When in doubt, cut it out. What the hell’s the difference?
When in doubt, cut it out. What the hell’s the difference?
From tribal Africa to dueling Germany, scars have been the accoutrements of fashionable society. Smaller, concealed scars continue to this day to be discreet symbols of prerogative and wealth. Often, the pale white tracks of the scalpel cover a variety of elective surgery (nonessential surgery performed at the patient’s request, often instead of long-term therapy) which affluent groups sign up for in greater number than their fellows, from hysterectomies through gall bladder surgery to appendectomies. Gradually, since the advent of universal medicare, elective operations are becoming a democratic institution—like the five-cent cigar. Indeed, they are spreading across the country with the virulence of a disease, logging statistics that in any other outbreak would be called epidemic.
An increase of 41% in hysterectomies and the 23% rise in gall bladder operations between 1968 and 1972 are among the startling data gathered by Dr. Eugene Vayda, an epidemiologist at the University of Toronto. There were only 4,521 heart operations in all Canada during 1973—the last year for which national figures are available—yet there were 67,710 hysterectomies, 88,290 gall bladder operations, and some 135,080 tonsillectomies.
While in some parts of the nation people are getting rid of unwanted organs as casually as if they were old shoes, the president of the Canadian Medical Association, Dr. Robert Gourdeau, does not find the surgery excessive. “Unnecessary surgery is not a problem in Canada,” he states flatly. It may not be a medical problem in the sense that most of the tens of thousands of operations end routinely. Often, however, the results aren’t quite what the patient hoped for and complications set in as readily as “instant relief.” For example, surgeons stripping varicose veins have severed arteries instead, causing gangrene and the final solution for varicosity—amputation of the leg. Elsewhere, the blunders of GPS filling in as anesthetists have led to death from brain damage, if not from the slip of a scalpel.
Despite Gourdeau’s optimism, there has been proof available for years that unnecessary surgery is performed at least in parts of Canada. A committee of the Saskatchewan College of Physicians and Surgeons found that nearly a quarter of the hysterectomies performed therein 1971 could not be “medically justified.” Yet when those figures were made public it took only two years for the number of unjustified hysterectomies to plummet to 8%.
As with the other dubious necessities of affluent society, cash determines when luxuries become necessities. That’s why rich provinces such as Alberta have very high rates for elective surgery, while Newfoundland has the lowest. “Our hysterectomy rates are high,” acknowledges Dr. Leroy le Riche, registrar of the Alberta College of Physicians and Surgeons, “because it’s often used here for sterilization. There’s probably a greater proportion of doctors in Alberta who would agree with removing a healthy uterus to prevent cancer or pregnancy than anywhere else in Canada. And we have more gall bladder surgery because Albertans live the rich kind of life that creates that problem.”
Studies show that elective rates are highest where hospital beds are plentiful and medical facilities accessible. But there is no proof that when these are expended on electives better health results. In some instances, the reverse is true. The mortality rate from gall bladder disease is twice as high for Canadians over 65 as for the same age group in England, reflecting the fact that gall bladder operations are performed five times as frequently here.
A doctor with the federal Department of Health and Welfare readily concedes that some of this is the price of medical fads. “Some surgery, such as circumcision and appendectomy, has always been a matter of fashion,” he says, pointing out that Canadian enthusiasm for tonsillectomies— averaging 170% higher than in the United
States—has recently waned. Between 1968 and 1972, it had fallen by 33% without any apparent damage to children’s health. But medical necessity is rarely the issue. Says the doctor: ‘“What we’re really talking about is the degree of discomfort people are prepared to suffer. When surgery was expensive and dangerous, they were content to put up with the pain, say, of varicose veins. Now, it’s like asking them to put on a sweater instead of turning up the heat.”
There’s no indication this surgical heat will abate. “It’s basic economics,” suggests Dr. John Carlyle, assistant registrar of the Ontario College of Physicians and Surgeons, “that as the cost of health care to Joe Public approaches zero, the demand will approach infinity. The doctors say, ‘Who am I to tell this guy waving the medicare card in my face that he can’t have surgery?’ So he ends up doing operations in which medical reasons are secondary. If a patient feels he needs gall bladder surgery, well, he needs it.”
Surgery may always be more attractive than slow, long-term therapy for a society conditioned by advertising to expect instant gratification. Many doctors agree privately that wherever surgeons’ offices and hospital beds stand ready, doctors and patients will devise the elective surgery to fill them. If North Americans consume pills, from Aspirins to antibiotics, as if they were candy for adults, why should elective surgery not be treated as an adult toy as well?
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