Unnecessary Surgeries   

                                   DR KS Dhillon

What is meant by unnecessary surgery? Unnecessary surgery is defined as any surgical intervention that is not needed or indicated and is not in the best interest of the patient [1,2].

In the USA, the threat of unnecessary surgery had been publicized as far back as 1953, when the Director of the American College of Surgeons,

Dr. Paul Hawley, stated that “the public would be shocked if it knew the amount of unnecessary surgery performed by dishonest doctors [3].

In 1976, the American Medical Association (AMA) called for a congressional hearing on unnecessary surgery. The association claimed that there were “2.4 million unnecessary operations performed on Americans at a cost of $3.9 billion and that 11,900 patients had died

from unneeded operations” [4].

In the USA it has been estimated that at least 20% of the money spent on health care is wasted which amounts to more than $700 billion dollars a year. Unnecessary medical care is a major contributor to this waste [5].

Types of unnecessary surgeries

There are many types of unnecessary procedures that are carried out. Some of them include [6]:

• Cardiac angioplasty and stents. According to a 2011 study in the Journal of the American Medical Association about 12 percent of all angioplasty interventions weren’t medically necessary. 
• Cardiac pacemakers. According to a 2011 study in the Journal of the American Medical Association, there was no medical evidence to support 22.5 percent of implantable cardioverter-defribrillator surgeries.
• Back surgery and spinal fusion. According to a 2011 study in the journal Surgical Neurology, over 17 percent of patients received unnecessary spinal surgery.
• Hysterectomy. About 70 percent of hysterectomies are unnecessary, according to a 2000 study for the American College of Obstetricians and Gynecologists.
• Knee and hip replacement. According to a 2012 study in Health Affairs, after patients received information on alternatives to joint replacement surgeries, researchers noted that approximately 26 percent of patients had fewer hip replacements and 38 percent had fewer knee replacements. 
• Cesarean section. According to a 2013 study in Health Affairs, C-section rates vary across hospitals. Even with lower-risk pregnancies, cesarean rates varied from 2.4 percent to 36.5 percent. 

There are many other areas of medical practice where unnecessary procedures are carried out.

In 2021, the existence of unnecessary surgery remains a daunting reality that continues to expose patients to unjustified surgical risk. There are multiple clinical trials that show that spinal fusions for back pain do not lead to improved long-term patient outcomes when compared to non-operative treatment [7,8]. Despite these insights from high-quality trials, spinal fusion rates continue to dramatically increase in the United States [9] and elsewhere in the world. 

Another example is arthroscopic partial meniscectomy. It is one of the most commonly performed surgical procedures in the world [10]. In the United States surgeons perform about 700,000 arthroscopic partial meniscectomies every year. A Finnish prospective randomized controlled trial that assessed patient outcomes after arthroscopic partial meniscectomy compared to sham surgery showed no benefit for patients from the surgical procedure at 12 months follow-up [11]. Although it is well known that any surgical procedure can be associated with a risk of severe intra- or postoperative complication [12] yet to date, a change in practice has not occurred, and arthroscopic meniscectomies continue to be performed on hundreds of thousands of patients in the USA every year [13,14].

In 2002 Moseley et al [15] published an article in the New England Journal of Medicine to show the futility of arthroscopic joint debridement for osteoarthritis of the knee but to date, such procedures are still carried out [15]. Moseley et al [15] did a randomized, placebo-controlled trial to assess the efficacy of arthroscopic knee surgery to relieve knee pain and improve function in patients with OA of the knee. They had three groups of patients who either had joint lavage, joint debridement, or sham incisions at the arthroscopic portals. Their study showed strong evidence that arthroscopic lavage with or without debridement is no better than placebo in relieving pain and improving self-reported knee function. The authors concluded that the billions of dollars spent annually on such procedures could be put to better use.

Kirkley et al [16] in 2008 published the outcome of a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. They randomly assigned patients to arthroscopic joint debridement with surgical lavage and physical plus medical therapy or to treatment with physical and medical therapy alone. At 2 years follow-up, they found that arthroscopic surgery for osteoarthritis of the knee provided no additional benefit as compared to optimized physical and medical therapy.

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing around the world and in Australia, it is among the highest in the world [17,18]. There is a general belief that all ACL injuries must be treated with reconstruction to minimize symptoms, improve quality of life and minimize the risk of future complications such as chondral and meniscal injury. Now, however, there is level 1 scientific evidence that the mid-term (5 years) patient-reported and radiographic outcomes between those patients treated with rehabilitation plus early ACL reconstruction and those treated with rehabilitation and optional delayed ACL reconstruction are the same in young active individuals [19]. Despite such good level I evidence the incidence of ACL reconstruction is increasing around the world.

There are many surgeons who recommend a repair of grade 3 injuries of the lateral ligament of the ankle but there is no evidence that such surgery gives better results than conservative treatment.

Pihlajamaki et al [20] did a prospective randomized controlled trial to compare surgical versus functional treatment for acute ruptures of the lateral ligament of the ankle in young men. They found that at a mean follow-up of 14 years, all patients in both groups had recovered the pre-injury activity level and they could walk and run normally. There was no significant difference in the ankle scores.

In the United States, more than 18.9 million adults report chronic shoulder pain each year and it accounts for over 4.5 million primary care visits every year [21]. Shoulder impingement can account for about 85% of all shoulder complaints. It is estimated that almost 300,000 surgical procedures for shoulder pathology including impingement are performed yearly in the USA, with the direct financial burden estimated to be over US$3 billion annually [22].

Impingement syndrome is treated by subacromial decompression often by arthroscopy. There has been a sevenfold increase in subacromial decompression surgery in the United Kingdom from 2000 to 2010 and a fourfold increase in the US from 1996 to 2006 [23,24,25].

These increases in the number of subacromial decompression rates exist despite the presence of high-quality evidence that shows that subacromial decompression does not provide clinically important benefits as compared to placebo as far as pain, function, and health-related quality of life is concerned [26,27].

In ENT there is one procedure that has been done unnecessarily on millions of patients and wasted tens of billions of dollars over the past several decades, with no evidence that it even works for most patients. This overused procedure is endoscopic sinus surgery (ESS) [5].

Another ENT operation that is frequently done when it is not necessary is tonsillectomies in children. About 88 percent of tonsillectomies carried out on children in the UK each year are unnecessary [28].

If surgery was a pharmaceutical drug, the procedure would be required

to undergo scrutiny of testing for its safety and feasibility in several trials. 

Subsequently, the efficacy would have to be proven in randomized controlled trials before the Food and Drug Administration (FDA) would approve it [19]. The FDA, however, does not regulate surgical procedures. Common sense would dictate that whenever new level 1 evidence disproves a benefit for a certain surgical procedure, the ineffective practice should be immediately abandoned. This, however, is obviously not the case as far as surgery is concerned.

Why do surgeons continue to perform unnecessary surgery?

The question which begs for an answer is why would a reasonable surgeon consider performing unneeded surgical procedures which carry the risk of morbidity and mortality. The only surgery without risk of complications is the surgery that is not performed. 

There are estimates that as many as 1.3 million Americans suffer disabling injuries in hospitals every year, and 198,000 of those may result in death,  seven out of ten of which were preventable (48% from faulty surgery), and a third from negligence [29].

Unnecessary surgical procedures can be associated with the following:

• Death
• Infection, paralysis, blood clots, and other surgical complications
• Unnecessary loss of organs or organ function
• The need for follow-up expensive procedures and surgeries
• Diminished health and quality of life
• Surgical scars and other cosmetic blemishes
• Days, weeks, or months of missed work
• Huge medical bills

Unnecessary surgeries also lead to a profound loss of trust in the surgeon.

Surgeons have stated 2 primary reasons why unneeded surgeries continue to be performed [30]:

1. “We perform surgery because we have been trained to do so and because “we have always done it this way” or we simply do not know any better. 

2. We are incentivized to perform surgical procedures, either for financial gain, renown, or both”.

The main incentive for performing unnecessary surgery is financial gain.

Financial conflicts of interest usually drive physicians to perform worthless surgeries, and the field of orthopedics "is one of the worst offenders,"[31].

In the USA there have been many headlines of lawsuit allegations, investigations, guilty pleas, and convictions concerning this problem [32].  

In the USA and probably in many other parts of the world there are a number of reasons that drive medical overtreatment. 

Fee-for-service model is part of the problem. A profit-driven surgeon agenda is a problem since over 70% of U.S. doctors themselves believe that doctors "are more likely to perform unnecessary procedures when they profit from them" [33]. Doctors acknowledge that conflict of interest occurs because surgeons "are paid approximately ten times more money to perform surgery than to manage your problem conservatively" [34]. Hence financial pressures can lead to unnecessary surgery. One doctor quotes his residency professor who said that "there is nothing more dangerous than a surgeon with an open operating room and a mortgage to pay" [35].

Some surgeons have speaking agreements with medical device manufacturers and pharmaceutical companies. These surgeons carry out large numbers of operations, many of which are unnecessary, using their devices and implants. Surgeons receive consultancy fees for talks at meetings and conferences where the surgeon encourages others to use these devices and implants. Payments are made by these companies for trips, travel, lodging, food, honoraria, gifts, etc [36].  A conflict of interest in this setting can lead the surgeon to use a particular type of surgical device, even when it is not the right one for the patient. Unfortunately, there are many surgeons who are “in bed with the device industry." [34].

This "symbiotic" relationship between medical device manufacturers and surgeons provides the surgeons with an important source of revenue [35].  

Many of the surgeons don't disclose these potential conflicts of interest in studies that they publish about these devices [36]. Surgeons often tend to perform a given surgery due to their relationship with the device manufacturer instead of what is in the best interests of the patient.  There are even cases where some device-makers have even paid millions of dollars to settle cases involving allegations of improper payments to surgeons [37]. 

There are teaching hospitals in the USA that have come under scrutiny for accepting revenue from medical device manufacturers as well [38]. There are also many surgeons who are owners or co-owners of ambulatory surgical centers. This ownership model can be associated with conflicts of interest that affect surgical decisions leading to a higher volume of surgeries [39].   

Hospitals are also sometimes involved in these conflicts of interest. They drive the surgeons to do unnecessary procedures. The hospital administrators put pressure on surgeons to generate more money by performing more procedures [34]. In some cases, hospitals have purchased very expensive surgical equipment or devices and they need to justify their use. Hospitals sometimes require surgeons to perform a minimum number of some procedures every year or two years. 

When is Unnecessary Surgery Medical Malpractice?

Unnecessary surgery can be medical malpractice. To file a malpractice lawsuit for unnecessary surgery, one has to prove negligence. There are several ways to prove negligence and these includes but are not limited to:

• Doctor failed to inform the patient of the risks or benefits of the surgery versus the risks of not having the surgery.
• Doctor recommends surgery without considering or offering reasonable alternative treatment.
• When there is a misdiagnosis and surgery is performed. 

A claim of medical negligence could be filed for a medical malpractice lawsuit if a medical mistake was made during the surgery. Compensation can be obtained for unnecessary surgery if medical negligence can be proved. 

In the USA a Virginia doctor was sentenced to 59 years in prison for performing irreversible hysterectomies, improper sterilizations, and other medically unnecessary surgeries on his patients. In November of 2019, Dr Javaid Perwaiz was charged with health care fraud and making false statements relating to health care matters. 

His conviction resulted from various patient complaints. One patient had her fallopian tubes removed without her consent, resulting in being unable to conceive naturally. In another patient, an unauthorized hysterectomy was carried out which resulted in a perforated bladder which resulted in a 6-day hospital stay. Besides performing irreversible hysterectomies he carried out improper sterilizations and other medically unnecessary surgeries on his patients. 

Perwaiz was an obstetrician-gynecologist in Chesapeake, Virginia, since the 1980s. From 2010 to 2019, he defrauded health insurance programs, resulting in about $20.8 million in losses to health care insurers. He would often trick his patients into having unnecessary surgeries by telling them they had cancer or needed the surgery to avoid cancer. 

In four years, from January 2014 to August 2018, he operated on 40% of his Medicaid beneficiaries, or a total of 510 patients. Out of those, 42% of the patients had at least two surgeries [40].

Unnecessary surgeries in Malaysia

Anecdotal evidence suggests that the number of unnecessary surgeries in Malaysia is also high. There are no studies published to show the high incidence of unnecessary surgeries in Malaysia. 

Apparently, every year about 2,000 to 4,000 deaths occur due to some form of medical negligence and a large number of these cases go unreported partly because of the out-of-court settlements and partly due to the fact that many patients accept the incidents as matters of fate. Many patients are not aware of their rights and others are too poor to afford litigation especially in Malaysia where there is no speedy and inexpensive system of administration of justice in medical negligence [41].

Some have estimated that medical errors could be the No 2 killer in Malaysia after heart diseases and cardiovascular disorders. Medical errors probably kill more Malaysians than either cancer, diabetes, or motor vehicle accidents. Apparently for every case of medical error reported, 10 cases go unreported. About 80 percent of medical procedures performed today have never been properly tested [42].

In Malaysia, there is a lack of proper machinery to deal with poorly performing doctors except through the court of law. Medical negligence cases and malpractice cases are excessively difficult to prove and they take a very long time to settle. 

The Malaysian Medical Council (MMC) is a “passive regulatory body”. It deals with complaints of ethics and professional behavior that are reported to it.  There is no inspectorate to detect offenses. The regulatory bodies as well as the regulatory processes in Malaysia do not show that they provide sufficient safeguards to protect the interests of the public [43]. 

There have been questions as to why aren't the interests and the safety of millions of patients in Malaysia protected against medical mishaps and errors? Patients are not only not assured of consistent quality medical care but they are also denied a speedy, effective, and fair avenue for justice when there is medical negligence and malpractice [44].

They are also victims of a lack of an effective system to protect their interests and safety. 

A careless, incompetent, or irresponsible medical professional has the power to kill, paralyze, disfigure or dismember his patients. The safety and well-being of all patients should be of paramount importance. Hence it is important that the medical profession is most stringently regulated. However, unfortunately, the medical profession and the way it deals with medical errors seems to be shrouded in mystery and secrecy. It lacks integrity, accountability, and transparency. 'Prevention is better than cure' should be practiced more by the medical profession in preventing medical negligence, malpractice and errors because there are no quick, cheap, or painless cures for botched-up medical procedures [44].

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