Measure Twice, Cut Once

There is a saying, “measure twice, cut once.” If you’ve ever done any construction you’d understand the value of this sage advice. It applies equally well to medicine and to surgery in particular. First, let me make it clear that I have great respect for surgery. To stand in the stainless steel sterility of an operating room, gowned and gloved, to place your hands into the body of another human being is nothing short of sacred. It brings together our most advanced technology with our deepest compassion to relieve suffering.

That said, surgery in most cases should be used only as a last resort. Over the years this common sense has been lost in the rush to what can only be called unnecessary surgeries. Why should surgery only be used as a last resort? For one thing, it can be dangerous, even fatal. Although the risk of an otherwise healthy individual dying from anesthesia is 1-4 deaths per 10,000, the risks of infection, bleeding, or post-operative complications is not trivial. In fact, just being hospitalized can be dangerous to your health as evidenced by an estimated 195,000 hospital deaths per year due to iatrogenic causes (human, medication and equipment failure). And while you might not suspect it from the confident, up-beat air surgeons exude, the promised results of a quick little surgery may fall far short of your expectations. It is precisely because surgery has the potential to make things worse that it should only be considered after all less invasive approaches have failed. In other words, when you finally get to the point of saying, “I can’t go on living like this,” the risk of surgery and its uncertain outcome become an acceptable option.

There is another saying which applies to life in general, “good judgment is based on experience and experience is based on bad judgment.” The following true stories will illustrate why caution is advisable when it comes to surgery.

Not long ago I performed a pre-operative physical exam for a woman in her mid-thirties who was scheduled for cataract surgery in her left eye. This was odd because cataracts are typically a problem of the aged. When I looked into her eye with my ophthalmoscope, I could see her retina perfectly. Generally, if I can see in, the patient can see out. Surprised, I confessed to her that I could not detect a cataract. She then told me that her optometrist had discovered it on a routine exam and referred her to a busy ophthalmology clinic he worked for in Denver. The ophthalmologist there, an MD, told her she indeed had a cataract and would need an artificial lens replacement. He also informed her that a second operation should be performed a month later to place an artificial lens in her healthy right eye so both eyes would be in focus! Shocked, I sent her to see my ophthalmology consultant in Boulder who confirmed that she did have a cataract, but a very subtle one that could only be seen with a special split-lamp examination and would probably be of little consequence for the next thirty years.

You might think this is just an isolated case of extremely poor medical care, and fortunately it is. But much more common is an orthopedic surgeon who recommends that a person with knee or shoulder pain undergo physical therapy and return for a follow-up visit one month later. If the problem does not significantly improve, which is often the case after a significant musculo-skeletal injury, endoscopic surgery is promptly recommended. However, once a joint is violated whether through accident, surgery or both, the risk of developing arthritis in the traumatized joint increases significantly.

Much closer to home is what happened to my mother-in-law, who crashed while riding her bike last summer. The next day I examined her painful shoulder. With a little coaxing, she could move her arm to above ninety degrees. I recommended she rest her shoulder in a sling, ice it for twenty-four hours and give it a little time to heal. Frustrated, she sought another opinion with her primary care doctor who immediately ordered an MRI. The radiologist read the film as a complete tear of the rotator cuff (surprising, given her ability to move her shoulder so well on examination). Before the week was out she had undergone endoscopic surgery on her shoulder. The good news was that she eventually recovered complete shoulder function. The bad news was that the surgery was not necessary. At the time of surgery the rotator cuff was found to be perfectly intact save some normal wear and tear appropriate for her age. The radiologist had misread the MRI. No one, not the orthopedic surgeon, the radiologist, nor her primary care physician ever offered her an apology.

Last is a truly tragic story. During my residency training, the three-year-old daughter of an ENT surgeon I knew underwent surgery to place two small Teflon tubes in her eardrums to treat her recurrent ear infections. This operation, performed by a colleague, was the same operation the father himself had performed hundreds of times in other children. The surgery went well, but the post-op recovery room nurse, unaccustomed to working with children, administered an excessive dose of narcotic painkiller causing her to fall into a drug-induced coma. When she awoke she tragically had suffered permanent brain damage.

There are several lessons to be gleaned from these case studies. Medicine is an imprecise science, and at best is a craft which sometimes goes wrong. A recent autopsy study found that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. Physicians should always treat the patient, not a test result, since tests can be misleading. And, “monkeys eat bananas,” which is to say, “surgeons think about surgery.”

“Measure twice, cut once” can mean getting a second opinion before reaching for the knife. It can also mean being measured in your approach to your own health. Many individuals who had been recommended surgery for sciatica, back, knee, or shoulder pain as well as other painful conditions can often achieve wonderful results with just a little acupuncture, therapeutic massage, common sense and patience. I have also treated more than a few people who continued to have pain after surgery. Even if the surgery is necessary and successful, as in removing a large herniated disk, it does nothing to address the underlying cause of the problem, i.e. lack of conditioning, poor movement habits, and/or stress, which if uncorrected may well lead to the problem re-occurring again down the road. And as always, if you haven’t got the correct diagnosis, you won’t get the right treatment.

If you ever find yourself contemplating surgery,
here is a prudent checklist of things to remember:

* Consider a trial of treatment with reputable alternatives; what could be called an aggressive, conservative approach, including an adequate period of rest. You may be amazed at how well the body can heal at a fraction of the cost and risk.
* Remember, just because insurance covers surgery doesn’t always make it the best or cheapest option.
* Seek a second opinion with a qualified MD from another office.
* Research available surgical options and approaches. The Grillo Center at the Boulder Public Library will assist you in researching your health questions.
* Carefully consider all the options and how it will effect your health now and in the future.
* Perform due diligence to choose the best surgeon for the right procedure at the right hospital. Would you do any less if you were going to buy a new car?
* Once you have decided to undergo surgery, prepare in advance mentally, physically, and spiritually with a positive attitude, good nutrition and physical conditioning as appropriate.
* Contemplate how surgery is going to give you a second chance and what you can do differently in the future.