I think the most immediately apparent thing that has struck me in Milan this week is the fact that in spite of every surgeon’s attempts to portray themselves as operating in the best interests of our patients, this simply cannot always be true. I say this because I have spent the last few days listening to surgeons passionately defending their operative choices, telling anyone who will listen that they continue to do X or Y operation (often in spite of evidence against doing so), because they truly believe that they are doing the best thing for their patients. I have heard these men and women describe what I would consider antiquated, out of date, often what I think are just crazy choices, and then defend them as being good for their patients, and therefore the right thing to do.
Now, as far as I can tell, the only way that this can be possible, is if in many (many) cases, the choices put to patients are limited by what a surgeon is capable of. And without any extra information in their possession, such patients believe that their surgeons really are offering them the very best care available.
“…the choices put to patients are limited by what a surgeon is capable of.”
So here is the thing: all surgeons are salesmen. We are all of us, selling our patients the procedures that we THINK are best. Some of us have evidence to back up our decisions. Some of us (as I have seen this week), do not. The issue with selling anything, is that to some extent there is potential for the buyer (the patient) to be manipulated based on how much, or how little, they know.
This week I have heard surgeons defending the routine use of pedicled TRAM flaps (which I find baffling in this era of microsurgical reconstruction); I have heard surgeons arguing that they would always use implant-based reconstructions in patients for whom post-operative radiotherapy is planned; and I have heard surgeons absolutely refuse to consider implants to be an option in any case! Irrespective of the argument, whenever the case being made is unbalanced, then buyer beware!
The really tricky part of all of this is that for every patient, a sometimes complex equation of patient factors, cancer details and various treatment options will determine that there are perhaps 1 or 2 BEST options available. So whilst I would encourage my patients to know as much as they can, they still need to be receptive to what their Plastic Surgeon tells them: as I have discussed previously, no matter how much a patient may want a certain reconstruction, it just may not be possible.
Suffice to say, the onus is on the patient to have either sufficient knowledge or sufficient curiosity to seek the necessary answers. Fortunately, it is easier than ever for patients to educate themselves. All I can say is that any patient considering breast reconstruction needs to be able to ask the right questions. If you feel that you haven’t been offered sufficient options, then look harder. Talk to your Plastic Surgeon.