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  • I am a neurosurgeon,

  • and I'm here to tell you today that people like me need your help.

  • And in a few moments, I will tell you how.

  • But first, let me start off by telling you about a patient of mine.

  • This was a woman in her 50s,

  • she was in generally good shape,

  • but she had been in and out of hospital a few times

  • due to curative breast cancer treatment.

  • Now she had gotten a prolapse from a cervical disc,

  • giving her radiating pain of a tense kind,

  • out into the right arm.

  • Looking at her MRI before the consultation,

  • I decided to suggest an operation.

  • Now, neck operations like these are standardized, and they're quick.

  • But they carry a certain risk.

  • You make an incision right here,

  • and you dissect carefully past the trachea,

  • the esophagus,

  • and you try not to cut into the internal carotid artery.

  • (Laughter)

  • Then you bring in the microscope,

  • and you carefully remove the disc and the prolapse

  • in the nerve root canal,

  • without damaging the cord and the nerve root

  • lying only millimeters underneath.

  • The worst case scenario is the damage to the cord,

  • which can result in paralysis from the neck down.

  • Explaining this to the patient, she fell silent.

  • And after a few moments,

  • she uttered a few very decisive words for me and for her.

  • "Doctor, is this really necessary?"

  • (Laughter)

  • And you know what I realized, right there and then?

  • It was not.

  • In fact, when I get patients like this woman,

  • I tend to advise not to operate.

  • So what made me do it this time?

  • Well, you see,

  • this prolapse was so delicate,

  • I could practically see myself pulling it out of the nerve root canal

  • before she entered the consultation room.

  • I have to admit it, I wanted to operate on her.

  • I'd love to operate on her.

  • Operating, after all, is the most fun part of my job.

  • (Laughter)

  • I think you can relate to this feeling.

  • My architect neighbor says he loves to just sit and draw

  • and design houses.

  • He'd rather do that all day

  • than talk to the client paying for the house

  • that might even give him restrictions on what to do.

  • But like every architect,

  • every surgeon needs to look their patient in the eye

  • and together with the patient,

  • they need to decide on what is best for the person having the operation.

  • And that might sound easy.

  • But let's look at some statistics.

  • The tonsils are the two lumps in the back of your throat.

  • They can be removed surgically,

  • and that's called a tonsillectomy.

  • This chart shows the operation rate of tonsillectomies in Norway

  • in different regions.

  • What might strike you is that there is twice the chance

  • that your kid -- because this is for children --

  • will get a tonsillectomy in Finnmark than in Trondheim.

  • The indications in both regions are the same.

  • There should be no difference, but there is.

  • Here's another chart.

  • The meniscus helps stabilize the knee

  • and can be torn or fragmented acutely,

  • topically during sports like soccer.

  • What you see here is the operation rate for this condition.

  • And you see that the operation rate inre og Romsdal

  • is five times the operation rate in Stavanger.

  • Five times.

  • How can this be?

  • Did the soccer players inre og Romsdal

  • play more dirty than elsewhere in the country?

  • (Laughter)

  • Probably not.

  • I added some information now.

  • What you see now is the procedures performed

  • in public hospitals, in light blue,

  • the ones in private clinics are light green.

  • There is a lot of activity in the private clinics

  • inre og Romsdal, isn't there?

  • What does this indicate?

  • A possible economic motivation to treat the patients.

  • And there's more.

  • Recent research has shown that the difference of treatment effect

  • between regular physical therapy and operations for the knee --

  • there is no difference.

  • Meaning that most of the procedures performed

  • on the chart I've just shown

  • could have been avoided, even in Stavanger.

  • So what am I trying to tell you here?

  • Even though most indications for treatments in the world

  • are standardized,

  • there is a lot of unnecessary variation of treatment decisions,

  • especially in the Western world.

  • Some people are not getting the treatment that they need,

  • but an even greater portion of you

  • are being overtreated.

  • "Doctor, is this really necessary?"

  • I've only heard that question once in my career.

  • My colleagues say they never heard these words from a patient.

  • And to turn it the other way around,

  • how often do you think you'll get a "no" from a doctor

  • if you ask such a question?

  • Researchers have investigated this,

  • and they come up with about the same "no" rate

  • wherever they go.

  • And that is 30 percent.

  • Meaning, three out of 10 times,

  • your doctor prescribes or suggests something

  • that is completely unnecessary.

  • And you know what they claim the reason for this is?

  • Patient pressure.

  • In other words, you.

  • You want something to be done.

  • A friend of mine came to me for medical advice.

  • This is a sporty guy,

  • he does a lot of cross-country skiing in the winter time,

  • he runs in the summer time.

  • And this time, he'd gotten a bad back ache whenever he went jogging.

  • So much that he had to stop doing it.

  • I did an examination, I questioned him thoroughly,

  • and what I found out is that he probably had a degenerated disc

  • in the lower part of his spine.

  • Whenever it got strained, it hurt.

  • He'd already taken up swimming instead of jogging,

  • there was really nothing to do,

  • so I told him, "You need to be more selective

  • when it comes to training.

  • Some activities are good for you,

  • some are not."

  • His reply was,

  • "I want an MRI of my back."

  • "Why do you want an MRI?"

  • "I can get it for free through my insurance at work."

  • "Come on," I said -- he was also, after all, my friend.

  • "That's not the real reason."

  • "Well, I think it's going to be good to see how bad it looks back there."

  • "When did you start interpreting MRI scans?" I said.

  • (Laughter)

  • "Trust me on this.

  • You're not going to need the scan."

  • "Well," he said,

  • and after a while, he continued, "It could be cancer."

  • (Laughter)

  • He got the scan, obviously.

  • And through his insurance at work,

  • he got to see one of my colleagues at work,

  • telling him about the degenerated disc,

  • that there was nothing to do,

  • and that he should keep on swimming and quit the jogging.

  • After a while, I met him again and he said,

  • "At least now I know what this is."

  • But let me ask you a question.

  • What if all of you in this room with the same symptoms had an MRI?

  • And what if all the people in Norway

  • had an MRI due to occasional back pain?

  • The waiting list for an MRI would quadruple, maybe even more.

  • And you would all take the spot on that list

  • from someone who really had cancer.

  • So a good doctor sometimes says no,

  • but the sensible patient also turns down, sometimes,

  • an opportunity to get diagnosed or treated.

  • "Doctor, is this really necessary?"

  • I know this can be a difficult question to ask.

  • In fact, if you go back 50 years,

  • this was even considered rude.

  • (Laughter)

  • If the doctor had decided what to do with you,

  • that's what you did.

  • A colleague of mine, now a general practitioner,

  • was sent away to a tuberculosis sanatorium as a little girl,

  • for six months.

  • It was a terrible trauma for her.

  • She later found out, as a grown-up,

  • that her tests on tuberculosis had been negative all along.

  • The doctor had sent her away on nothing but wrong suspicion.

  • No one had dared or even considered confronting him about it.

  • Not even her parents.

  • Today, the Norwegian health minister

  • talks about the patient health care service.

  • The patient is supposed to get advice from the doctor about what to do.

  • This is great progress.

  • But it also puts more responsibility on you.

  • You need to get in the front seat with your doctor

  • and start sharing decisions on where to go.

  • So, the next time you're in a doctor's office,

  • I want you to ask,

  • "Doctor, is this really necessary?"

  • And in my female patient's case,

  • the answer would be no,

  • but an operation could also be justified.

  • "So doctors, what are the risks attached to this operation?"

  • Well, five to ten percent of patients will have worsening of pain symptoms.

  • One to two percent of patients

  • will have an infection in the wound or even a rehemorrhage

  • that might end up in a re-operation.

  • 0.5 percent of patients also experience permanent hoarseness

  • and a few, but still a few,

  • will experience reduced function in the arms or even legs.

  • "Doctor, are there other options?"

  • Yes, rest and physical therapy over some time

  • might get you perfectly well.

  • "And what happens if I don't do anything?"

  • It's not recommended,

  • but even then, there's a slight chance that you will get well.

  • Four questions.

  • Simple questions.

  • Consider them your new toolbox to help us.

  • Is this really necessary?

  • What are the risks?

  • Are there other options?

  • And what happens if I don't do anything?

  • Ask them when your doctor wants to send you to an MRI,

  • when he prescribes antibiotics

  • or suggests an operation.

  • What we know from research

  • is that one out of five of you, 20 percent,

  • will change your opinion on what to do.

  • And by doing that, you will not only have made your life

  • a whole lot easier, and probably even better,

  • but the whole health care sector

  • will have benefited from your decision.

  • Thank you.

  • (Applause)

I am a neurosurgeon,

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【TED】Christer Mjåset: 4 questions you should always ask your doctor (4 questions you should always ask your doctor | Christer Mjåset)

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    林宜悉 posted on 2019/10/14
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