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Christer Mjåset: 4 questions you should always ask your doctor
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"Doctor, is this really necessary?" Backed by startling statistics about overtreatment, neurosurgeon Christer Mjåset explains the power of this and other simple questions in the context of medical treatment and surgery -- and shares how patients can better work with doctors to get the care they need.
Christer Mjåset - Neurosurgeon
Christer Mjåset, M.D. is a neurosurgeon, author, columnist and lecturer who currently works as a Harkness fellow in Health Care Policy and Practice at Harvard T.H. Chan School of Public Health in Boston studying value-based health care models. Full bio
Christer Mjåset, M.D. is a neurosurgeon, author, columnist and lecturer who currently works as a Harkness fellow in Health Care Policy and Practice at Harvard T.H. Chan School of Public Health in Boston studying value-based health care models. Full bio
Double-click the English transcript below to play the video.
00:12
I am a neurosurgeon,
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and I'm here to tell you today
that people like me need your help.
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.
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
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,
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,
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.
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,
past the trachea,
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the esophagus,
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and you try not to cut
into the internal carotid artery.
into the internal carotid artery.
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01:08
(Laughter)
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Then you bring in the microscope,
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and you carefully remove
the disc and the prolapse
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
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,
is the damage to the cord,
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which can result in paralysis
from the neck down.
from the neck down.
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Explaining this to the patient,
she fell silent.
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.
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?
right there and then?
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It was not.
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In fact, when I get patients
like this woman,
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
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.
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.
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
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
paying for the house
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that might even give him
restrictions on what to do.
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
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.
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.
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
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
is that there is twice the chance
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that your kid --
because this is for children --
because this is for children --
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will get a tonsillectomy in Finnmark
than in Trondheim.
than in Trondheim.
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The indications
in both regions are the same.
in both regions are the same.
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There should be
no difference, but there is.
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.
for this condition.
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And you see that the operation
rate in Møre og Romsdal
rate in Møre og Romsdal
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is five times the operation
rate in Stavanger.
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?
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
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.
are light green.
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There is a lot of activity
in the private clinics
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.
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
that the difference of treatment effect
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between regular physical therapy
and operations for the knee --
and operations for the knee --
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there is no difference.
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Meaning that most
of the procedures performed
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.
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
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,
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,
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.
once in my career.
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My colleagues say they never heard
these words from a patient.
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
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
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
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?
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.
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,
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.
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,
I questioned him thoroughly,
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and what I found out is
that he probably had a degenerated disc
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,
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
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."
through my insurance at work."
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"Come on," I said --
he was also, after all, my friend.
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."
to see how bad it looks back there."
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"When did you start interpreting
MRI scans?" I said.
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."
"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,
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.
and quit the jogging.
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After a while,
I met him again and he said,
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?
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.
would quadruple, maybe even more.
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And you would all take
the spot on that list
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,
also turns down, sometimes,
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an opportunity
to get diagnosed or treated.
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.
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,
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,
now a general practitioner,
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was sent away to a tuberculosis
sanatorium as a little girl,
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.
had been negative all along.
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The doctor had sent her away
on nothing but wrong suspicion.
on nothing but wrong suspicion.
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No one had dared or even considered
confronting him about it.
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.
health care service.
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The patient is supposed to get advice
from the doctor about what to do.
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.
responsibility on you.
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You need to get in the front seat
with your doctor
with your doctor
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and start sharing
decisions on where to go.
decisions on where to go.
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So, the next time
you're in a doctor's office,
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?"
attached to this operation?"
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Well, five to ten percent of patients
will have worsening of pain symptoms.
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
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
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.
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
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.
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,
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,
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
not only have made your life
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a whole lot easier,
and probably even better,
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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ABOUT THE SPEAKER
Christer Mjåset - NeurosurgeonChrister Mjåset, M.D. is a neurosurgeon, author, columnist and lecturer who currently works as a Harkness fellow in Health Care Policy and Practice at Harvard T.H. Chan School of Public Health in Boston studying value-based health care models.
Why you should listen
Christer Mjåset, M.D. holds a position as a researcher at the Oslo University Hospital analyzing data from The Norwegian Spine Registry and as a lecturer at the Department of Health Management and Economics, University of Oslo, where he teaches in a leadership program for young physicians. Mjåset was president of the Norwegian Junior Doctors 2015-2019 and the Vice President of the Norwegian Medical Association 2017-2019. This work led him to be involved with the international Choosing Wisely campaign which seeks to advance a national dialogue avoiding unnecessary medical tests, treatments and procedures. From 2017-2019 he was responsible for implementing the campaign in Norway
Mjåset is a published author of five fictional books and several short stories. He won the Oslo City Cultural Scholarship for writers in 2006. He got his medical degree and bachelor’s degree in literature and philosophy at University of Oslo, both in 2000.
Christer Mjåset | Speaker | TED.com