clearly expresses the belief that surgeons have in these approaches.

There is another important reason why surgeons should become increasingly engaged in nonoperative treatment strategies. The credibility of the recommendation to consider NOT having surgery is exponentially higher if the recommendation is made by a surgeon. Patients know that surgeons like to operate, are trained to operate, and, in many cases, are paid to operate. In this setting, the recommendation to forgo or, at least, postpone an operation is particularly influential.

There is widespread public acceptance of Abraham Maslow’s statement, “if all you have is a hammer, everything looks like a nail.” When a surgeon recommends something other than surgery it is a much stronger endorsement of the nonoperative treatment than if a nonsurgeon had made the same recommendation. Perhaps equally important is that a recommendation against surgery with ongoing engagement by the surgeon is an illustration of the surgeon’s acting in the patient’s best interests rather than in the surgeon’s best interests. Even though it may always be more difficult not to offer an operation to a patient, surgeons should not shy away from recommending nonoperative strategies when there is clear evidence that such strategies may be better for patients. Although not every patient will be comfortable with a nonoperative approach, surgeons should seek every opportunity to participate fully in such decisions when nonoperative treatments may be in the patients’ best interests.

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