The Business of Surgery: Has Love Been Lost?

The following is excerpted from The Cost of Cutting, by Paul Ruggieri. Tune in to Science Friday on September 19, 2014 to hear Ruggieri dissect the politics and money behind healthcare.

The woman seated on the exam table was lean and fit and seemed to be enjoying perusing one of the magazines from our slightly out-of-date offerings. She looked like she was in her midforties; her chart showed her age to be fifty-two. Her face did not express any distress and when she returned my greeting she spoke in a clear, friendly tone. As I scanned her medical history, the portrait of a person in good health came into view—her lab work, blood pressure, weight: All were excellent.

Healthy and thin are two adjectives I do not often use to describe my patients. Why was this woman in my office?

Several weeks earlier, it turned out, her primary care physician had ordered an abdominal CT scan to investigate a nagging pain that he hadn’t been able to diagnose. Eureka: The radiologist reviewing the scan noticed gallstones. Mystery solved. The patient (we’ll call her Mrs. Brogan) was subsequently referred to me for a “surgical opinion,” a consultation to determine whether surgery could help. As I performed the physical exam, I questioned her and soon concluded that her gallbladder was working perfectly. While some of her symptoms were vague and nonspecific, the gallstones found during the CT were what we in medicine call an incidental finding, nothing more. The true source of Mrs. Brogan’s pain had yet to be determined.

An incidental finding happens when an apparent abnormality of some kind—unrelated to the source of the person’s symptoms—is discovered during a diagnostic imaging exam. For example, if a CT scan of the abdomen is ordered to help with the diagnosis of a bowel problem and the radiologist notices a dark area, a “density,” on the kidney, that information becomes part of the report and is considered an incidental finding. Similarly, if a CT scan of the chest for diagnosis of coronary artery disease reveals a nodule in the lung, that incidental finding is shared with the referring physician and, ultimately, with the patient. Let the testing (and worrying) begin.

Over the past fifteen years there has been a dramatic increase in the use of two sophisticated diagnostic imaging tools: CT and MRI scans. CT (often referred to as a CAT scan), stands for computerized (or computer-aided) tomography, which uses x-ray technology. MRI, which stands for magnetic resonance imaging, uses a magnetic field and radio waves. Both create incredibly detailed views of the organs and soft tissue. According to the Radiological Society of North America (RSNA), while between three and four million CT scans were performed in 1995, seventy million were done in 2010. A report published in the Journal of the American Medical Association (JAMA) in 2012 showed a 400 percent increase in the use of MRI during this same period. It is no wonder, then, that incidental findings are becoming more common and surgery as a result of them is on the rise.

While the advance of technology has tremendous benefits in medicine, the information these tools provide can present problems as well. For example, according to the RSNA, one-third or more of all CT scans will reveal incidental findings, yet fewer than 1 percent of these abnormalities are cancer or in need of any medical treatment. Where is the problem in that? you may be wondering. Knowledge is power, is it not? The problem is that once the radiologist spots the abnormality, he or she will most likely include it in the report. (Seasoned radiologists struggle with “nonspecific” incidental findings and whether to say anything at all. Frequently, the decision to report them is heavily influenced by the ever-present shadow of a malpractice lawsuit.) This often means your doctor must share that news with you, causing you anxiety and necessitating further tests, exposing you to more radiation and often a visit to an operating room for a surgical biopsy.

By the way, the phenomenon of incidental findings is especially prevalent in the Medicare population (those age sixty-five and over). One study, published in the American Journal of Roentgenology in 2005, showed incidental findings to be as high as 75 percent in 259 individuals over age fifty who underwent CT scans. The reason: An aging body coupled with technology powerful enough to produce high-definition images of structures doctors have never seen before is a surefire recipe for incidental findings. Pandora’s box has been opened.

There is, of course, a financial cost for all this information. Americans now spend an estimated $100 billion a year on medical imaging. But more important than the cost in dollars and cents is the cost to a person’s quality of life. As H. Gilbert Welch, M.D., noted in his book, Overdiagnosed, “Imaging technologies are very helpful in finding the abnormalities that are making patients sick. But they are also increasingly able to find abnormalities in people who are well,” a vicious cycle he refers to as “seeing more, finding more, and doing more.” The studies cited in Welch’s book are provocative; it’s difficult to acknowledge that the number of individuals who are hurt by unnecessary medical treatment is far greater than the number helped by the advances in diagnostic imaging, but that’s what the numbers show.

To take a closer look, consider another study from the journal Health Affairs in 2009 looking at how the increased use of MRIs can lead to potentially unnecessary surgery. This data showed that as the use of MRIs for generalized back pain increased, more spine abnormalities were detected. Whether these abnormalities were the true cause of the back pain is unclear. Yet the subsequent increase in back surgery correlates with the increase in MRI diagnostic imaging, despite the lack of definitive evidence that surgery would be beneficial. What that means is a significant number of individuals underwent major surgery on their spines (ranging from a laminectomy to spinal fusion) and yet continued to experience the pain that precipitated the MRI or, even worse, a more severe and disabling pain.

Doctors order diagnostic imaging exams for the best of reasons. The results can be definitive and lifesaving. But they can also be equivocal, unclear. What you, the prospective patient, need to understand is that in some ways your doctor is a detective searching for clues, and what’s “wrong” is not always immediately clear. Incidental findings are often a red herring, diverting attention from the real problem.

Back to Mrs. Brogan.

I had in front of me a woman whose primary care physician had told her of the gallstones revealed on her CT scan. He had recommended that she seek a surgical opinion with me, telling his patient, “I can send you to a surgeon who will try to find any reason to operate on you. I can also send you to a surgeon who will find any excuse not to operate on you. Or I can send you to Dr. Ruggieri, who is somewhere in between.” Mrs. Brogan was free of “underlying conditions” (obesity or a chronic disease such as diabetes that can cause complications during what is usually a straightforward operation). And she was willing. As a matter of fact, when I told her there was nothing wrong with her gallbladder, she had said, “Why not just take the thing out? I don’t need it anyway, do I?”

All that and she had very good health insurance. Reimbursement would not be a problem.

I had an opening in my schedule that week. . . . For a brief moment—and this is difficult to admit—I found myself tempted to schedule the surgery. A completely unnecessary surgery. The operation would have taken me twenty stress-free minutes, Mrs. Brogan would have gone home a few hours after the operation, and I would have been paid close to $1,000.

The only problem: There was no medical reason to do so.

Yes, the CT study had revealed gallstones. But they were totally asymptomatic, which is to say they were not the source of the pain she had been experiencing. Most likely, the gallstones would never in her lifetime become a problem.

Mrs. Brogan’s referring primary care physician had recommended the surgery based on his extensive workup. (He also had no idea where to go next.) He was convinced the gallbladder had to be the source of her pain since the rest of her workup had turned up nothing. Mrs. Brogan had decided that the years of vague left-sided (sometimes right-sided) abdominal pain must be gallstones. All I had to do was recommend surgery. And, like so many people who consult with me, she was of the school of thought that says, If you don’t need it, remove it. The only problem: In my mind, there was no solid medical reason to perform surgery. I was, however, not deaf to the nonmedical “reasons” to schedule the surgery—Mrs. Brogan wanted it; I wanted to please her referring physician; and as a self-employed surgeon, I needed to earn a living and resist turning away potential business. Yet . . . The gallstones discovered on the patient’s CT scan were, in my judgment, strictly an incidental finding, not the cause of her abdominal pain.

Despite the report of gallstones, Mrs. Brogan’s clinical history and physical exam were not consistent with gallstone pain. All of us—her primary care physician, the radiologist who read the CT scan, and I—were missing something. Something else was the source of Mrs. Brogan’s pain; we just didn’t know what it was. I believed her gallstones were asymptomatic, and I reassured her they were no threat. She was, as I explained, one of the millions of Americans walking around with an incidental finding. She did not need to see the overhead lights of an operating room.

According to the University of Michigan Center for Healthcare Outcomes and Policy, unnecessary surgery costs the U.S. healthcare system over $150 billion a year. This is not a new problem. As far back as 1974, a congressional subcommittee report estimated that more than 2.4 million patients a year underwent unnecessary surgery (resulting in twelve thousand deaths). Today it’s estimated that 10 to 20 percent of all operations are not needed. Of course, surgery is not the only way we waste our healthcare dollars; the Institute of Medicine uncovered $750 billion in unnecessary healthcare spending in 2009. Of this, more than $130 billion was spent on higher-cost procedures, such as operations. The cost of unnecessary surgery that can’t be calculated is the price to the individual in lost days at home and work; emotional and physical suffering; and the risks associated with anesthesia, surgical site infection, and medication side effects—not to mention the possibility that the person will become one of the 100,000 a year seriously harmed by a medical error during a hospital stay.

Mrs. Brogan’s story is not unusual in my profession. Every day I evaluate men and women who come to me with a variety of complaints, all believing they are potential candidates for surgery. Some, frankly, do not need surgery—two in four of the new patients I see should be treated in other ways. For others, the problem is obvious and treatable by an operation.

You may find this picture contradictory. Surgeons, including me, need to operate to make a living. When I perform surgery, I am reimbursed by insurance companies for the service I provide. So why would we turn away “business”? The answer lies in our commitment to “first, do no harm.”

When I sit with a prospective surgical patient and recommend an operation, my decision has enormous consequences, both personal and financial, that will affect both of us. What if despite my best intentions, I am wrong in my judgment? What if I mistakenly subject that person to the unnecessary risk of surgery for no true benefit? What financial burdens will I be subjecting the patient to (not to mention the American healthcare system)? What if there is a poor outcome, with complications?

A surgeon’s recommendation to take a person to the operating room should be solely influenced by medical facts, sound judgment, and experience. However, particularly today, other influences are weighing on the surgical decision-making process. Nowadays, surgeons are more pressured by “business” factors than ever before—they feel compelled to keep hospital operating rooms busy, to keep their practices going, and to maintain a living. After twenty years as a surgeon, I can say this: The line between operating for love or for money isn’t as distinct as it once was. The reality is that some surgeons (and hospitals) are more motivated by money than the Hippocratic oath they promised to uphold.

Reprinted from The Cost of Cutting by Paul A. Ruggieri, M.D. with permission of Berkley, a member of Penguin Random House. Copyright 2014 by Paul A. Ruggieri, M.D.