Hold That Scalpel! You need thorough research and expert guidance before you decide whether you should go under the knife. Begin by reading this.
By Joe Levine

(MONEY Magazine) – When Janet Sarno's doctor first suggested that she needed an operation to remove her gallbladder, she had little trouble making up her mind. ''I said, 'No way,' '' the New York City actress recalls. ''The anesthesia, the tampering with your body -- it just seemed as if so much could go wrong.'' Her fears were justified. Removing a gallbladder -- a fig-size abdominal organ that stores digestive juices -- is a simple operation; it takes only an hour, and many patients are home in a week. Yet any surgery is taxing and can lead to serious complications, especially as one gets older. Sarno, who is in her fifties, decided instead to fight her occasional attacks of stomach pain by changing her diet and making the rounds of specialists. Exploring every option, she even endured something called a liver flush at the hands of a nutritionist she had met at a party. But after five years of false hope and several thousand dollars in doctor bills, she became convinced her sharp, twisting pains would not go away. ''I felt I was going to become a psychological slave to the condition,'' she says. ''I was afraid to go anywhere or do anything. What if I had an attack while I was flying someplace, or when I was onstage?'' Last fall, after seeking a second surgical opinion, Sarno had the gallbladder removed. It wasn't cheap: the surgeon alone cost $2,300; with hospital, anesthesiology and nursing bills, the total came to $6,200. But Sarno's insurance will pay virtually all of that. And even if it didn't, she says, the trouble and expense would have been worth it: ''It's great to be able to eat again without feeling as if I'm playing Russian roulette.'' Like Sarno, more and more Americans are choosing surgery. Some 16 million of us have operations each year, 40% more than the number who did so in 1971, though the U.S. population has grown only 18% in that time. Despite success stories like Janet Sarno's, many doctors worry that the national passion for surgery has cut too deeply. In particular, they worry that too many patients are having various kinds of elective surgery -- operations that people choose to have as the lesser of medical evils, rather than ones they undergo in order to save their lives. One study in the Journal of the American Medical Association last July, for example, estimated that nearly half of all coronary artery bypasses (open-heart surgery) are done for questionable or inappropriate reasons. Another study came to a similar conclusion about a third of carotid endarterectomies (operations intended to prevent stroke; 85,000 are performed each year). The American College of Obstetricians and Gynecologists has been concerned enough about reports of unnecessary hysterectomies (removal of the uterus) that it is reconsidering criteria for doing the operation. And an eye operation called radial keratotomy is the subject of continuing lawsuits and countersuits between surgeons who perform it and the American Academy of Ophthalmology, which calls the procedure ''investigational.'' The fact that doctors are divided over when to perform such operations means that if you are facing this kind of surgery, you need to consider your decision carefully. You should begin by learning enough to make informed choices about your own care, take part in decisions and play an active role in deciding what's right for you, rather than just being a passive recipient of whatever care you are given. As Dr. Lawrence Horowitz, former director of the U.S. Senate Subcommittee on Health, puts it: ''At its best, American medicine is the finest in the world. But you can't get the best by chance -- you have to work at it. And often, the choices you make are more important in determining the outcome than the nature of the disease itself.'' Most people, for example, choose the first surgeon who is recommended to them and go to the hospital he happens to be affiliated with. That may work for a simple operation like a hernia repair. But it could be dangerous with a complicated procedure such as bypass surgery, for which mortality rates at U.S. hospitals vary from less than 1% to as high as 20%. ''If you're the one who climbs on the operating table,'' says Horowitz, ''it makes an awfully big difference whether your chances of climbing off are 99 out of 100 or only eight out of 10.'' Even the question of whether you need surgery at all may be answered differently depending on what city you live in. Dr. John Wennberg and his colleagues at Dartmouth Medical School, for example, found that a person living in New Haven is about twice as likely to have a coronary bypass operation as someone living in Boston -- though both cities have excellent teaching hospitals, comparable rates of heart disease and populations of similar ethnic and cultural background. For carotid endarterectomy, the situation is reversed: those in New Haven are only half as likely to have them. And equally puzzling regional discrepancies have turned up in studies of other often-elective procedures, including knee and hip replacement, hysterectomy and back surgery. Why the discrepancies? No one really knows beyond the obvious -- that well- meaning doctors cannot agree on when to cut. ''The fact is that with a lot of surgery, we just don't know whether it's worth doing or not,'' says Wennberg. ''Drug companies pour $1.5 billion a year into clinical studies of new drugs, but virtually nothing goes into comparing surgery and other forms of treatment. Until we remove this double standard and test the efficacy of all options, physicians and patients will continue to face unnecessary uncertainty about the value of the treatment they choose.'' In the absence of objective criteria with which to judge, surgeons adapt to regional patterns that are as strong as geographic differences in accent, taste and slang. For the patient, the fact that doctors disagree should be a strong warning sign. ''It means beware,'' says Horowitz, now an investment adviser with James Wolfensohn Partners in Menlo Park, Calif., in his new book Taking Charge of Your Medical Fate (Random House, $18.95). ''It means the medical profession is unsettled and divided over when to operate. It means that style of practice rather than objective scientific information may be responsible for your physician's recommendation. And it means that you, as the one who cares most about the outcome, are the one most likely to make the best decision.'' In the case of elective surgery, Horowitz says, the first question is whether an operation is necessary at all. Here are some steps to help you decide: -- Learn as much as possible about the procedure. Start with your physician or surgeon. Ask him or her to describe the operation and the intended result in detail. Ask about possible complications, their likelihood and how to deal with them should they arise. Find out whether less radical surgery would accomplish the same thing. For example, many surgeons now prefer to do a myomectomy -- which removes only portions of the uterus -- rather than a hysterectomy for women with benign growths called fibroids who want to retain the capacity to bear children. -- Make sure you investigate any nonsurgical alternatives thoroughly. Remember that surgeons have a natural bias for their specialty. ''They are trained to operate,'' says Thomas B. Graboys, a practicing cardiologist who teaches at Harvard Medical School, ''and if you present them with a patient with suitable anatomy, chances are they are going to say, 'This patient will do better by having an operation.' '' But as most surgery is irreversible, it is usually best to exhaust other treatments -- drugs, diets, exercise and so forth -- before seeking surgery as a last resort. Don't neglect books, magazine and newspaper articles, and patient groups as sources of information (the table on pages 106 and 107 lists several). Often they can alert you to the latest treatment trends and any controversies. For instance, many doctors and patient brochures dismiss as myth the idea that women who have total hysterectomies become depressed or lose interest in sex. But Nora Coffey, founder and president of HERS Foundation (Hysterectomy Educational Resources and Services) in Bala Cynwyd, Pa. (215-667-7757), which has counseled 21,000 patients, says both complaints are more common than many doctors think. -- Get a second opinion. In voluntary second-opinion programs -- those where the insurer will pay for a second opinion but the patient doesn't have to get one -- fewer than 5% of patients bother to do so, according to at least one study. This is a serious mistake. Even minor surgery is dangerous enough that you should not contemplate it unless two independent experts believe it's worthwhile. ''Be as thorough in your questions to the second surgeon as you were with the first,'' Horowitz says. ''You don't want a rubber-stamp confirmation of what you've been told. You want an independent evaluation. For this reason, you should get the second opinion from someone who is not an associate of the first surgeon.'' Fortunately, a growing number of public and private agencies can help you find another physician to review your case. Many employers' health insurance companies today require second opinions. And most major insurance companies, including Prudential, Metropolitan, Equitable and many of the Blue Cross/Blue Shield groups, can refer you to someone. The U.S. Department of Health and Human Services (800-638-6833, 800-492-6603 in Maryland) makes referrals free of charge. Local Social Security offices will refer Medicare recipients; welfare offices do the same for those on Medicaid. Most insurers like second opinions because they reduce the frequency of surgery -- as much as 35% in one study of Medicaid patients. But for once, cost-effectiveness seems to dovetail with quality care. A survey by the New York City Employee Benefits Program found that city employees liked its mandatory second-opinion program. ''A lot of doctors think that people don't want second opinions, but our studies show that most people are just afraid to ask for their physician's cooperation,'' says Steven Rosenberg, medical director of the program. ''This gets the patient off the hook because he can say to his doctor, 'Look, I trust you completely, but I can't collect my insurance if I don't go for a second opinion.' '' -- Clarify your own expectations. Make sure you understand what an operation can and cannot achieve; patients looking for a quick fix are as much to blame for excessive surgery as are overzealous surgeons. ''Probably 85% of people between the ages of 35 and 50 will at some time have rather severe pain in their lower back,'' says Dr. Henry Huber Sherk, chief of orthopedics at the Medical College of Pennsylvania in Philadelphia. Yet Sherk, who sees nearly 1,000 such patients a year, operates on only about 10 of them. ''You perform surgery only when the case meets certain strict criteria,'' he says. ''A lot of patients who don't meet those criteria want surgery anyway because they can't deal with the pain. Well, thank God it's a free country -- they can see someone else.'' If you decide you want surgery, next make sure you are seeing the right surgeon. Horowitz suggests these steps: -- Ask your primary physician to recommend two surgeons and describe the relative strengths and weaknesses of each. ''This will enable you to see how candid and comprehensive he is,'' says Horowitz. ''If he sees both as equal and fully acceptable and can make no effective comparisons, then there is more cause to suspect the validity of the recommendation.'' -- Get advice from other physicians. Ask whom they would recommend if you could go anywhere in the country for treatment, and also whom they would suggest if you decided to stay in your state or community. For simple operations like hernia repair, you probably don't need a world-renowned specialist, but for a quadruple bypass you might want one. -- Listen to the advice of friends and relatives, but treat it with caution. While the experience of others is informative, it can be misleading. One tip- off: find out how thorough a search your friend did before picking his doctor. If he was methodical, place greater faith in his choice. -- Check the surgeon's professional qualifications. The American College of Surgeons (55 E. Erie St., Chicago, Ill. 60611; 312-664-4050) can recommend members in your area. You may want to limit your search to those who are board certified in the specialty you need; this means the doctor is more likely to be aware of recent trends in his field, though it is not a guarantee of surgical skills. You can look up a physician's training and credentials in the Directory of Medical Specialists, available in most public libraries.

-- Ask what your surgeon's success rate is for this type of operation. ''The best doctors never mind being questioned because they know that better- informed patients are better patients,'' says Horowitz. ''If a doctor takes offense at questions about the operation and his skills, that's a red flag that maybe you ought to find another doctor. People who do something well usually don't mind telling you about it.'' -- Select a doctor affiliated with a topnotch hospital. The best care for complicated operations is likely to be at a large, university-affiliat ed teaching hospital whose expert surgeons treat hundreds of cases like yours a year, not just a dozen or so. If yours is relatively uncomplicated surgery, on the other hand, you can often find a warmer atmosphere and better service at a smaller community hospital. In any event, pick one that is accredited by the Joint Commission on the Accreditation of Hospitals, which has tougher standards than most state licensing boards. -- Finally, don't be afraid to raise the issue of cost, though that is not usually a big factor for people with good health insurance. ''Studies show that about 85% of all surgery is performed without a discussion of the fee between doctor and patient,'' says Dr. Eugene McCarthy, a professor at Cornell University Medical Center in New York City and founder of Health Benefits Research, a consulting service that arranges second opinions. ''But surgeons' fees aren't set in stone. What they charge often depends on the individual's insurance and his capacity to pay.'' As a result, Health Benefits and a few other consulting firms around the U.S. are experimenting with helping clients negotiate a lower fee when appropriate. One who benefited was Jacklyn Torres, a 27-year-old union employee who had been told she would have to pay $2,100 to have her seven- year-old daughter Jennifer's double hernia repaired. ''We liked the surgeon, but we knew our insurance wouldn't cover all of it,'' says Torres. Through Health Benefits' negotiation, the bill was cut to $1,575. ''All we ended up paying out of pocket was about 15% of theanesthesiologist's fee,'' says Torres. This kind of research and questioning takes courage and resourcefulness, but better health will be your reward. As Bill Hembree, director of the California-based consulting firm Health Research Institute, puts it: ''If people spend $15,000 on a car, they kick the tires and look it over. But if they spend $15,000 on an operation, most people won't do anything at all. They just wait until they get the bill and then complain.'' When someone says you need elective surgery, Hembree and others advise, lace up your kicking boots.

BOX: A consumer's guide to common elective operations Here are thumbnail sketches of seven surgeries that are frequently done electively -- meaning they are intended to improve the quality of a person's life, not save it. In cases where these operations are not mandatory, it is especially important that the patient weigh the pros and cons of surgery carefully and gather as much information as possible from medical and consumer sources, some of which are listed below. The cost estimates are national averages and are subject to wide regional variation. Medicare and standard health insurance cover all the procedures except radial keratotomy -- provided that a second surgeon confirms the operation is needed.