Health Care

When surgeons say ‘we can fix it,’ patients may misunderstand risks

When surgeons prepare patients for an operation by describing how it can fix a problem, patients may agree to procedures without fully understanding the risks, a small study suggests. 

"As doctors, we really want to help patients to understand what is wrong with them and how to treat it, and that's really complicated, so the ‘fix-it’ model can simplify the issues for patients," senior study author Margaret Schwarze, a researcher at the University of Wisconsin School of Medicine and Public Health in Madison, said in an email.

But there are two big problems with the "fix-it" approach, she said.

"The patient gets the message that because something is broken, it has to be fixed, and that might not be the case," Schwarze said. Another flaw is the assumption that surgery will return patients back to how they normally were before they got sick or hurt. “For many patients, especially patients with lots of medical problems who need big operations, they are not normal after surgery."

Schwarze and colleagues analyzed 48 recordings of surgeons explaining high-risk operations to patients treated at three different academic hospitals in Madison, Boston and Toronto and found that variations on the "fix-it" theme regularly cropped up in these conversations.

Researchers reviewed transcripts of the discussions to see how surgeons deployed "fix-it" analogies to describe operations, which included various heart and brain surgeries as well as complex tumor-removal procedures.

About half the patients in the study were weighing procedures with a death risk of at least 3 percent, indicating a higher than usual potential for complications.

Often, surgeons portrayed medical conditions as broken parts and defective organ functions and then proposed an operation as a way to fix the problem.

They rarely used the "fix-it" model as the only decision-making framework and rationale for operating, however. The surgeons laid out risks and benefits of various treatment options. They might stress that the patient's medical problem might not be cured by an operation or note that the most prominent symptoms might not be eased by surgery.

While the researchers didn't speak to patients to see how well they actually understood their options, it's possible that they might agree to a risky operation without really knowing the limits of what surgery can do to improve their lives, the study team writes in the Annals of Surgery.

It may not work to use a simple "fix-it" analogy during deliberation about treatment options, said Dr. Michael Rothberg, vice chair for research in the medicine institute at the Cleveland Clinic in Ohio.

"There's a role for it; the role is in trying to explain the procedure once somebody understands the risks and benefits and decides they want to have it," said Rothberg, who wasn't involved in the study.

Patients need to understand their condition, and know that sometimes the surgery can ease symptoms but can't solve the underlying problem, he said. Symptom relief can also be an open question.

"There are a lot of surgeries where we really don't know how well they are going to relieve the symptoms or prevent something bad from happening in the future," Rothberg said.

To make sure they grasp the risks and benefits, patients should always ask surgeons to explain what will happen if they do the procedure, and what will happen if they don't, he added.

Those questions will help take the conversation in a direction that makes it easier to make an informed decision, Schwarze said. She also suggested that patients ask whether surgery will make them feel better, or help them live longer, as well as what daily life might look like in the days and months after surgery and over the long haul.

"Fix-it might be a great model for appendicitis but it's not a good model for patients who need major surgery and have multiple chronic conditions," she said.

For example, Schwarze does a lot of bypass surgery on patients with atherosclerosis, when fatty deposits build up inside arteries creating a risk for heart attacks and strokes. Often, these patients also have diabetes or kidney disease, she said.

"The bypass is not fixing their problem," Schwarze said. "It will often make them feel better because their leg doesn't hurt so much but to even imply that I am fixing this patient's disease is incorrect."