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Operating Blind

Courtesy Prevention Magazine

Factoids          

Every year, nearly 2.5 million people go under the knife unnecessarily,
often with devastating consequences. Make sure you're not one of them.

Due to the power and corrupting influence of Big Pharma, the teaching
of nutritional science and the use of vitamin and herbal supplements is
not taught to any significant extent in our medical schools. The obvious
reason is that teaching this science reduces the use of prescription drugs.

Two years ago, when Leah Coppersmith went in for back surgery, she expected to be lacing up her running shoes within days. She's been in pain ever since.

A car accident in 1991 left this mother of four with nagging lower-back pain--annoying, but not bad enough to keep her from running 5-Ks. But in 2005, the nag grew to a scream.

An MRI revealed that two disks -- the gel-filled cushions between the vertebrae -- were badly worn. Coppersmith expected the doctor to recommend a diskectomy, in which part of a troublesome disk is removed to relieve pressure on the nerve; the low-risk surgery had helped her once before. But this time, the surgeon wanted to replace a disk with an artificial one. The procedure was getting great results, he said. Coppersmith was skeptical until he told her she'd be back running 5-Ks again in no time. She laughs bitterly at the memory.

Pain is now the defining feature of her life. She can't sit down to family dinners. She quit her job because she can't work at a desk. Her misery has company: While looking for help online, she found a study showing that 64% of people who received the disk, called the Charité, still needed narcotic painkillers 2 years after surgery.

Every year, upward of 15 million Americans go under the knife -- and for most of them, surgery provides relief or a new lease on life. Joints are replaced, organs are transplanted, lives are saved. But Congress has estimated that surgeons perform 2.4 million unnecessary surgeries a year in the United States, with a cost of roughly $3.9 billion--and a toll of about 11,900 deaths. The reason isn't simple.

"The majority of surgeons who perform these procedures are actually very enthusiastic about their benefits," says Mark Chassin, MD, chair of the department of health policy at Mount Sinai School of Medicine. "It's not like they get up in the morning and ask themselves, How many unnecessary procedures can I do today? But there's a lot of financial incentive to do surgery that may not benefit the patient, and very little oversight."

So how do you know when someone is suggesting surgery you don't need -- and what can you do to prevent it? Your first line of defense is to become your own advocate. One study showed that when patients and doctors share the decision making, rates of surgery drop by as much as 44%. Here, we explain what's behind four of the procedures most often done unnecessarily and give you expert advice on the best alternatives.

BE SKEPTICAL: SPINAL SURGERY

The waiting room of Charles Rosen, MD, a spinal surgeon and an associate professor of orthopedic surgery at the University of California, Irvine, was filled with patients who, like Coppersmith, had failed disk implants. "In my 20 years of orthopedics, I'd never seen so many people in such a severe state of constant pain," he says. So Rosen examined the evidence backing the Charité disk. He was shocked to see that the researchers had compared patients who got the disk with those who received a type of fusion surgery with a particularly high failure rate -- 60%. (Even before the study's publication, that procedure had been largely abandoned.) Then he discovered that researchers on other Chariti studies were paid consultants for the device maker. Outraged, Rosen founded the Association of Ethical Spine Surgeons. Members agree not to take money from device makers or form partnerships with the companies.

The spine is ground zero for unnecessary surgeries partly because back pain is incredibly common and notoriously tough to treat. More than 1 million sufferers opt for surgery each year, and spinal fusion -- the use of bone grafts, screws, and other devices to secure one or more vertebrae -- is one of the most popular choices. Between 1996 and 2001, the number of spinal fusions skyrocketed 113%, while the number of knee- and hip-replacement surgeries rose just 15% and 13%, respectively. But unlike those procedures, spinal surgeries often fail -- instead of relieving pain, they can turn it into agony. According to Aaron Filler, MD, PhD, director of the Peripheral Nerve Surgery Program, Institute for Spinal Disorders, at Cedars-Sinai Medical Center in Los Angeles, there are tremendous rewards for spinal surgeons who do aggressive procedures: Because of the hardware involved, an operation on the spine can pay a surgeon 10 times as much as one on the brain. Yet the moneymaking back surgeries help in only a small proportion of cases. What's more, back surgeons are rarely held accountable if the operation fails. "The referring doctor has low expectations," Filler says. "So does the patient, because everyone thinks of back problems as so difficult to treat."

Protect Yourself
Pinpoint the pain: If your doctor labels your back pain as "nonspecific," it means he doesn't know the cause; if he suggests surgery, alarm bells should go off, says Filler. Spinal fusion is most beneficial when vertebrae slip out of place and press on the ones below, which is easily detected on an x-ray. "When properly done for the right reasons, spinal surgery can be extremely effective," says Filler.

Make lifestyle adjustments: A 2003 study compared spinal fusion surgery with a lifestyle approach to back pain: Docs taught patients how to protect their backs, by bending at the knees when lifting, for instance. They also encouraged exercise, like water aerobics. A year later, the nonsurgical approach reduced pain and increased mobility just as much as surgery did. Alternative treatments such as chiropractic and acupuncture can also pay off, studies show. For more info on finding alternative treatments, go to prevention.com/links.

Consider a helpful shot: A nerve-blocking injection called an epidural, given by a surgeon or a rehab specialist like a physiatrist, may quiet the pain for up to a year; it helps in about 50% of patients.

Skip the hardware: If surgery seems like the right approach, get the simplest procedure possible. There's a much smaller chance of complications if you have a diskectomy, for example, than if you have an artificial disk implanted.

BE SKEPTICAL: HYSTERECTOMY

Lori Jo Vest was 36 when three doctors told her a hysterectomy was the only fix for her heavy bleeding caused by uterine fibroids. Terrified that she'd be thrust into early menopause--in half of all hysterectomies, surgeons end up removing the ovaries, too--Vest went online and discovered myomectomy, in which the surgeon cuts out the fibroids, sparing the uterus. But her doctors nixed the idea; after all, they said, Vest, who had a toddler, didn't want more children. Then Vest called the nearby University of Michigan, Ann Arbor--and nearly leaped through the phone when she heard they had a clinic for women seeking alternatives to hysterectomy.

"The doctor said I was a perfect candidate for myomectomy," Vest says. She also told Vest that many surgeons dislike the surgery because it's more difficult than a hysterectomy. Now 44, Vest no longer is troubled by heavy bleeding, but she still has her uterus and ovaries. *"I don't want to go through menopause until my body is ready," she says.

Hysterectomy is second only to C-section as the most common surgery performed on women in the United States. Each year more than 600,000 Americans have the procedure--twice the rate as in England. A 2000 study found that 70% of the hysterectomies performed in nine Southern California managed-care organizations were recommended inappropriately. "The most common mistake we saw was that doctors didn't try safer, less-invasive approaches first," says lead author Michael Broder, MD, an assistant professor of obstetrics and gynecology at UCLA's David Geffen School of Medicine.

Hysterectomy can be warranted if a woman has cancer, and it can be the right choice in other cases, too--for instance, if medical treatment didn't get your bleeding under adequate control, and you don't want to try a surgery like myomectomy because of the risk of recurrence. But unless you have cancer, "having a doctor say, 'You absolutely need a hysterectomy,' is akin to a waiter at a restaurant saying, 'You've got to have the steak,'" says Malcolm G. Munro, MD, a professor of obstetrics and gynecology at UCLA. "A good doctor should give you a menu of choices."

Protect Yourself
Try hormones or drugs first: Most hysterectomies are done on women under age 45, but if you can manage symptoms of fibroids with medication until menopause, symptoms usually ease naturally. Birth control pills or other drugs help control irregular bleeding. Also check into getting a progestin-releasing IUD (Mirena): It can dramatically decrease bleeding caused by fibroids.

Consider a less drastic procedure: Like myomectomy, uterine fibroid embolization (UFE) preserves the uterus: An "interventional" radiologist carefully closes off blood vessels feeding the fibroids, starving them. A woman may need more treatment after either procedure if the fibroids come back, and both cause a fair amount of discomfort. (UFE can require serious pain meds, although recovery is quicker than after a hysterectomy, and the risks are lower.) For more info on hysterectomy alternatives, go to prevention.com/links.

BE SKEPTICAL: ANGIOPLASTY

When Irwin Melnicoff, a forensic engineer in Boynton Beach, FL, felt a stabbing chest pain at age 45, he went straight to the cardiologist. The diagnosis? A narrowed artery. The answer? Angioplasty. But Melnicoff was scared of surgery; even when the doctor told him he'd die without the artery-opening procedure, he chose drug therapy instead. (He also chose a new doctor.) That was 25 years ago. With the help of daily heart medications, his chest pain vanished. He walks 30 minutes a day, 7 days a week, and feels great.

He made the right choice. Though angioplasty has been hailed by some as a wonder fix for decades, it now turns out that most of the time, the procedure doesn't help. Angioplasty can save your life if it's done during or right after a heart attack. But in other circumstances, it may not do you much good.

"Doctors used to think of heart disease as a plumbing problem--that arteries were like drainpipes gradually being clogged by plaque made up mostly of cholesterol," says Arthur Agatston, MD, a preventive cardiologist and author of The South Beach Heart Program. So it seemed to make sense to use angioplasty, in which a small balloon is inflated in the artery, to get that gunk out of the way by squashing it against the vessel wall. However, research has since shown that problematic plaque actually forms within the delicate inner lining of artery walls.

What does cause a heart attack? If the plaque within the wall ruptures, it injures the artery, producing a blood clot as part of the healing process. Unfortunately, the clot can close off the entire artery--that's a heart attack, and you need angioplasty or bypass surgery immediately. If you have angioplasty, the doctor may also insert a stent, a mesh scaffolding, to hold open the artery.

But if you're not having a heart attack, angioplasty (with or without a stent) won't help and may even do some harm. That's the news from a large trial published in April in the New England Journal of Medicine. People with "stable" heart disease--they weren't having a heart attack, but a vessel was at least 70% closed--fared no worse if they received medical therapy, such as aspirin, blood thinners, and cholesterol-lowering drugs, than if they got angioplasty. During the next 4 1/2 years, neither group was more likely to have a heart attack or stroke or die.

A study published late last year helps pinpoint exactly when it's worth getting angioplasty. That trial showed that if the procedure was done 3 or more days after a heart attack, it didn't help. "We were very surprised--we thought angioplasty would be beneficial even if it was done later," says lead author Judith Hochman, MD, director of the cardiovascular clinical research center at New York University School of Medicine. "But that's why we do studies: to see if the patient really does benefit."

Protect Yourself
Insist on being convinced: If your doctor says you need a non-emergency angioplasty, ask if it will prolong your life. "That question puts a cardiologist on the spot," says Agatston. If the procedure isn't needed to save your life, it still may make sense if angina (bouts of chest discomfort caused by a lack of blood flow to the heart) interferes with daily activities. But get a second opinion--from a preventive cardiologist, not a cardiac surgeon.

Eat right, exercise, and lose weight if necessary: You needn't avoid fats and carbs to keep your heart healthy--just choose wisely. A diet high in omega-3-rich canola and olive oils can actually protect your heart. High-fiber carbs in whole grains, fruits, and veggies also help get fats out of your blood.

Use the meds known to save lives: Many people with high cholesterol aren't on statins, though the drugs slash the risk of heart attack by more than 30%. Similarly, most people with high blood pressure don't get adequate treatment, studies show. Lifestyle changes can bring down both cholesterol and BP, but if they're not enough, medication can be lifesaving. Your doctor may also put you on daily aspirin or another drug to lower the risk of a blood clot.

BE SKEPTICAL: KNEE ARTHROSCOPY

Soon after Diana Aceti turned 50, the ache in her knee began to keep her from walking and playing tennis, two activities she loved. An orthopedist said that she had a small tear in her cartilage and recommended arthroscopic surgery. "He said I'd back on my feet in a few weeks," says the public relations director from Bridgehampton, NY.

But afterward, Aceti's knee hurt worse than ever. So she got a second opinion--and the news wasn't good. In a rare complication, her cartilage was damaged beyond repair, and she needed a partial knee replacement. "Doctors talk about surgery like it's getting your teeth cleaned," says Aceti. "If he'd told me this was a possibility, I never would have done it."

Knee arthroscopy is most often used for people, like Aceti, who have osteoarthritis--cartilage damaged by wear and tear. A surgeon makes small incisions and inserts instruments to remove tissue fragments and wash out the joint in the hopes of reducing pain. Yet in 2002, when knee arthroscopy was put to the test in a randomized, controlled trial, it failed royally. Osteoarthritis patients given arthroscopy reported no more improvement than those who got sham surgery--incisions were made but no arthroscope was inserted. Still, 5 years later, the procedure remains among the top 10 outpatient surgeries: More than 650,000 knee arthroscopies are performed annually.

Critics say that almost everyone has small tears in their knee cartilage visible on MRIs, providing a never-fail excuse for surgery. "Patients have arthroscopy for what is clearly the result of a bruise or a bump," says Ronald Grelsamer, MD, an associate professor of orthopedic surgery at Mount Sinai Medical Center in New York City. "For many orthopedists it's the only way left to make a half-decent living. Does that justify it? No."

The procedure can help in certain situations, Grelsamer says: If a piece of cartilage is catching, like a hangnail, clipping it can make you feel better. And some doctors still believe that for some osteoarthritis patients, flushing the interior of the knee during arthroscopy can ease pain, perhaps by getting rid of irritating chemicals. Researchers can't predict who will benefit from a washout, though--and surgeon Bruce J. Moseley, MD, who led the sham surgery comparison, argues that any improvement in arthritis patients is due to the placebo effect.

Protect Yourself
Wait a while: Arthroscopy is most frequently done after a twist or fall, but those injuries often get better within a few months with physical therapy, anti-inflammatory meds, a cortisone injection--or just the passage of time.

Be skeptical of MRI results: Arthroscopy is most apt to help if there's a detached fragment of cartilage or a severe tear--a 3 on a 1-to-3 scale, as rated by a radiologist. But even a bad tear may not cause pain, so ask whether it matches up with the area that hurts. --

 


Extra Testosterone ... Could Mean
An Alpha Decision-Maker Type
Look for a long fourth finger.
If your significant other's ring finger is longer than
his or her index finger, it's an indication that he or
she was exposed to higher than average amounts of
testosterone in the womb, says Dr. John T. Manning of
Rutgers University in his book 'Digit Ratio.' This correlates
to a personality type , which tends to be logical, decisive,
and ambitious. Thus the testosterone exposure influences
your personality and subsequently who you love.


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  *Consultation with a health care professional should occur before applying adjustments or treatments to the body, consuming medications or nutritional supplements and before dieting, fasting or exercising. None of these activities are herein presented as substitutes for competent medical treatment. See Disclaimer.

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