The Elective Surgery Second Opinion Program WILLIAM R. GRAFE, M.D., CHARLES K. MCSHERRY, M.D.,* MADELON L. FINKEL, M.P.A., EUGENE G. McCARTHY, M.D., M.P.H.
The results of the Cornell Elective Surgery Second Opinion Program are presented. From February 1972 to January 1978, 7053 patients were evaluated for proposed elective surgery, and in 27.6% of these, the operations were not approved. The subspecialties of orthopedics and gynecology demonstrated the highest rates of non-confirmation, while that for general surgery was 18%. A group of 318 patients with general surgical diagnoses are reviewed. The percentage of nonconfirmed surgery for this group was 15 percent. The most common reasons for not approving the operations were absence of pathology and failure to utilize medical therapy when indicated.
From the Departments of Surgery and Public Health, Cornell University Medical College, New York, New York
are patient oriented and are not designed to measure the reliability of physicians' recommendations.
E LECTIVE SURGERY SECOND OPINION programs are
designed to provide a means for obtaining at least one additional surgical consultation by a board-certified surgical specialist for those patients who have been advised to undergo an elective surgical procedure. Elective surgery is defined as an operation which is subject to the choice or decision of the patient and physician and is not of an emergency nature. Surgery required as the result of trauma, normal vaginal deliveries, and elective abortions, are specifically excluded. The primary objective of the program is to improve the medical care of the subscribers. These programs reimburse the full cost of the consultation and all ancillary tests required to complete the consultation through the sponsoring agency or third party insurer, thereby removing a potential financial barrier to patients' access to specialty consultation. The consultants of the programs evaluate proposed elective surgical procedures. Some of these may be considered to be not indicated based on the physical findings; in some patients medical treatment may be the preferred therapy; in others, further evaluation may be considered essential before surgery is undertaken. However, it should be emphasized that these programs Presented at the Annual Meeting of the American Surgical Association April 26-28, 1978, Dallas, Texas. * Present address: Beth Israel Medical Center, New York, New York 10003. Supported in part by Social Security Administration Grant #60075-0175. Reprint requests: William R. Grafe, M.D., Cornell University Medical College, 1300 York Avenue, New York, New York 10021. The technical assistance of Mrs. Patricia May is gratefully acknowledged.
The Cornell University Second Opinion Program The first elective surgery second opinion program was implemented by Cornell University Medical College and several union security welfare funds in 1972. The program utilizes consultation with a board certified surgeon for evaluation of the necessity of the recommended elective surgical procedure as the next appropriate therapeutic step. The consultants are based either at teaching or community hospitals in the Greater New York City area and represent all of the surgical subspecialties. According to the program's research design, the consultants may agree with the referring physician and recommend surgery, may suggest that the surgery is not indicated at present or at all, may suggest that an alternative method of treatment be instituted instead, may advise further diagnostic evaluation for the clinical problem, or may suggest that surgery be performed on an ambulatory basis. The recommendation for alternative treatment does not preclude the possibility of surgery being performed at a later date. Moreover, if the consultant suggests that surgery is not indicated or that the operation be deferred, the patients are allowed to proceed with the surgery. The final decision always belongs to the patient. A third opinion is available should an individual make such a request, but in practice, they are infrequent. Consultants are assigned from the panel and cannot be recommended by the referring physician. The consultants are not permitted to perform the surgery. There are two subdivisions of second opinion programs: voluntary. and mandatory, depending upon the individual unions involved. The former implies that an individual recommended for elective surgery voluntarily schedules a consultation for a second opinion
0003-4932/78/0900/0323 $00.85 C J. B. Lippincott Company
323
GRAFE4AND OTH[ERS
324
TABLE 1. Patients Examined in Elective Surgery Second Opinion Program, February, 1972 to January, 1978
Not confirmed Confirmed Total
Voluntary
Mandatory
No.
%
No.
%
No.
%
1524 3031
33.5 66.5
424 2074
17.0 83.0
1948 5105
27.6 72.4
4555
100.0
2498 100.0
7053
100.0
Voluntary
Mandatory
Not Confirmed
Specialty Orthopedics Gynecology Urology Opthalmology Otolaryngology General Surgery
No. No. 707 894 324 344 491 1375
323 358 117 110 141 328
Not Confirmed
%
No.
No.
%
45.7 40.0 36.1 32.0 28.7 23.9
203 522 158 217 306 992
63 127 22 45 43 109
31.0 24.3 13.9 20.7 14.1 11.0
Total % 42.0 34.0 28.8 27.6 23.0 18.0
Mandatory
Not Confirmed
Procedure
Surgery of the knee Hysterectomy
Prostatectomy
TABLE 2. Per Cent Not Confirmed for Elective Surgery According to Surgical Specialty
Surg. * September 1978
TABLE 3. Per Cent Not Confirmed for Elective Surgery According to Most Frequently Screened Procedures
Total
through the sponsoring agency. The voluntary program cannot be projected to represent the universal since it encompasses a small self-selective population. In the mandatory programs, all those recommended for elective surgery must obtain a second opinion in order to receive benefits. However, benefits will be paid to those individuals in the mandatory programs should the consultant not recommend surgery and the patient elect to have the operation. It is estimated that only 10% of those in voluntary programs who are eligible will seek a second opinion whereas 80% of those in the mandatory programs will seek such consultation. Therefore a more accurate cross-section of surgical consultations is obviously seen in the mandatory programs. All of the patients not confirmed for elective surgery and a randomly selected sample of patients confirmed for surgery are contacted six months after their consultation, and information relating to surgical and medical treatment is obtained. For those patients who report having had surgery, information on the type of surgical procedure, the necessity for medical care, and general health status is elicited. For those who report that surgery has not been performed, information concerning the type and frequency of medical treatment, the reasons for not having had the surgery, and general health status is obtained. These individuals are contacted again at six month intervals over the ensuing 18 months and similar information obtained. The follow-up phase of the second
Voluntary
Ann.
D&C Cataract extraction Surgery of the breast Surgery of soft tissue mass, cyst, skin lesion Cholecystectomy
Not Confirmed
No.
No.
%
No.
158 505 147 129 186 283
76 212 61 43 56 80
48.1 42.0 41.5 33.3 30.1 28.3
48 172 29 214 107 164
701 183
195 27.8 22 12.0
438 105
No.
%
10 40 19 22
20.8 27.3 20.7 18.7 17.8 13.4
63 11
14.4 10.5
47 6
opinion study may extend for one or two years from the date of the consultation. The length of the follow-up depends on the necessity for medical treatment. If a patient reports no such treatment for two consecutive six month periods, he or she is considered asymptomatic and no additional follow up effort is made. This phase of the program commenced in 1974. Those who had consultations prior to 1974 were contacted and the questions were asked retrospectively. Therefore, some patients have been followed for more than five years. The present study includes the patients not confirmed for surgery and an analysis of 318 patients evaluated for elective general surgical procedures. Analysis of the data compiled since the inception of the program from February, 1972, to January, 1978, indicates that of a total of 7,053 patients, 27.6% were not confirmed for elective surgery by a board-certified consultant. Table 1 discloses that 33.5% of those in the voluntary group and 17.0% in the mandatory group were not confirmed for surgery. Table 2 depicts the distribution of those not confirmed for elective surgery according to the consultant's surgical specialty. Within the voluntary group, 45.7% were not confirmed for orthopedic conditions and 40% were not confirmed for gynecological conditions. Within the mandatory group 31% were not confirmed for orthopedic conditions, 24.3% were not confirmed for gynecological conditions, and 20.7 % were not confirmed for ophthalmological conditions. The distribution of those patients not confirmed for surgery according to the most frequently screened procedures is listed in Table 3. Within the voluntary group, 48.1% were not confirmed for surgery of the knee, and roughly 40% were not confirmed for hysterectomies and prostatectomies, 42.0% and 41.5%, respectively. Within the mandatory group, 27.3% were not
Vol. 188
o
No. 3
SECOND OPINIK)N PROGRAM
confirmed for hysterectomies, and one-fifth were not confirmed for knee surgery and prostatectomy, 20.8% and 20.7%, respectively. Table 4 shows the distribution of those not confirmed according to the board status of the initial diagnosing physician. Within the voluntary group, approximately 40% of the initial diagnosing physicians who were board certified in orthopedics and board certified in obstetrics-gynecology, 41.1% and 39.6%, respectively had their original recommendation for surgery not confirmed by the respective board certified consultant. Over one-third (36.6%) of the board certified urologists had their recommendations for surgery not confirmed by a board certified consultant. Among the surgical specialists there was no statistically significant difference in the non-confirmation rate of those who were or were not board certified (X2 = 1.94 df = 1 (Yates' correction employed) 0.1 > p > 0.2 N.S.). However, the nonconfirmation rate of the board certified internists was 24.9% compared to 32.7% of those who were board certified in other specialties, a statistically significant difference (X2 = 5.13 df = 1 (Yates' correction) 0.02 > p > 0.05). Within the mandatory group, the proportion of patients not confirmed for surgery recommended by board-certified orthopedists and gynecologists was 22.6 and 22.5% respectively. Chi square testing showed no significant difference between the board certified and the nonboard certified surgical specialists. There was also no statistically significant difference between the board certified internists and other board certified specialists. Results from the first follow-up questionnaire, submitted six months after the consultation reveal that 81.8% of those patients who were not confirmed for surgery had not had the surgery performed. Within the voluntary group, 84.7% who were not confirmed for surgery had not had the operation, and within the mandatory group, 69.9%. The majority of patients within the voluntary and mandatory groups reported that they had decided against surgery on the basis of the consultants' recommendations. The majority of those who decided to undergo surgery did so within three months from the date of consultation and the most frequent reason stated was that the symptoms persisted or became worse. Results from the second follow-up questionnaire, 12 months after the date of consultation, show that 77.7% who were not confirmed for surgery had not had the surgery performed one year after the date of consultation. Within the voluntary group, 80.4% had not had surgery while 62.6% within the mandatory group had not had surgery. Of those patients who were not confirmed for surgery and did not have an operation, 60%
325
TABLE 4. Per Cent Not Confirmedfor Elective Surgery According to Board Status of Initial Diagnosing Physician
Voluntary
Mandatory
Not Confirmed
Board Certification
Surgery Ob-Gyn Orthopedics Otolaryngology Urology Ophthalmology Medicine Other* Total Board Certified Total Not Board Certified
No. No. 526 455 297 216 142 183 189 128 2136 876
126 180 122 62 52 55 47 39 683 304
Not Confirmed
%
No. No.
%
24.0 39.6 41.1 28.7 36.6 30.1 24.9 30.5 32.0 34.7
468 44 316 71 115 26 173 27 95 10 134 24 67 9 85 12 1453 223 418 69
9.4 22.5 22.6 15.6 10.5 17.9 13.4 14.1 15.3 16.5
* Includes Psychiatry, Thoracic surgery, Neurosurgery, Pediatrics, Dermatology.
reported receiving no medical treatment in both the voluntary and mandatory groups. Two of the authors (WRG and CKMcS) have served as general surgical consultants to the program since its inception six years ago and have evaluated 318 patients for recommended elective surgical procedures. The patients were referred from seven participating unions in the New York Metropolitan area. There were 195 (61%) females and 123 (39%) males. The need for elective surgery as recommended was not confirmed by the consultants in 48 (15%) patients. The diagnoses of the 318 patients referred for evaluation are listed in Table 5. The relative distribution of conditions evaluated is similar to those normally encountered in a general surgical practice. Table 6 lists the proposed elective operations which were not confirmed. The reasons for not endorsing the proposed surgery fell into six categories: no pathology demonstrated, medical treatment preferable, surgery deferred pending results of medical treatment, surgery approved on an ambulatory basis only, further diagnostic evaluation considered necessary, and surgery contraindicated. In 18 of the 48 (37.5%) patients not confirmed, no pathology could be demonstrated. There were seven patients with a diagnosis of breast tumor in whom no mass was evident on examination. Three patients who were considered for excision of benign skin lesions were found to have lentigos. Chronic cholecystitis in two patients was unconfirmed by oral cholecystography. The presence of a rectal polyp and an anal fissure could not be confirmed by proctoscopy and anoscopy in two patients, nor could an inguinal hernia be palpated in another. One patient recommended for laparotomy for abdominal pain after extensive negative
GRAFE AND OTHERS
326 TABLE 5. Referral Diagnoses
53
Chronic cholecystitis Benign breast disease Inguinal hernia Benign skin lesions Benign anal lesions Carcinoma, breast Carcinoma, lung Varicose veins Thyroid disease Pilonidal sinus Carcinoma, colon or rectum Duodenal ulcer Benign lung lesions Abdominal pain Ganglion Malignant skin lesions Umbilical hernia Aortoiliac occlusion Femoral artery occlusion Hiatus hernia Ulcerative colitis Diverticulosis Parotid tumor Carcinoma, stomach Rectal polyp Idiopathic thrombocytopenic purpura One diagnosis of each: Lymphoma of stomach, polyps of stomach, carcinoma of esophagus, lymphoma of mediastinum, mesenteric cyst, pericardial cyst, regional enteritis, splenomegaly, drug-induced purpura, undescended testis, pectus excavatum, hematoma of leg, ulcer of foot, hydrocele, infected toenail bed, lipoma of arm, sebaceous cyst, and metallic foreign body, soft tissues.
42
35 28 27
20 I
0 8
7 5 4
4
4
Surg. September 1978
sequently responded to steroid therapy. A patient with esophageal carcinoma, distant metastases, and pleural effusions was not approved for exploratory thoracotomy. A man with a traumatic hematoma of the leg
felt not to require drainage and the lesion resolved treatment. One patient with abdominal pain was not considered to be a candidate for diagnostic laparotomy, and his symptoms responded to mild sedatives. An obese female with a mildly symptomatic sliding hiatus hernia without reflux was advised on weight reduction and a medical regimen. In five patients (10%), the consultant decided that although surgical treatment might be necessary in the was
on conservative
4 4
future, confirmation of suggested surgery was denied
4
pending results of concurrent medical therapy. In one patient with recurrent pain from duodenal ulcer medical therapy was reinstituted. A female with thyrotoxicosis was denied thyroidectomy until a euthyroid state was attained with drugs. A male referred for superficial lobectomy of a parotid mass resolved a sialadenitis on antibiotic therapy. One patient with a small anal fistula and another with constipation and sigmoid diverticulosis were continued on conservative treatment. In five patients (10%) further diagnostic and medical evaluation was considered necessary before the proposed surgery. Two patients with abdominal pain had had inadequate diagnostic evaluations and were not regarded as candidates for laparotomy. An elderly female with asymptomatic cholelithiasis and a recent massive cerebrovascular accident was not approved for elective cholecystectomy. A young woman with
3 3 3
3
3 2 2
2
18 318
diagnostic evaluation was felt to have psychosom atic complaints. One patient with a diagnosis of gastric 1 ymphoma was found to have hypertrophic gastritis on gastrointestinal x-rays and endoscopy. In the remairiing patient recommended for thyroidectomy, a normal gland was demonstrated. In 15 (31%) patients, medical therapy was conside red preferable or had not been instituted where indicalted. Four patients with benign anorectal disease were c,onsidered candidates for conservative therapy. For Itwo patients with uncomplicated peptic ulcer disease, an adequate trail of medical therapy had never been Iprescribed. One patient with postpartum mastitis responded to antibiotics and did not require draina Lge. One patient with an asymptomatic nodular goiter and a negative scan had been recommended for thyroidlectomy. In view of severe heart disease and obes ity, the benefits of the proposed surgery did not app ear to justify the operative risk, and medical treatmlent was advised. One patient with a small ulcer of the fFoot was felt not to require a skin graft. One patient vvith uncomplicated sigmoid diverticulosis was advisedL on diet and bowel habits. One patient with drug-indu ced purpura was not confirmed for splenectomy and s ub-
Ann.
ulcerative colitis was referred for proposed transproctoscopic excision of pseudopolyps of the rectum TABLE 6. Referral Diagnoses -Surgery Not Confirmed
Chronic cholecystitis Benign breast disease Inguinal hernia Benign skin lesions Benign anal lesions Thyroid disease Duodenal ulcer Abdominal pain Diverticulosis Ulcerative colitis Hiatus hernia Parotid tumor Rectal polyp Carcinoma, esophagus Lymphoma, stomach Drug-induced purpura Foot ulcer Hematoma, leg Lipoma, arm Sebaceous cyst
No.
Not Confirmed
53 42 35 28 27 9 5 4 3 3 3 3 2 1 I I 1 1 1 1 224
3 8 1 5 6 3 3 4 3 1 1 1 2 1 I I 1 1 1 1 48
SECOND OPINIION PROGRAM
Vol. 188.e No. 3
and this surgery was not confirmed. One patient with long-standing sigmoid diverticulosis and anemia of recent onset was not confirmed for sigmoid resection pending further diagnostic evaluation of the anemia. Surgery was felt to be contraindicated in one patient (2%), following radical mastectomy with a large asymptomatic lipoma of the ipsilateral arm. Surgery was approved, but on an ambulatory basis only, in four patients (8%). Hospitalization and general anesthesia had been advised for the excision of small benign skin lesions in two patients, excision of a rectal polyp in one and incision and drainage of an infected sebaceous cyst in another. Discussion
Interesting observations may be obtained by an examination of the type and frequency of surgical procedures performed throughout the country. Data provided by the National Center for Health Statistics indicate a dramatic increase in surgical rates from 1971 to 1975. However, the 1976 figures indicate that the rate per 100,000 population has decreased from the 1975 rate. This decrease is the first noted since 1968. The rate of in-hospital surgical procedures per 100,000 population was 7,805 in 1971; 8,952 in 1973; and 9,585 in 1975. The 1976 rate declined to 9,539. The number of surgical procedures was 20,040,000 in 1975 and 20,086,000 in 1976, the smallest increase since 1971.4 Operations performed on in-patients discharged from short-stay hospitals in 1976 were less than those in 1975 for many surgical procedures. For example, there was a 16.7% decrease in partial mastectomies from 1975 to 1976. Tonsillectomies and/or adenoidectomies decreased 8.2% and hysterectomies, which had increased from 1971-1975, decreased by 6.3% from 1975 to 1976. In contrast, surgery of the back increased by 12.8% from 1975 to 1976.4 Among the explanations presented for the rise in surgical rates, it has been suggested, that there may be a surplus of surgeons for the needs of the population and that this has led to excessive surgery.5 In 1970, Bunker reported a comparative study of surgery in the United States and in England and Wales, indicating that for twice the number of surgeons per 100,000 of population in the United States, twice the number of operations were performed compared to England and Wales.1 Recent manpower studies, including the SOSSUS Report, emphasize that many physicians performing surgery are not board certified and suggest that there is a need to reduce the number of surgical residency positions offered. Other studies support the hypothesis that surgical rates are related to the supply of surgeons.367 The problem of an excessive number of physicians perform-
327
ing surgery may be solved in the long term by more stringent hospital regulations for granting surgical privileges and by more realistic appraisal of future manpower needs by the professional organizations and possibly by federal regulatory agencies. For the shortterm, it would seem appropriate to review the reasons for recommended surgery before the operations are performed. The findings of The Cornell prospective study indicate that second opinion programs can monitor elective surgery without jeopardizing the health and well-being of the patients. The group of 318 patients with general surgical diagnoses reported in detail in this study represents a sample of the entire program from which several conclusions can be drawn. This group confirms the validity of the study as a whole, and closely reproduces the nonconfirmed percentage of the total 2,367 general surgical cases reviewed, 15% compared to 18%. Reasons for nonconfirmation can be divided into six categories, and of these, absence of pathology and the preferability of medical therapy account for the majority of rejections. Admittedly, there will always be valid differences of opinion in many clinical situations. However, it is evident that inadequate training and, ethically questionable motives may result in inappropriate surgery. The elective surgery second opinion program may also be viewed as one possible means of limiting the increases in health care costs. While a two year economic study is now in progress to calculate both the direct and indirect fiscal benefits of the second opinion programs, two union welfare funds which have developed mandatory second opinion programs have already reported a substantial reduction in surgical claims of 8 and 10% in a three year period. Another interesting observation is the recognition of what we have named the "Sentinel Effect." As the existence of second opinion programs becomes known, a decline in the rate of in-hospital surgical claims has been observed. This observation was also made in Saskatchewan where the number of hysterectomies performed decreased by 32.8% during the period 19701974 after a study committee for retrospective case review was appointed.2 It is evident that there is an increasing demand by the public for a role in the decision making processes relating to health care. The second opinion programs are patient oriented and provide a mechanism by which individuals are enabled to make more informed decisions. While a physician's recommedation for surgery is based on the advantages of such treatment to the patient, the ultimate decision belongs to the patient. The means of improving the quality of health care and reducing its .cost are the responsibility of both physicians and patients.
328
Ann. Surg. * September 1978
GRAFE AND OTHERS
Summary The Cornell elective surgery second opinion program has evaluated 7,053 patients since its inception in 1972. The need for proposed elective surgery was not confirmed by a board-certified consultant in 27.6 percent of these patients. The conditions with the highest unconfirmed rates were orthopedic and gynecologic. The board status of the initial diagnosing surgical specialist was unrelated to the percentage of surgery which was not confirmed. Analysis of 318 patients with general surgical conditions disclosed that absence of pathology and failure to utilize indicated medical therapy were the major reasons for not confirming the proposed surgery. The second opinion programs are believed to be one means of increasing patients' intelligent participation in matters related to their health care as well as a means of containing the costs of this care. DISCUSSION DR. GEORGE D. ZUIDEMA (Baltimore, Maryland): Dr. Grafe and his coauthors have begun to clarify some questions about what happens to individuals whose surgery is not confirmed, and, more importantly, it tells us why the 18% of individuals recommended for elective general surgery were not confirmed. This is important information which is necessary to understand the basis for the decision to defer operation. I'd like to make a few comments and ask the authors a few questions. This study shows that one year after surgery was deferred, in both groups, four out of five patients had not had the operation performed. The reverse, however, may well be significant, for one of the five went ahead to have the procedure performed anyway, and here it is important to ask why. Was the second opinion wrong, or were patients dissatisfied with the judgment of the second consultant? Secondly, a significant feature of this paper is to examine the reasons why 18% of patients were not confirmed for elective general surgery. The figures in the paper today are at variance, somewhat, with those in the abstract, but, in general, something under half of the patients not confirmed apparently would require follow-up, additional medical treatment or a trial of nonsurgical therapy, at least. In about half, the decision to defer operation indefinitely appears to be a good one. These findings, however, point out the need for some longitudinal studies, following the patients for several years, if necessary, before drawing final conclusions regarding either outcome or cost/ benefit analysis. Also, there is a need to attempt to measure the quality of life under both surgical and medical modes of treatment, and this may turn out to be an important determinant, especially to the patients involved. I would appreciate some comments regarding longitudinal studies of this kind.
DR. FRANCIS D. MOORE (Boston, Massachusetts): Dr. McCarthy and his colleagues have introduced a sort of a numerical, or mathematical, analysis of physician/physician and physician/patient interaction. I hope that the authors will avoid the connection that has been made between the surgical second opinion program, which is a new word for an old thing-consultation-and the number of un-needed operations in the United States. That is a long jump. It is a connection they made in their abstract, but possibly have decided now not to make.
References 1. Bunker, J. P.: Surgical Manpower: A Comparison of Operating Surgeons in the United States and in England and Wales. N. Engl. J. Med., 282:135, 1970. 2. Dyck, F. J., Murphy, F. A., Murphy, T. K., et al.: Effect of Surveillance on the Number of Hysterectomies in the Province of Saskatchewan. N. EngI. J. Med., 296:1326, 1977. 3. Lewis, E. E.: Variations in the Incidence of Surgery. N. EngI. J. Med., 281:880, 1969. 4. National Center for Health Statistics: Hospital Discharge Survey. Government Printing Office, Washington, D. C. In Press. 5. Nickerson, R. J., Colton, T., Peterson, 0. L., et al.: Doctors who Perform Operations: A Study on In-hospital Surgery in Four Diverse Geographic Areas. N. Engl. J. Me.d., 295:921, 1976. 6. Wennberg, J. and Gittelsohn, A.: Small area variations in surgical health care delivery. Science, 182:1102, 1973. 7. Wennberg, J.: Health care delivery in Maine: patterns of use of common surgical procedures. J. Maine Med. Assoc., 66: 123, 1975.
It connotes a sort of global socioeconomic role for consultation about surgery. After all, consultation is a part of all of medicine. How about a second opinion program on initiation of insulin therapy versus oral agents in the treatment of diabetes? How about a second opinion program on whether or not digitalis should be started, whether or not psychoanalysis should be started? It's all there. Disagreement does not impugn one alternative. It's just part of good medicine. It is interesting that cardiac surgery and gastrointestinal surgery are two fields of surgery where the interaction between the physician and the surgeon is so close that the second opinion is automatic. I have always expected Dr. McCarthy and his group to come up with a study of negative first opinions. I think we ought to see that. How many patients who ought to have a total hip are wandering around with canes and crutches? How many patients that can't see deserve to have that cataract taken out? How many patients that can't hear deserve to have a second opinion from a surgeon and get middle-ear surgery? And how about the patients who can't urinate? Maybe the second opinion would let them see a urologist. How many of all these patients are being held away from therapeutic relief by a negative and often biased, first opinion? So before we understand the social implications of this, we've got to look at both sides of the fence, and see how many patients in this country are being withheld from definitive therapy. surgery or otherwise, because of a fallacious initial opinion? This program has always seemed to me a little bit one-sided. Right from the start, in Dr. McCarthy's first article in the Newt Englanid Journal of Medicine, the misquotation and misuse of these data in the press and in congressional hearings has really been based on a mystical connection between a few hundred cases of disagreementhere, 318 have been carefully analyzed-and the huge populational needs of this country. It's a jump that we're just not ready to make. Now, the second opinion program must involve the second opinions of peer experts-not just those instances in which a specialist sees the patient for the first time. I have coined a word called PESO. That's a good term because it is not very much money. It means "Peer Expert Second Opinion". This is the second opinion that counts-when two experts see the patients. Early in the program, in the case of a patient, a child, let's say, who couldn't void, the pediatrician might have said to the mother, "Maybe you need to have a bladder neck resection." Then the child was seen by an experienced pediatric urologist, who said, "No, it's not time yet. It's the wrong age for that patient to have that." This goes down as a negative surgical second opinion. It is not. It is a first opinion. It was parlayed into some sort of a national
The results of the Cornell Elective Surgery Second Opinion Program are presented. From February 1972 to January 1978, 7053 patients were evaluated for proposed elective surgery, and in 27.6% of these, the operations were not approved. The subspecialties of orthopedics and gynecology demonstrated the highest rates of non-confirmation, while that for general surgery was 18%. A group of 318 patients with general surgical diagnoses are reviewed. The percentage of nonconfirmed surgery for this group was 15 percent. The most common reasons for not approving the operations were absence of pathology and failure to utilize medical therapy when indicated.
From the Departments of Surgery and Public Health, Cornell University Medical College, New York, New York
are patient oriented and are not designed to measure the reliability of physicians' recommendations.
E LECTIVE SURGERY SECOND OPINION programs are
designed to provide a means for obtaining at least one additional surgical consultation by a board-certified surgical specialist for those patients who have been advised to undergo an elective surgical procedure. Elective surgery is defined as an operation which is subject to the choice or decision of the patient and physician and is not of an emergency nature. Surgery required as the result of trauma, normal vaginal deliveries, and elective abortions, are specifically excluded. The primary objective of the program is to improve the medical care of the subscribers. These programs reimburse the full cost of the consultation and all ancillary tests required to complete the consultation through the sponsoring agency or third party insurer, thereby removing a potential financial barrier to patients' access to specialty consultation. The consultants of the programs evaluate proposed elective surgical procedures. Some of these may be considered to be not indicated based on the physical findings; in some patients medical treatment may be the preferred therapy; in others, further evaluation may be considered essential before surgery is undertaken. However, it should be emphasized that these programs Presented at the Annual Meeting of the American Surgical Association April 26-28, 1978, Dallas, Texas. * Present address: Beth Israel Medical Center, New York, New York 10003. Supported in part by Social Security Administration Grant #60075-0175. Reprint requests: William R. Grafe, M.D., Cornell University Medical College, 1300 York Avenue, New York, New York 10021. The technical assistance of Mrs. Patricia May is gratefully acknowledged.
The Cornell University Second Opinion Program The first elective surgery second opinion program was implemented by Cornell University Medical College and several union security welfare funds in 1972. The program utilizes consultation with a board certified surgeon for evaluation of the necessity of the recommended elective surgical procedure as the next appropriate therapeutic step. The consultants are based either at teaching or community hospitals in the Greater New York City area and represent all of the surgical subspecialties. According to the program's research design, the consultants may agree with the referring physician and recommend surgery, may suggest that the surgery is not indicated at present or at all, may suggest that an alternative method of treatment be instituted instead, may advise further diagnostic evaluation for the clinical problem, or may suggest that surgery be performed on an ambulatory basis. The recommendation for alternative treatment does not preclude the possibility of surgery being performed at a later date. Moreover, if the consultant suggests that surgery is not indicated or that the operation be deferred, the patients are allowed to proceed with the surgery. The final decision always belongs to the patient. A third opinion is available should an individual make such a request, but in practice, they are infrequent. Consultants are assigned from the panel and cannot be recommended by the referring physician. The consultants are not permitted to perform the surgery. There are two subdivisions of second opinion programs: voluntary. and mandatory, depending upon the individual unions involved. The former implies that an individual recommended for elective surgery voluntarily schedules a consultation for a second opinion
0003-4932/78/0900/0323 $00.85 C J. B. Lippincott Company
323
GRAFE4AND OTH[ERS
324
TABLE 1. Patients Examined in Elective Surgery Second Opinion Program, February, 1972 to January, 1978
Not confirmed Confirmed Total
Voluntary
Mandatory
No.
%
No.
%
No.
%
1524 3031
33.5 66.5
424 2074
17.0 83.0
1948 5105
27.6 72.4
4555
100.0
2498 100.0
7053
100.0
Voluntary
Mandatory
Not Confirmed
Specialty Orthopedics Gynecology Urology Opthalmology Otolaryngology General Surgery
No. No. 707 894 324 344 491 1375
323 358 117 110 141 328
Not Confirmed
%
No.
No.
%
45.7 40.0 36.1 32.0 28.7 23.9
203 522 158 217 306 992
63 127 22 45 43 109
31.0 24.3 13.9 20.7 14.1 11.0
Total % 42.0 34.0 28.8 27.6 23.0 18.0
Mandatory
Not Confirmed
Procedure
Surgery of the knee Hysterectomy
Prostatectomy
TABLE 2. Per Cent Not Confirmed for Elective Surgery According to Surgical Specialty
Surg. * September 1978
TABLE 3. Per Cent Not Confirmed for Elective Surgery According to Most Frequently Screened Procedures
Total
through the sponsoring agency. The voluntary program cannot be projected to represent the universal since it encompasses a small self-selective population. In the mandatory programs, all those recommended for elective surgery must obtain a second opinion in order to receive benefits. However, benefits will be paid to those individuals in the mandatory programs should the consultant not recommend surgery and the patient elect to have the operation. It is estimated that only 10% of those in voluntary programs who are eligible will seek a second opinion whereas 80% of those in the mandatory programs will seek such consultation. Therefore a more accurate cross-section of surgical consultations is obviously seen in the mandatory programs. All of the patients not confirmed for elective surgery and a randomly selected sample of patients confirmed for surgery are contacted six months after their consultation, and information relating to surgical and medical treatment is obtained. For those patients who report having had surgery, information on the type of surgical procedure, the necessity for medical care, and general health status is elicited. For those who report that surgery has not been performed, information concerning the type and frequency of medical treatment, the reasons for not having had the surgery, and general health status is obtained. These individuals are contacted again at six month intervals over the ensuing 18 months and similar information obtained. The follow-up phase of the second
Voluntary
Ann.
D&C Cataract extraction Surgery of the breast Surgery of soft tissue mass, cyst, skin lesion Cholecystectomy
Not Confirmed
No.
No.
%
No.
158 505 147 129 186 283
76 212 61 43 56 80
48.1 42.0 41.5 33.3 30.1 28.3
48 172 29 214 107 164
701 183
195 27.8 22 12.0
438 105
No.
%
10 40 19 22
20.8 27.3 20.7 18.7 17.8 13.4
63 11
14.4 10.5
47 6
opinion study may extend for one or two years from the date of the consultation. The length of the follow-up depends on the necessity for medical treatment. If a patient reports no such treatment for two consecutive six month periods, he or she is considered asymptomatic and no additional follow up effort is made. This phase of the program commenced in 1974. Those who had consultations prior to 1974 were contacted and the questions were asked retrospectively. Therefore, some patients have been followed for more than five years. The present study includes the patients not confirmed for surgery and an analysis of 318 patients evaluated for elective general surgical procedures. Analysis of the data compiled since the inception of the program from February, 1972, to January, 1978, indicates that of a total of 7,053 patients, 27.6% were not confirmed for elective surgery by a board-certified consultant. Table 1 discloses that 33.5% of those in the voluntary group and 17.0% in the mandatory group were not confirmed for surgery. Table 2 depicts the distribution of those not confirmed for elective surgery according to the consultant's surgical specialty. Within the voluntary group, 45.7% were not confirmed for orthopedic conditions and 40% were not confirmed for gynecological conditions. Within the mandatory group 31% were not confirmed for orthopedic conditions, 24.3% were not confirmed for gynecological conditions, and 20.7 % were not confirmed for ophthalmological conditions. The distribution of those patients not confirmed for surgery according to the most frequently screened procedures is listed in Table 3. Within the voluntary group, 48.1% were not confirmed for surgery of the knee, and roughly 40% were not confirmed for hysterectomies and prostatectomies, 42.0% and 41.5%, respectively. Within the mandatory group, 27.3% were not
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SECOND OPINIK)N PROGRAM
confirmed for hysterectomies, and one-fifth were not confirmed for knee surgery and prostatectomy, 20.8% and 20.7%, respectively. Table 4 shows the distribution of those not confirmed according to the board status of the initial diagnosing physician. Within the voluntary group, approximately 40% of the initial diagnosing physicians who were board certified in orthopedics and board certified in obstetrics-gynecology, 41.1% and 39.6%, respectively had their original recommendation for surgery not confirmed by the respective board certified consultant. Over one-third (36.6%) of the board certified urologists had their recommendations for surgery not confirmed by a board certified consultant. Among the surgical specialists there was no statistically significant difference in the non-confirmation rate of those who were or were not board certified (X2 = 1.94 df = 1 (Yates' correction employed) 0.1 > p > 0.2 N.S.). However, the nonconfirmation rate of the board certified internists was 24.9% compared to 32.7% of those who were board certified in other specialties, a statistically significant difference (X2 = 5.13 df = 1 (Yates' correction) 0.02 > p > 0.05). Within the mandatory group, the proportion of patients not confirmed for surgery recommended by board-certified orthopedists and gynecologists was 22.6 and 22.5% respectively. Chi square testing showed no significant difference between the board certified and the nonboard certified surgical specialists. There was also no statistically significant difference between the board certified internists and other board certified specialists. Results from the first follow-up questionnaire, submitted six months after the consultation reveal that 81.8% of those patients who were not confirmed for surgery had not had the surgery performed. Within the voluntary group, 84.7% who were not confirmed for surgery had not had the operation, and within the mandatory group, 69.9%. The majority of patients within the voluntary and mandatory groups reported that they had decided against surgery on the basis of the consultants' recommendations. The majority of those who decided to undergo surgery did so within three months from the date of consultation and the most frequent reason stated was that the symptoms persisted or became worse. Results from the second follow-up questionnaire, 12 months after the date of consultation, show that 77.7% who were not confirmed for surgery had not had the surgery performed one year after the date of consultation. Within the voluntary group, 80.4% had not had surgery while 62.6% within the mandatory group had not had surgery. Of those patients who were not confirmed for surgery and did not have an operation, 60%
325
TABLE 4. Per Cent Not Confirmedfor Elective Surgery According to Board Status of Initial Diagnosing Physician
Voluntary
Mandatory
Not Confirmed
Board Certification
Surgery Ob-Gyn Orthopedics Otolaryngology Urology Ophthalmology Medicine Other* Total Board Certified Total Not Board Certified
No. No. 526 455 297 216 142 183 189 128 2136 876
126 180 122 62 52 55 47 39 683 304
Not Confirmed
%
No. No.
%
24.0 39.6 41.1 28.7 36.6 30.1 24.9 30.5 32.0 34.7
468 44 316 71 115 26 173 27 95 10 134 24 67 9 85 12 1453 223 418 69
9.4 22.5 22.6 15.6 10.5 17.9 13.4 14.1 15.3 16.5
* Includes Psychiatry, Thoracic surgery, Neurosurgery, Pediatrics, Dermatology.
reported receiving no medical treatment in both the voluntary and mandatory groups. Two of the authors (WRG and CKMcS) have served as general surgical consultants to the program since its inception six years ago and have evaluated 318 patients for recommended elective surgical procedures. The patients were referred from seven participating unions in the New York Metropolitan area. There were 195 (61%) females and 123 (39%) males. The need for elective surgery as recommended was not confirmed by the consultants in 48 (15%) patients. The diagnoses of the 318 patients referred for evaluation are listed in Table 5. The relative distribution of conditions evaluated is similar to those normally encountered in a general surgical practice. Table 6 lists the proposed elective operations which were not confirmed. The reasons for not endorsing the proposed surgery fell into six categories: no pathology demonstrated, medical treatment preferable, surgery deferred pending results of medical treatment, surgery approved on an ambulatory basis only, further diagnostic evaluation considered necessary, and surgery contraindicated. In 18 of the 48 (37.5%) patients not confirmed, no pathology could be demonstrated. There were seven patients with a diagnosis of breast tumor in whom no mass was evident on examination. Three patients who were considered for excision of benign skin lesions were found to have lentigos. Chronic cholecystitis in two patients was unconfirmed by oral cholecystography. The presence of a rectal polyp and an anal fissure could not be confirmed by proctoscopy and anoscopy in two patients, nor could an inguinal hernia be palpated in another. One patient recommended for laparotomy for abdominal pain after extensive negative
GRAFE AND OTHERS
326 TABLE 5. Referral Diagnoses
53
Chronic cholecystitis Benign breast disease Inguinal hernia Benign skin lesions Benign anal lesions Carcinoma, breast Carcinoma, lung Varicose veins Thyroid disease Pilonidal sinus Carcinoma, colon or rectum Duodenal ulcer Benign lung lesions Abdominal pain Ganglion Malignant skin lesions Umbilical hernia Aortoiliac occlusion Femoral artery occlusion Hiatus hernia Ulcerative colitis Diverticulosis Parotid tumor Carcinoma, stomach Rectal polyp Idiopathic thrombocytopenic purpura One diagnosis of each: Lymphoma of stomach, polyps of stomach, carcinoma of esophagus, lymphoma of mediastinum, mesenteric cyst, pericardial cyst, regional enteritis, splenomegaly, drug-induced purpura, undescended testis, pectus excavatum, hematoma of leg, ulcer of foot, hydrocele, infected toenail bed, lipoma of arm, sebaceous cyst, and metallic foreign body, soft tissues.
42
35 28 27
20 I
0 8
7 5 4
4
4
Surg. September 1978
sequently responded to steroid therapy. A patient with esophageal carcinoma, distant metastases, and pleural effusions was not approved for exploratory thoracotomy. A man with a traumatic hematoma of the leg
felt not to require drainage and the lesion resolved treatment. One patient with abdominal pain was not considered to be a candidate for diagnostic laparotomy, and his symptoms responded to mild sedatives. An obese female with a mildly symptomatic sliding hiatus hernia without reflux was advised on weight reduction and a medical regimen. In five patients (10%), the consultant decided that although surgical treatment might be necessary in the was
on conservative
4 4
future, confirmation of suggested surgery was denied
4
pending results of concurrent medical therapy. In one patient with recurrent pain from duodenal ulcer medical therapy was reinstituted. A female with thyrotoxicosis was denied thyroidectomy until a euthyroid state was attained with drugs. A male referred for superficial lobectomy of a parotid mass resolved a sialadenitis on antibiotic therapy. One patient with a small anal fistula and another with constipation and sigmoid diverticulosis were continued on conservative treatment. In five patients (10%) further diagnostic and medical evaluation was considered necessary before the proposed surgery. Two patients with abdominal pain had had inadequate diagnostic evaluations and were not regarded as candidates for laparotomy. An elderly female with asymptomatic cholelithiasis and a recent massive cerebrovascular accident was not approved for elective cholecystectomy. A young woman with
3 3 3
3
3 2 2
2
18 318
diagnostic evaluation was felt to have psychosom atic complaints. One patient with a diagnosis of gastric 1 ymphoma was found to have hypertrophic gastritis on gastrointestinal x-rays and endoscopy. In the remairiing patient recommended for thyroidectomy, a normal gland was demonstrated. In 15 (31%) patients, medical therapy was conside red preferable or had not been instituted where indicalted. Four patients with benign anorectal disease were c,onsidered candidates for conservative therapy. For Itwo patients with uncomplicated peptic ulcer disease, an adequate trail of medical therapy had never been Iprescribed. One patient with postpartum mastitis responded to antibiotics and did not require draina Lge. One patient with an asymptomatic nodular goiter and a negative scan had been recommended for thyroidlectomy. In view of severe heart disease and obes ity, the benefits of the proposed surgery did not app ear to justify the operative risk, and medical treatmlent was advised. One patient with a small ulcer of the fFoot was felt not to require a skin graft. One patient vvith uncomplicated sigmoid diverticulosis was advisedL on diet and bowel habits. One patient with drug-indu ced purpura was not confirmed for splenectomy and s ub-
Ann.
ulcerative colitis was referred for proposed transproctoscopic excision of pseudopolyps of the rectum TABLE 6. Referral Diagnoses -Surgery Not Confirmed
Chronic cholecystitis Benign breast disease Inguinal hernia Benign skin lesions Benign anal lesions Thyroid disease Duodenal ulcer Abdominal pain Diverticulosis Ulcerative colitis Hiatus hernia Parotid tumor Rectal polyp Carcinoma, esophagus Lymphoma, stomach Drug-induced purpura Foot ulcer Hematoma, leg Lipoma, arm Sebaceous cyst
No.
Not Confirmed
53 42 35 28 27 9 5 4 3 3 3 3 2 1 I I 1 1 1 1 224
3 8 1 5 6 3 3 4 3 1 1 1 2 1 I I 1 1 1 1 48
SECOND OPINIION PROGRAM
Vol. 188.e No. 3
and this surgery was not confirmed. One patient with long-standing sigmoid diverticulosis and anemia of recent onset was not confirmed for sigmoid resection pending further diagnostic evaluation of the anemia. Surgery was felt to be contraindicated in one patient (2%), following radical mastectomy with a large asymptomatic lipoma of the ipsilateral arm. Surgery was approved, but on an ambulatory basis only, in four patients (8%). Hospitalization and general anesthesia had been advised for the excision of small benign skin lesions in two patients, excision of a rectal polyp in one and incision and drainage of an infected sebaceous cyst in another. Discussion
Interesting observations may be obtained by an examination of the type and frequency of surgical procedures performed throughout the country. Data provided by the National Center for Health Statistics indicate a dramatic increase in surgical rates from 1971 to 1975. However, the 1976 figures indicate that the rate per 100,000 population has decreased from the 1975 rate. This decrease is the first noted since 1968. The rate of in-hospital surgical procedures per 100,000 population was 7,805 in 1971; 8,952 in 1973; and 9,585 in 1975. The 1976 rate declined to 9,539. The number of surgical procedures was 20,040,000 in 1975 and 20,086,000 in 1976, the smallest increase since 1971.4 Operations performed on in-patients discharged from short-stay hospitals in 1976 were less than those in 1975 for many surgical procedures. For example, there was a 16.7% decrease in partial mastectomies from 1975 to 1976. Tonsillectomies and/or adenoidectomies decreased 8.2% and hysterectomies, which had increased from 1971-1975, decreased by 6.3% from 1975 to 1976. In contrast, surgery of the back increased by 12.8% from 1975 to 1976.4 Among the explanations presented for the rise in surgical rates, it has been suggested, that there may be a surplus of surgeons for the needs of the population and that this has led to excessive surgery.5 In 1970, Bunker reported a comparative study of surgery in the United States and in England and Wales, indicating that for twice the number of surgeons per 100,000 of population in the United States, twice the number of operations were performed compared to England and Wales.1 Recent manpower studies, including the SOSSUS Report, emphasize that many physicians performing surgery are not board certified and suggest that there is a need to reduce the number of surgical residency positions offered. Other studies support the hypothesis that surgical rates are related to the supply of surgeons.367 The problem of an excessive number of physicians perform-
327
ing surgery may be solved in the long term by more stringent hospital regulations for granting surgical privileges and by more realistic appraisal of future manpower needs by the professional organizations and possibly by federal regulatory agencies. For the shortterm, it would seem appropriate to review the reasons for recommended surgery before the operations are performed. The findings of The Cornell prospective study indicate that second opinion programs can monitor elective surgery without jeopardizing the health and well-being of the patients. The group of 318 patients with general surgical diagnoses reported in detail in this study represents a sample of the entire program from which several conclusions can be drawn. This group confirms the validity of the study as a whole, and closely reproduces the nonconfirmed percentage of the total 2,367 general surgical cases reviewed, 15% compared to 18%. Reasons for nonconfirmation can be divided into six categories, and of these, absence of pathology and the preferability of medical therapy account for the majority of rejections. Admittedly, there will always be valid differences of opinion in many clinical situations. However, it is evident that inadequate training and, ethically questionable motives may result in inappropriate surgery. The elective surgery second opinion program may also be viewed as one possible means of limiting the increases in health care costs. While a two year economic study is now in progress to calculate both the direct and indirect fiscal benefits of the second opinion programs, two union welfare funds which have developed mandatory second opinion programs have already reported a substantial reduction in surgical claims of 8 and 10% in a three year period. Another interesting observation is the recognition of what we have named the "Sentinel Effect." As the existence of second opinion programs becomes known, a decline in the rate of in-hospital surgical claims has been observed. This observation was also made in Saskatchewan where the number of hysterectomies performed decreased by 32.8% during the period 19701974 after a study committee for retrospective case review was appointed.2 It is evident that there is an increasing demand by the public for a role in the decision making processes relating to health care. The second opinion programs are patient oriented and provide a mechanism by which individuals are enabled to make more informed decisions. While a physician's recommedation for surgery is based on the advantages of such treatment to the patient, the ultimate decision belongs to the patient. The means of improving the quality of health care and reducing its .cost are the responsibility of both physicians and patients.
328
Ann. Surg. * September 1978
GRAFE AND OTHERS
Summary The Cornell elective surgery second opinion program has evaluated 7,053 patients since its inception in 1972. The need for proposed elective surgery was not confirmed by a board-certified consultant in 27.6 percent of these patients. The conditions with the highest unconfirmed rates were orthopedic and gynecologic. The board status of the initial diagnosing surgical specialist was unrelated to the percentage of surgery which was not confirmed. Analysis of 318 patients with general surgical conditions disclosed that absence of pathology and failure to utilize indicated medical therapy were the major reasons for not confirming the proposed surgery. The second opinion programs are believed to be one means of increasing patients' intelligent participation in matters related to their health care as well as a means of containing the costs of this care. DISCUSSION DR. GEORGE D. ZUIDEMA (Baltimore, Maryland): Dr. Grafe and his coauthors have begun to clarify some questions about what happens to individuals whose surgery is not confirmed, and, more importantly, it tells us why the 18% of individuals recommended for elective general surgery were not confirmed. This is important information which is necessary to understand the basis for the decision to defer operation. I'd like to make a few comments and ask the authors a few questions. This study shows that one year after surgery was deferred, in both groups, four out of five patients had not had the operation performed. The reverse, however, may well be significant, for one of the five went ahead to have the procedure performed anyway, and here it is important to ask why. Was the second opinion wrong, or were patients dissatisfied with the judgment of the second consultant? Secondly, a significant feature of this paper is to examine the reasons why 18% of patients were not confirmed for elective general surgery. The figures in the paper today are at variance, somewhat, with those in the abstract, but, in general, something under half of the patients not confirmed apparently would require follow-up, additional medical treatment or a trial of nonsurgical therapy, at least. In about half, the decision to defer operation indefinitely appears to be a good one. These findings, however, point out the need for some longitudinal studies, following the patients for several years, if necessary, before drawing final conclusions regarding either outcome or cost/ benefit analysis. Also, there is a need to attempt to measure the quality of life under both surgical and medical modes of treatment, and this may turn out to be an important determinant, especially to the patients involved. I would appreciate some comments regarding longitudinal studies of this kind.
DR. FRANCIS D. MOORE (Boston, Massachusetts): Dr. McCarthy and his colleagues have introduced a sort of a numerical, or mathematical, analysis of physician/physician and physician/patient interaction. I hope that the authors will avoid the connection that has been made between the surgical second opinion program, which is a new word for an old thing-consultation-and the number of un-needed operations in the United States. That is a long jump. It is a connection they made in their abstract, but possibly have decided now not to make.
References 1. Bunker, J. P.: Surgical Manpower: A Comparison of Operating Surgeons in the United States and in England and Wales. N. Engl. J. Med., 282:135, 1970. 2. Dyck, F. J., Murphy, F. A., Murphy, T. K., et al.: Effect of Surveillance on the Number of Hysterectomies in the Province of Saskatchewan. N. EngI. J. Med., 296:1326, 1977. 3. Lewis, E. E.: Variations in the Incidence of Surgery. N. EngI. J. Med., 281:880, 1969. 4. National Center for Health Statistics: Hospital Discharge Survey. Government Printing Office, Washington, D. C. In Press. 5. Nickerson, R. J., Colton, T., Peterson, 0. L., et al.: Doctors who Perform Operations: A Study on In-hospital Surgery in Four Diverse Geographic Areas. N. Engl. J. Me.d., 295:921, 1976. 6. Wennberg, J. and Gittelsohn, A.: Small area variations in surgical health care delivery. Science, 182:1102, 1973. 7. Wennberg, J.: Health care delivery in Maine: patterns of use of common surgical procedures. J. Maine Med. Assoc., 66: 123, 1975.
It connotes a sort of global socioeconomic role for consultation about surgery. After all, consultation is a part of all of medicine. How about a second opinion program on initiation of insulin therapy versus oral agents in the treatment of diabetes? How about a second opinion program on whether or not digitalis should be started, whether or not psychoanalysis should be started? It's all there. Disagreement does not impugn one alternative. It's just part of good medicine. It is interesting that cardiac surgery and gastrointestinal surgery are two fields of surgery where the interaction between the physician and the surgeon is so close that the second opinion is automatic. I have always expected Dr. McCarthy and his group to come up with a study of negative first opinions. I think we ought to see that. How many patients who ought to have a total hip are wandering around with canes and crutches? How many patients that can't see deserve to have that cataract taken out? How many patients that can't hear deserve to have a second opinion from a surgeon and get middle-ear surgery? And how about the patients who can't urinate? Maybe the second opinion would let them see a urologist. How many of all these patients are being held away from therapeutic relief by a negative and often biased, first opinion? So before we understand the social implications of this, we've got to look at both sides of the fence, and see how many patients in this country are being withheld from definitive therapy. surgery or otherwise, because of a fallacious initial opinion? This program has always seemed to me a little bit one-sided. Right from the start, in Dr. McCarthy's first article in the Newt Englanid Journal of Medicine, the misquotation and misuse of these data in the press and in congressional hearings has really been based on a mystical connection between a few hundred cases of disagreementhere, 318 have been carefully analyzed-and the huge populational needs of this country. It's a jump that we're just not ready to make. Now, the second opinion program must involve the second opinions of peer experts-not just those instances in which a specialist sees the patient for the first time. I have coined a word called PESO. That's a good term because it is not very much money. It means "Peer Expert Second Opinion". This is the second opinion that counts-when two experts see the patients. Early in the program, in the case of a patient, a child, let's say, who couldn't void, the pediatrician might have said to the mother, "Maybe you need to have a bladder neck resection." Then the child was seen by an experienced pediatric urologist, who said, "No, it's not time yet. It's the wrong age for that patient to have that." This goes down as a negative surgical second opinion. It is not. It is a first opinion. It was parlayed into some sort of a national
