To operate or not to operate: a serious question with no clear answers
What goes into a surgeon’s decision to operate -- or to recommend an alternative treatment option?
Two UCLA-led studies published online May 18 by the peer-reviewed Annals of Surgery sought to answer that question. The upshot is: It might depend as much on how surgeons perceive the world as it does on the patient’s diagnosis.
To ascertain surgeons’ opinions on whether or not to recommend surgery, the researchers emailed invitations to members of the American College of Surgeons who were enrolled in or had completed a general surgery residency program; almost 800 surgeons participated in the online survey. The researchers presented the surgeons with four hypothetical clinical cases – mesenteric ischemia, gastrointestinal bleeding, bowel obstruction and appendicitis. In none of those cases was the best treatment option obvious.
In the first study, the researchers found that surgeons differ in their recommendations for surgery largely because they differ in how they perceive the risks and benefits of operating versus not operating. The surgeons’ estimates of these risks and benefits varied widely. When assessing outcomes such as the likelihood that a patient would suffer a serious complication, for instance, one surgeon could perceive zero risk for a given procedure while another would see a 100 percent chance of that same procedure leading to a major complication.
“These findings suggest that surgeons are possibly communicating to their patients very different estimates on the risks and benefits of treatment, and a patient's likelihood of getting surgery depends largely on how the surgeon happens to perceive these risks and benefits,” said lead investigator Dr. Greg Sacks, a general surgery resident at UCLA and a Robert Wood Johnson/Veterans Affairs Clinical Scholar.
For the second study, the same team of researchers examined how the use of a surgical risk calculator would influence surgeons’ decision to pick up a scalpel under the same set of hypothetical circumstances.
The online risk calculator, developed by the American College of Surgeons National Surgical Quality Improvement Program, uses national registry data to gauge the chances of postoperative complications based on type of surgery, patient demographics, and the state of a patient’s health. While the calculator led surgeons to make more accurate predictions on average and resulted in less variance in their judgments, there was no change in a surgeon’s likelihood of recommending an operation.
“Risk calculators are a useful tool to inform patients and surgeons on the risks involved with an operation,” Sacks said. “However, our data suggest that surgical decisions could further be enhanced by decision tools that also provide estimates on other important parameters, such as the risks and benefits of not operating.”
The take-home message of both studies is that there may not always be clear answers on the best treatment. For that reason, patients might benefit from getting involved in the decision-making process, Sacks said.
“In areas of such uncertainty, these studies suggest that the best we can do is estimate the risks and benefits of each possible treatment and then work with the patient to find a treatment that matches his or her preferences and values,” he said. “It is important to understand that treatment decisions involve complex trade offs, and patients should be prepared to participate in the decision-making process to ensure that the particular trade offs chosen are aligned with their own preferences.”