As you may have noticed, we've been quoting Stephen Fulder a good deal lately in these pages. Fulder (author of How to be a Healthy Patient; Hodder & Stoughton) advocates a combination of the judicious use of conventional treatment with a variet
One in five people who goes to hospital contracts a health problem there that he didn't have before. The hospital is the focus of iatrogenic, or medically induced, disease. It comes from:
Unnecessary surgery. In the US some six million unnecessary operations and invasive tests are performed each year, leading to perhaps 50,000 deaths. In the UK, 20,000 normal appendixes are removed.
Drug side effects. The incidence of side effects from drugs given in hospital can be as high as one in five of all patients.
Hospital infections. As many as 5 to 10 per cent of all patients contract an infection while in hospital, and a few per cent, perhaps 100,000 people in the US, die from them.
Mistakes in diagnosis and treatment. Of all deaths in hospital, 10 per cent are thought to result from misdiagnosis. On average, hospital doctors misdiagnose about 15 per cent of the time.
There are also more complications and risk of surgery than are realized. Those who partially recover may remain vulnerable, semi sick, depressed and suffering from "unrelated" health problems which go unrecorded. The average risk of dying from non emergency surgery is 1 in 100, but the fact that 30 per cent of women who have hysterectomies do not have sex again remains a risk that surgeons are unlikely to talk about .
The risks are greater the longer the operation. They depend on the type of operation, the place where it occurs and the surgeon in charge. For example at one London hospital 1 in 20 patients has infected wounds after orthopaedic surgery, six times the rate of a smaller hospital in the north of the country.
The risks derive from:
Anaesthesia. One death in 5,000, but more risks for the old, the very young and those with heart problems.
Infections. Many people pick up an infection during surgery for example more than 30 per cent of women who have hysterectomies. In the UK 3,000 people die from such infections per year, and long illnesses are much more common.
Blood transfusions. Diseases (such as AIDS or hepatitis), errors and complications cause about one death in 9,000 operations and more illness.
Haemorrhage. Internal bleeding during or after surgery is the major cause of death.
Blood clots that wander, shock, slips of the knife, or wrong operations.
Scarring. The major cause of pain, discomfort and ill health, which may last for years, scarring is often unrecognized by the medical profession.
Psychological complications. These can be a sad sequel to surgery and just as crippling as physical complications, yet they are rarely taken very seriously. Minor brain damage can be quite common in cardiac surgery, arising from toxic residues of anaesthetics, sterilizing gases or plastic tubes, and clots or bubbles in the circulation. Hysterectomies are notorious for causing long bouts of depression, and even caesareans can leave a mother inexplicably depressed for months.
Seeing your GP
The office or clinic of your general practitioner is the point where the ball starts rolling. Your open dialogue with your GP (or, in the US and elsewhere, your internist) should be able to assign correctly your stomach problem to your marriage, and that of your heart to your imagination, or correctly detect a more serious problem and send you for a checkup to the specialist. You should be careful, open and ask lots of questions. He should be caring, communicative and knowledgeable enough to answer them. "I want you to go for a checkup" should be the beginning not the end of your dialogue.
Here are the 10 questions to ask your practitioner when he recommends a visit to a specialist:
What exactly is the problem and why do you think I have got it at this time?
Why do you think I should see that kind of specialist?
Why do you recommend that particular specialist?
Can you give me any advice on how to look after myself so that the problem is stabilized or improved?
What will happen if I delay my visit to the specialist?
What will happen if I choose not to visit the specialist?
What tests do you recommend and what questions do you need to answer?
What are the risks of the tests or any possible discomfort?
How reliable are they?
Are there any other ways to arrive at a diagnosis?
Take time. Tests are rarely so urgent that you cannot take time to be prepared. Don't be rushed into the consultant's appointment, unless it is very urgent, without giving yourself preparation time.
Get informed. Read about your suspected condition in health books, health magazines and medical texts. Contact self help groups. Check with them as to whether the consultant and hospital you have been referred to is the best for your problem. If necessary go back to your GP to ask further questions if the information you have found conflicts with his earlier explanations.
Prepare a record of your symptoms and the questions you want to ask the consultant. You will be faced with a busy specialist, behind a pile of papers, who may hardly look at you. You may be rationed to a few squeaks about your symptoms interrupted by the telephone. So have your questions ready.
Consider obtaining a a consultation with a complementary practitioner before the specialist appointment. Most diseases can be helped to some extent by dietary, acupuncture, osteopathic/chiropractic, psychotherapeutic, homoeopathic or herbal methods. (Some can be dealt with so successfully by complementary medicine that you can expect to avoid all further medical intervention.)
Seeing the consultant
Before you've had your appointment, ask your practitioner to be referred to a surgeon who has a great deal of experience of the operation in question, who has a good reputation among medical people and who works in the hospital that is renowned for the treatment of this particular condition. If you are paying then you can shop around.
When you go to him and tell him of your problem, ask the following:
What is the illness and why have I got it?
What are the treatment options? How do their results compare? What are the statistics and research evaluations of each?
What will treatment or surgery do? What are the risks? What will be the physical and psychological consequences and how long will it take to be back on form?
What will happen if I say no? Will it reduce the quality of my future life more than the side effects of the treatment might?
What will happen if I delay it?
What will be the costs of surgery, tests, hospital stay, anaesthetist (if private)?
How frequently do you do this procedure?
Before surgery you must sign a form of consent, which states that you have been fully informed. If your surgeon is a bit recalcitrant about answering the above, you might remind him of this consent form and say: "How can I give informed consent if you do not provide me with information?"
There are studies demonstrating that if patients are fully informed before surgery, they enter it with less stress, and after it they have less pain, fewer complications and a faster recovery. Tell him that you need the answer to your questions so as to be less anxious during and after the event.
Your trust in your doctor and surgeon is important for your recovery. But this trust must come after you have made your decisions. While you assess treatment options it would be wise to be wary.
As medical critic Robert Mendelsohn often advised:
Don't assume that the operation is necessary.
Don't be deceived by a well polished air of confidence.
Don't assume that all the treatment choices have been considered.
Don't assume that the surgery will actually make you feel better.
Don't assume that the surgeon cannot make mistakes.
In addition, ask your consultant these five questions:
What is the complication rate for this procedure?
How many of these operations have you done? (If under 10 don't use this surgeon/consultant.)
How long will it take me to recover, and how long to be back to my normal routine?
What should I do after the operation to promote recovery?
Will you do the surgery yourself or will you just supervise?
The competence of the surgeon is vital to the success of the operation. A survey of 1,500 complications by the American College of Surgeons in 95 US hospitals found that three quarters of the complications were due to surgeon errors. You need the best. Therefore if it turns out that. . .
He will not be doing the surgery himself (in the case of private medicine)
He does not give satisfactory answers to the other questions
He cannot be persuaded to give you the information that you need
He "feels" all wrong and you would be very nervous under his hands
. . . then you probably ought to change him.
If you are not happy with his answers and you want to check them you can go for a second opinion. If he refuses to answer your questions or you become aware that this consultation and the hospital do not have a good reputation for your condition you can change him.
Changing your consultant is easy, of course, if you are paying him. You ask for your notes to be transferred, take your X-rays in your hand and exit stage left. Under the NHS it is more difficult since you cannot choose him in the first place and you must accept a junior in the consultant's team if you are under a consultant. Your options are: to go private, to start again completely with another General Practitioner (not advisable); or to go back to your doctor, convince him of your case, and enlist his help. He will often do so despite the fact that he may be put in a somewhat embarrassing situation with the present surgeon consultant by supporting your lack of faith in him.
If the procedure is at all serious, or if the answers to the above questions do not completely satisfy you, or if your own preparation has uncovered less risky treatment options, you should have a second consultation as a matter of course.
The second consultant to whom you refer should do all the necessary tests except those that are hazardous, including X-rays, which you should bring with you. The consultant should know you want advice, not treatment, so he will give a detached picture. You should not tell him about the diagnosis and conclusion of the first consultant. Don't choose a consultant for a second opinion who is from the same practice or hospital as, or is recommended by, the first one.
When you and your GP choose a specialist the hospital goes with him. But since under the NHS you may not be able to get the specialist himself to treat you, you must pay attention to the reputation and quality of the hospital as well. In general:
Smaller community hospitals are often friendlier, with less chance of giving you a new disease or complication than the big teaching hospitals.
Teaching hospitals are, by contrast, better when there is a life threatening or unusual condition.
Some hospitals have less waiting time than others for non emergency surgery.
You may want to look for hospitals which include some form of natural medicine (relaxation, say) in their repertoire.
The atmosphere and quality of nursing care, and availability of physiotherapists, are as important in long hospital stays as the excellence of the doctors.