4 questions you should always ask your doctor | Christer Mjåset

116,927 views ・ 2019-10-14

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I am a neurosurgeon,
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and I'm here to tell you today that people like me need your help.
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And in a few moments, I will tell you how.
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But first, let me start off by telling you about a patient of mine.
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This was a woman in her 50s,
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she was in generally good shape,
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but she had been in and out of hospital a few times
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due to curative breast cancer treatment.
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Now she had gotten a prolapse from a cervical disc,
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giving her radiating pain of a tense kind,
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out into the right arm.
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Looking at her MRI before the consultation,
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I decided to suggest an operation.
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Now, neck operations like these are standardized, and they're quick.
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But they carry a certain risk.
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You make an incision right here,
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and you dissect carefully past the trachea,
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the esophagus,
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and you try not to cut into the internal carotid artery.
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(Laughter)
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Then you bring in the microscope,
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and you carefully remove the disc and the prolapse
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in the nerve root canal,
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without damaging the cord and the nerve root
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lying only millimeters underneath.
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The worst case scenario is the damage to the cord,
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which can result in paralysis from the neck down.
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Explaining this to the patient, she fell silent.
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And after a few moments,
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she uttered a few very decisive words for me and for her.
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"Doctor, is this really necessary?"
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(Laughter)
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And you know what I realized, right there and then?
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It was not.
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In fact, when I get patients like this woman,
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I tend to advise not to operate.
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So what made me do it this time?
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Well, you see,
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this prolapse was so delicate,
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I could practically see myself pulling it out of the nerve root canal
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before she entered the consultation room.
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I have to admit it, I wanted to operate on her.
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I'd love to operate on her.
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Operating, after all, is the most fun part of my job.
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(Laughter)
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I think you can relate to this feeling.
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My architect neighbor says he loves to just sit and draw
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and design houses.
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He'd rather do that all day
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than talk to the client paying for the house
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that might even give him restrictions on what to do.
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But like every architect,
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every surgeon needs to look their patient in the eye
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and together with the patient,
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they need to decide on what is best for the person having the operation.
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And that might sound easy.
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But let's look at some statistics.
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The tonsils are the two lumps in the back of your throat.
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They can be removed surgically,
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and that's called a tonsillectomy.
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This chart shows the operation rate of tonsillectomies in Norway
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in different regions.
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What might strike you is that there is twice the chance
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that your kid -- because this is for children --
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will get a tonsillectomy in Finnmark than in Trondheim.
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The indications in both regions are the same.
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There should be no difference, but there is.
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Here's another chart.
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The meniscus helps stabilize the knee
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and can be torn or fragmented acutely,
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topically during sports like soccer.
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What you see here is the operation rate for this condition.
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And you see that the operation rate in Møre og Romsdal
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is five times the operation rate in Stavanger.
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Five times.
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How can this be?
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Did the soccer players in Møre og Romsdal
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play more dirty than elsewhere in the country?
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(Laughter)
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Probably not.
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I added some information now.
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What you see now is the procedures performed
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in public hospitals, in light blue,
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the ones in private clinics are light green.
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There is a lot of activity in the private clinics
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in Møre og Romsdal, isn't there?
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What does this indicate?
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A possible economic motivation to treat the patients.
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And there's more.
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Recent research has shown that the difference of treatment effect
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between regular physical therapy and operations for the knee --
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there is no difference.
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Meaning that most of the procedures performed
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on the chart I've just shown
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could have been avoided, even in Stavanger.
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So what am I trying to tell you here?
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Even though most indications for treatments in the world
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are standardized,
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there is a lot of unnecessary variation of treatment decisions,
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especially in the Western world.
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Some people are not getting the treatment that they need,
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but an even greater portion of you
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are being overtreated.
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"Doctor, is this really necessary?"
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I've only heard that question once in my career.
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My colleagues say they never heard these words from a patient.
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And to turn it the other way around,
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how often do you think you'll get a "no" from a doctor
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if you ask such a question?
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Researchers have investigated this,
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and they come up with about the same "no" rate
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wherever they go.
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And that is 30 percent.
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Meaning, three out of 10 times,
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your doctor prescribes or suggests something
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that is completely unnecessary.
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And you know what they claim the reason for this is?
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Patient pressure.
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In other words, you.
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You want something to be done.
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A friend of mine came to me for medical advice.
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This is a sporty guy,
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he does a lot of cross-country skiing in the winter time,
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he runs in the summer time.
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And this time, he'd gotten a bad back ache whenever he went jogging.
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So much that he had to stop doing it.
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I did an examination, I questioned him thoroughly,
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and what I found out is that he probably had a degenerated disc
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in the lower part of his spine.
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Whenever it got strained, it hurt.
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He'd already taken up swimming instead of jogging,
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there was really nothing to do,
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so I told him, "You need to be more selective
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when it comes to training.
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Some activities are good for you,
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some are not."
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His reply was,
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"I want an MRI of my back."
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"Why do you want an MRI?"
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"I can get it for free through my insurance at work."
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"Come on," I said -- he was also, after all, my friend.
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"That's not the real reason."
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"Well, I think it's going to be good to see how bad it looks back there."
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"When did you start interpreting MRI scans?" I said.
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(Laughter)
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"Trust me on this.
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You're not going to need the scan."
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"Well," he said,
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and after a while, he continued, "It could be cancer."
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(Laughter)
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He got the scan, obviously.
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And through his insurance at work,
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he got to see one of my colleagues at work,
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telling him about the degenerated disc,
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that there was nothing to do,
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and that he should keep on swimming and quit the jogging.
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After a while, I met him again and he said,
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"At least now I know what this is."
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But let me ask you a question.
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What if all of you in this room with the same symptoms had an MRI?
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And what if all the people in Norway
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had an MRI due to occasional back pain?
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The waiting list for an MRI would quadruple, maybe even more.
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And you would all take the spot on that list
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from someone who really had cancer.
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So a good doctor sometimes says no,
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but the sensible patient also turns down, sometimes,
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an opportunity to get diagnosed or treated.
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"Doctor, is this really necessary?"
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I know this can be a difficult question to ask.
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In fact, if you go back 50 years,
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this was even considered rude.
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(Laughter)
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If the doctor had decided what to do with you,
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that's what you did.
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A colleague of mine, now a general practitioner,
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was sent away to a tuberculosis sanatorium as a little girl,
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for six months.
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It was a terrible trauma for her.
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She later found out, as a grown-up,
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that her tests on tuberculosis had been negative all along.
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The doctor had sent her away on nothing but wrong suspicion.
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No one had dared or even considered confronting him about it.
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Not even her parents.
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Today, the Norwegian health minister
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talks about the patient health care service.
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The patient is supposed to get advice from the doctor about what to do.
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This is great progress.
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But it also puts more responsibility on you.
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You need to get in the front seat with your doctor
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and start sharing decisions on where to go.
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So, the next time you're in a doctor's office,
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I want you to ask,
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"Doctor, is this really necessary?"
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And in my female patient's case,
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the answer would be no,
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but an operation could also be justified.
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"So doctors, what are the risks attached to this operation?"
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Well, five to ten percent of patients will have worsening of pain symptoms.
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One to two percent of patients
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will have an infection in the wound or even a rehemorrhage
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that might end up in a re-operation.
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0.5 percent of patients also experience permanent hoarseness
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and a few, but still a few,
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will experience reduced function in the arms or even legs.
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"Doctor, are there other options?"
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Yes, rest and physical therapy over some time
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might get you perfectly well.
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"And what happens if I don't do anything?"
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It's not recommended,
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but even then, there's a slight chance that you will get well.
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Four questions.
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Simple questions.
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Consider them your new toolbox to help us.
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Is this really necessary?
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What are the risks?
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Are there other options?
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And what happens if I don't do anything?
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Ask them when your doctor wants to send you to an MRI,
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when he prescribes antibiotics
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or suggests an operation.
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What we know from research
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is that one out of five of you, 20 percent,
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will change your opinion on what to do.
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And by doing that, you will not only have made your life
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a whole lot easier, and probably even better,
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but the whole health care sector
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will have benefited from your decision.
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Thank you.
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(Applause)
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