So begins a Perspectives piece in this week's New England Journal that addresses surgical decision making. As we look on, in April 2014, what is the likely narrative for this patient's care? Perhaps the initial diagnosis was made by a community gastroenterologist who found the mass. How does he proceed? It is unlikely that the referral would be other than to a surgeon. As a matter of fact, the very language of Medicine reinforces the pathway: the patient has a "surgical" problem. Preoperative evaluation by colleagues in General Medicine, Cardiology and/or Pulmonary Medicine serve to address our hospital's requirements (some of which are imaginary). Often this process delays the surgery or threatens to do so as data are assembled in the eleventh hour. Occasionally, additional testing is identified that will reassure us. Ultimately, the patient is (almost always) "cleared." (What does this really mean?)
None of the actors in this play are positioned to address the broad issues outlined above. Appropriately, the surgeon will explain the purpose of the operation and the expected recovery. He will diligently outline a number of potential complications - bleeding, thromboembolism, infection, adhesions and so forth, and will tell the patient, accurately and reassuringly, that (individually) they occur in only a small minority of patients. Age-specific risks of deconditioning or cognitive decline and overall outcomes are not - to the best of my knowledge - part of this discussion. (And not because of any conscious intent to withhold information. My best guess is that most surgeons would view such considerations as both speculative and beyond their scope of practice.)
We stand at a cross roads. In the current, fee-for-service world, significant change would create few winners (the patient) and many losers (the surgeon, consulting physicians, the hospital) so efforts in shared surgical decision making have been limited to a limited number of promising experiments by payers and integrated health systems. In the Accountable Care world that is emerging, however, the right alignments exist to make it feasible for patients to routinely receive team-based consultation, and comprehensive disease-management planning that does not proceed from the premise that the patient possesses "a surgical problem." Notably, our own Health System - now that it has embarked on the path of integration with the Care Connect insurance product - is positioned to engage in this kind of work.
It will take time. Some patients and families, steeped in the culture of "more is better," will be skeptical of such well-intentioned efforts. Additionally, physicians will need the right knowledge and skill sets to have these conversations. (Currently, these are the discussions that Palliative Medicine physicians conduct, but that field will require a make-over for pre-procedure consultation to make sense to patients and families.) One thing is clear, however - there is change in the air.
Ref: Lance, G. et. al.; Redesigning surgical decision-making for high-risk patients. New Engl Jl Med 370(15):1379; April 10, 2014
