Walking, Ticking Time Bombs

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Fear Mongering
Little leaves me more sputtering with helpless anger than the phenomenon of medical fear mongering. Its purpose is to make you afraid, eliminate critical thinking, intuition and to render you passive in the face of questionable advice.

The, “You’re a walking time bomb”, disqualifies the offending doctor from your care. Nothing should make you run faster from the doctor who intones it. It’s a deal breaker.

A real-life time bomb will explode. It’s just a matter of time. Happily, medical conditions do not often offer the certainties of time bombs. Even conditions that are worthy of anxiety, even surgery, only pose risk. The risks you’re facing may or may not be real. Even if they are real, risks are played out over time. And ‘time’ may be counted in months, years or even decades before they become sufficiently likely to prompt action. You might indeed require an invasive procedure if the risks are high enough, and play out over a few days or weeks. But calling you a time bomb is a lie. And it’s done to scare you into surgery. You may be a “risk bomb” or a “high-probability bomb” but these more accurate statements won’t scare you enough to sign the consent form.

Rule Of Thumb
If you are physically able to walk into the hospital or the doctor’s office, then you are not likely to be subject to the sudden and assured catastrophes that some doctors promise. This is likely even if you’re not feeling so great. It’s almost a certainty if you’re feeling just fine. Judge  harshly the bearer of the news that you are a ’ticking’ time bomb, This doctor wants you to ‘hear’ the tick, tick, tick every moment until you do something.

And when doctors falsely act as if you are in the midst of an emergency, you’ll more likely be treated as if it really is one. That means many of the preoperative evaluations and assessments may be short circuited.

So why do doctors scare you into unwise decisions? Some, even many, do it out of conviction. They honestly feel you are making a huge error if you don’t do what they recommend. Most doctors offer opinions they feel are sincere and correct. It would be naïve to deny that some physicians deliberately send people for unnecessary surgery, but it’s more likely that many doctors are influenced by their own honest biases, by exposure to faulty, dishonest, and conflicting data, by fears of malpractice and by the public’s demand, spurred on by the media, for a “quick fix.”Overconfidence, assuredness, righteousness and infatuation with our opinions are rife in our profession. And the more confident a doctor acts, the more confidence you have in them. It’s great for us but dangerous for you.

I don’t suspect the advice is money driven
When the plea comes from a doctor who is not making money from the urgent endorsement, then profit motive is less likely. Not impossible, mind you, just less likely. You have no knowledge of your doctor’s investments in medical technology, CT and MRI scanners (although he’s obliged to inform you, few do). Some providers have vested interests in other doctor’s profits. Her business deals and contractual obligations are not on display. If she belongs to a large multi-specialty group, a part of the proceeds from every test, surgery or intervention may land up in her pocket through the group’s profit sharing plan.

But if the doctor who is leading the charge is also making the charge, then it’s a….

A Call to Harms
When money talks, we don’t want you to walk. We want you to run (into a hurried decision).

First, you may not need what is being demanded. There is no need to discuss profit motive. Medicine is a fee-based business. The more tests or procedures we do, the more money we make.The more we do the more money we make. Often it’s a deliberate and conscious betrayal of your trust. Sometimes it’s not. Being money-primed means that profit-driven attitudes are so ingrained and so reflexive, we can pass polygraphs swearing it’s for your welfare, not ours.

Second, even if you do need it, the doctor who is offering the warning may not be the right one to treat it. But when a false sense of urgency is manufactured, it’s not likely a ‘time bomb’ will take the time to seek another opinion. “Tick, tick….KABOOM…right?!”

Third, after your own research, it may be the right thing to do. And the doctor may be a good candidate for performing it. But his hospital may not be. For many interventions, you need a both a Top Doc and a Top Spot.

But when you are a walking ticking human time bomb you will be psychologically coerced into the wrong decision with the wrong doctor, in the wrong hospital at the wrong time and without the right backup. Several conditions are so inherently frightening that, just as in last week’s blog, “they dare not speak their names” without making you run for the immediacy of a shelter you don’t and may never need.

Most Decisions are Elective
Most surgical procedures are elective. Webster’s defines “elective” in this context as “beneficial to the patient but not essential for survival”. Elective surgery can also be defined as those interventions that are not urgent. They may be suggested by doctors or requested by patients.

Some interventions may be necessary for your survival. But, remember the above Rule of Thumb. If you walked in, but walk out scared to death, get another opinion or get another doctor. Our opinions should not scare you. Life threatening conditions pose a threat. Threats are not certainties. Even most certainties are not immediate. If you become anxious, it’s our job to reassure and guide you.

Most surgical procedures and interventional techniques are elective, and many may be necessary. Whether it’s a pacemaker, cancer, a suspicious shadow on your CT scan or a clogged artery in your heart, neck, leg or brain there’s time to learn more. Fifteen million operations were performed in 2007. Only 20% of the patients who went to the operating room were in the category of those with the highest degree of disease severity.

OR patients were, in fact, healthier than non-OR patients.

This means that when you are contemplating having elective surgery, most of the time there’s plenty of time. Plenty of time to think, study and inquire because hundreds of thousands of these procedures are not needed.

Seven of the fifteen most frequently performed surgeries have come under scrutiny. Both the increasing volume of these operations and the lax, non-evidenced based indications used to rationalize their performance have been questioned.

I don’t want to decide
Decide about my leaky valve? I can’t decide about what to watch tonight on TV. Fix my bladder? I don’t know how to fix my toaster.

It’s true. Some people really don’t want to make their own medical decisions. Many don’t want to do their own research. Now-a-days, fewer people surrender their autonomy to their providers. Trusting, listening and following the orders doctor offers is one thing. But being terrified by him is quite another. I’ll bet the farm that it won’t be your trusted family doctor who drops the ‘time bomb’ bomb. It will come from someone you have the least reason to trust and with whom your association has been the briefest.

My Carotids are Blocked
If you never had a stroke and have no symptoms, relax. But an obstruction of the main artery to your brain sounds ominous. Some will take advantage. “Better let me unblock that thing. You’re a walking, ticking……”. Well the risk of stroke is 1-5% a year. Or you have a 95- 99% chance of NOT having a stroke in the next year.

I Have Angina
If you have stable chest pain due to angina there will be some who suggest a stent; others will push open heart bypass. Are they wrong? No, but did they offer you the option of medical therapy? Or, did they tell you, “Remember Tim Russert? He dropped dead and he had stable angina too. You are a walking…….”? Run! This is an area of controversy and you plenty of time to make your mind up whatever your final decision.

My Aortic Valve is Tight
A severely tight (stenotic) aortic valve does require surgery. No one doubts this. Even those too ill for surgery can have it replaced via punctures in the artery and have the valve placed non-surgically. This is one of the surgeries many do but few do well. You want to be in a place crawling with many cardiac surgeons. This means the hospital has done hundreds a year and the surgeon dozens. If you live in a small community you might want to travel. But if you hear, “The risk of sudden death is huge. You are a ………” Well, here again the risk is real but runs about 1%/year. You need surgery but have the time to think it over. Who, where and when are on the table.

Aortic Aneurysms
Abdominal Aortic Aneurysms can cause fatal disasters, but only when they reach a certain size. But even when they cross the threshold…there’s time. “Oh My God! You’re going to blow!” plays no role here. Dump that Doc. Even at the 5.5 cm level many will scare you. The only reason to be scared is to have surgery at all. And even if you do want it before the aneurysm hits the 6 cm mark, fine. But this is one surgery on everyone’s list of high risk, high mortality surgeries. This is when it’s time to travel to a place that does them every day, all day.

And So It Goes
Screening CT scans for coronary heart disease, total body scans, hysterectomies, hips, knees, vaccines, Pitocin during labor, pacemakers, cardio version, colonoscopies, elective bowel surgery for diverticulosis or cancer etc. etc. There’s time. You may want to stay local. My “Choosing A Hospital” section in Doctor, Your Patient Will See You Now, starts with “Staying Local”. But not with fear mongers.

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