One Out of Every Three Operations Is Unwise, Says Surgeon George Crile
The eldest son of a founder of the nonprofit Cleveland Clinic, Crile belonged to the Hotchkiss School Mandolin Club, played football for Yale and graduated sum ma from Harvard Medical School. After 12 years as chairman of the Cleveland Clinic's department of general surgery, he retired in 1972 at the age of 65. He still is a consulting doctor, but no longer operates. Last April, 65 years after his father received an honorary fellowship from Britain's Royal College of Surgeons, Crile also got one—the first time in history that a father and son have shared the distinction. Crile was an outspoken critic of the classical radical mastectomy even before his first wife was stricken with breast cancer in 1958. Following her death five years later, Crile was remarried, to Carl Sandburg's author-poet daughter Helga, who underwent a partial mastectomy operation five years ago. Helga has written 15 books, Crile 12, the latest titled Surgery: Your Choices and Alternatives. At their house in Cleveland, Crile explored that subject with Giovanna Breu of PEOPLE.
Are surgeons often wrong?
It might be better to ask, "How often are they right?" I think medicine in this country is good, except I also think there is too much of it.
What is your approach to surgery?
I've tried all my life to eliminate surgery if it means high risk and crippling effects. Take cancer. I've always felt that surgeons view cancer the way people in the Middle Ages viewed the Devil, as something to be exorcised—even if you have to kill or maim the patient to do it.
Is this changing?
Yes. For instance, there has been a striking change in our attitude toward the treatment of breast cancer in the last year. Right now at the Cleveland Clinic, only 50 percent of patients with breast cancer have their breasts removed.
When is surgery absolutely necessary?
If you are in an accident, surgery may be necessary to stop the bleeding. But outside of such emergencies, there is really no time when surgery is immediately necessary. Everybody should be aware of one fact: Any operation involves a calculated risk.
How much of a risk?
It varies from operation to operation, from patient to patient, from surgeon to surgeon. But let's just say that when physicians went on strike in Los Angeles County for five weeks in 1976 and did not do anything but emergency operations, the number of operations dropped by half, and the death rate went down by a hefty 25 percent.
Why do people take these risks?
Basically for comfort. You do not have to have a hernia operated on, for instance. It is probably safer to put up with it. The same is true of gallstones. You are not going to die from the pain. Most people want them out because they are uncomfortable. So they take the half of one percent or so risk.
When does the risk outweigh the possible benefits?
Take cancer of the rectum, for example. There are thousands of colostomies performed each year, although there are often alternate kinds of operations and treatment. The average mortality rate is 10 percent. But only six out of 100 people operated on are actually cured. So we are killing 10 people to save six!
What, specifically, should the patient ask the surgeon?
If, say, your doctor wants you to have your thyroid removed, ask the surgeon what his complication rate is for that particular operation. Ask him how many he has done, if he really is a specialist in this area—and for God's sake don't go to the guy who does that particular operation only occasionally.
What else can be done to make the patient more aware of the dangers?
I think each hospital should publish its mortality rates for each operation so that a patient can know what risk he is running. The way that can be achieved is to pass a simple directive declaring that no Medicare or Medicaid patients can be treated in an institution where the mortality rates are not available. The average hospital would go broke without federal money. If you operate on enough people who are so sick that you kill off a high proportion of them, then you shouldn't be operating. What the heck, people lived for years without any operations for heart disease—and they still can. But they don't live if they are poor risks and some surgeon bumps them off.
Do the mortality rates vary much?
Yes. An operation for cancer of the rectum has a 1.8 percent mortality rate at St. Mark's Hospital in London and an 18 percent mortality rate at a certain Midwest university center. That's a tenfold disparity.
Should a patient always seek a second opinion?
Boy, I certainly would! Remember, a surgeon does not decide. The final decision is the patient's. It's a sad commentary on our profession that the Department of Health, Education, and Welfare has urged that all Medicare and Medicaid patients get a second opinion before elective surgery.
How do you find such a doctor?
You go back to your family doctor and ask him who is the authority in the community. Generally you should go to a salaried staff surgeon for a second opinion, rather than one who is paid by the operation. The unsalaried surgeon gets paid if he operates, and doesn't get paid if he doesn't operate. Surgery is the one profession in which conflict of interest is not only tolerated but extolled as a shining example of free enterprise.
How can this conflict be prevented?
Only allow operations by full-time salaried staff surgeons. I've been on salary all my life.
How can a hospital get rid of an incompetent salaried surgeon?
You can hire and fire GM executives, so why can't a hospital do the same?
Aren't surgeons humbled by the dangers of their profession?
There are so many life-and-death decisions that after a while you forget all your failures and remember only your successes. You begin to think you are God.
Do you agree with the recent congressional study that three out of four preventable mishaps are due to errors made by the surgeon?
I think that is putting it mildly. Surgery is like driving—most of what goes wrong is the fault of the driver.
Is it better to go to a large medical center for surgery instead of a small hospital?
Usually, yes—even if you have to travel a few hundred miles. A coronary bypass is a standard procedure, but in small hospitals they only do a few each year, and the results are terrible. They have 10 times the mortality rate of medical centers where one or more surgeons have a great deal of experience with a given operation.
Are annual checkups important?
It's a nice luxury, but not worth the expense. If you want reassurance from your doctor, fine. But that doesn't mean you won't drop dead on the way out of his office. There are some things you should check, every few years: your eyes for glaucoma, a Pap smear and your blood pressure.
Are a lot of unnecessary tests done because of fear of malpractice suits?
Absolutely. This is the age of defensive medicine. The overuse of hospitals and of diagnostic tests is going to lead to the socialization of American medicine. Patients on Medicaid have a higher number of operations than the national average. If the government starts paying for everybody, there will be no end to the abuse. It will be a tragedy for the government, the taxpayers and the medical profession.
What is the solution?
The government should encourage prepayment plans like the Health Maintenance Organizations. In such prepayment programs, there is no incentive to overtreat.
Do you consider yourself a maverick?
Yes, but I never expressed my views until I retired. I could never afford to express myself like this if I was practicing. For goodness sake, no one would have referred me patients!