It doesn’t take a neurosurgeon to realize that there’s a lot that needs fixing about the way we approach health care in this country. But being a neurosurgeon, I can boil our challenge down to one key word. That word? Need.
If that strikes you as strange, consider the following two scenarios. Patient A, God forbid, has cancer of the spine, which I commonly treat. She goes to see her doctor, who advocates surgery. Should she decline the procedure, the likely outcome would be paralysis or death.
Does Patient A need surgery? Few would argue otherwise.
Now consider Patient B, a middle-aged avid tennis player who just hurt his back while playing. His spinal condition, maybe a disc herniation, could be surgically addressed, a common procedure that may result in Patient B gaining something close to his usual athletic prowess.
Does Patient B need surgery? That’s a much more complicated question. He could just as easily decide that giving up tennis for a few months is not much of a sacrifice, and that he’s perfectly fine walking a bit slower for a while if that means not going under the knife. Patient B, in other words, could calmly weigh all potential outcomes of all courses of treatment, understand the risks and opportunities associated with each one, and make an informed decision.
Sadly, that’s not necessarily the scenario unfurling in doctor’s offices daily. Which is a considerable challenge, given that roughly 80-90 percent of all surgeries in the United States are defined as non-essential, or elective, leaving patients to decide whether or not they wish to pursue the procedure in question. Many patients, understandably, enter a consultation with their physician expecting the doctor to give them a definitive verdict; they want to be told exactly what to do, and they want guaranteed outcomes. Many more seek a second opinion, and are flustered and confused when it contradicts the originally proposed course of treatment.
Both approaches are ill-advised. Both are likely to result in patients feeling a strong case of buyer’s remorse after the operation, complaining that the procedure did not deliver the hoped-for outcomes. And both revolve around a profound misunderstanding of that four-letter word, need.
Because, if we’re being honest, it is the rare scenario in which someone actually needs surgery. To understand this better, imagine, God forbid, being robbed: when someone points a gun or a knife at you and demands your wallet, you don’t think twice. You give them what they want and hope for the best. That’s the sort of knee-jerk, no-brainer urgency someone like Patient A might feel when thinking about surgery. It’s not at all what most of us should experience when walking into a hospital and wondering how to proceed, because most of us, thank God, have a lot of options to consider. No one wants to be held hostage mentally and emotionally during a medical decision-making process, but that’s often what the word need does.
It’s time, then, to limit our use of the word “need” from our medical lexicon. Instead, we should talk about “the best option right now.”
A “best option” conversation is different from a “need” conversation in several key ways.
First, it doesn’t revolve around an either/or decision. Its goal isn’t simply to determine if something is necessary or unnecessary, but rather to understand the (often complex) set of circumstances and considerations associated with each possible course of action. A “best option” conversation, therefore, allows for far greater nuance, as it considers all possible permutations and takes into account intricate matters like odds, side-effects, complications etc.
This being the case, a “best option” conversation requires greater communication between patient and physician. It requires, in fact, a true partnership in care. To make it work, the patient must abandon the mindset, still sadly common among too many Americans, that it is ill-advised—maybe even disrespectful—to ask your doctor difficult questions. Instead, patients should realize that no one, not even the world’s most qualified and celebrated surgeon, knows their bodies and their lives better than they themselves do. And doctor’s should realize this, too, and proceed accordingly.
Instead of focusing on a binary choice—do I need surgery or don’t I?—a patient, then, should begin by giving a candid, detailed account of what it is he or she is hoping to achieve by electing to have the procedure. The doctor should then explain the possible risks and potential benefits at length. Together, both should weigh pros and cons, understand timelines and implications, and arrive at a personal and nuanced decision.
How do we drive people towards such open and fruitful communication? That, sadly, is a tall order, requiring a fundamental shift in attitudes and perspectives. For starters, we need to train doctors to be better, more mindful communicators, understand the anxieties and trepidations of their patients, and help stir their patients away from overly simplistic and ultimately regrettable decision-making processes. And if that’s not difficult enough, we also need to encourage patients to approach conversations with their doctors differently, giving up on the soothing illusion of certainty—few, if any, procedures offer a sure-fire promise of complete and uncomplicated recovery—and engaging instead in a more demanding and detailed adult conversation.
But here’s the good news: We don’t have to wait for legislation or some technological breakthrough to take this step that will improve the care and wellbeing of millions of Americans dramatically. We can begin this long and absolutely essential process of healing and improvement simply by talking. And we already have our conversation starter, one word, need, we vow rarely to say again.