Overconfidence of Your Surgeon - How it affects your outcome

Overconfidence is something that you'll encounter everywhere in life, but never more-so than in health-related areas. That's especially true if you are looking to surgery as your snoring solution. Your surgeon is absolutely sure that surgery is your best bet. The question is, how confident should you be?

You've heard the old saying: "If the only tool you have is a hammer, then every problem looks like a nail."

That's as true of medical doctors as it is of anybody else. If somebody is trying to sell you their throat-spray snoring remedy, then that's all they'll talk about, and they'll exude confidence that the spray is the best remedy. But you'll get the same attitude and bias from the guy who wants to sell you a special pillow - his "anti-snoring" pillow is the solution. And again from the guy who wants to sell you a mouth appliance or a head/jaw-strap. Overconfidence based on a blinkered view of the situation. Your situation, but seen from their point of view - the point of view of somebody who has one thing to sell.

Nothing unexpected about that, but keep in mind that whether or not they (and their customers have had success), their solution isn't always the best one for every sufferer. So, often, overconfidence is misplaced confidence.

The same applies to doctors, especially surgeons. Doctors in general (GPs and Ear-Nose-Throat specialists) will prescribe chemicals first and then surgery, because that's the standard, conservative, approved medical approach. Surgeons will prescribe surgery, because that's all that they do - they have a hammer called surgery, and every problem looks like a nail .... er... that is... a surgery candidate.

Also, surgeons tend to have big egos. The selection process in medical training tends to select for certain types - including a very high confidence in their own abilities - who are allowed into the surgery specialties. If you aren't naturally imbued with overconfidence, or can't fake it convincingly, you don't get in.

So, if you present to a surgeon with a fairly severe snoring problem, you will be a candidate for surgery, and the surgeon will bristle with confidence that the surgery will go smoothly and your outcome will be all you could hope for.

Statistically speaking that might turn out to be true, but statistically speaking, there's a very good chance that not everything will be perfection.

Because, you see, the bell curve, the normal distribution, applies to surgeons, too.

• Statistically speaking, it is not possible for every surgeon to be the best - some were at the top of their class, some were at the bottom, the rest were somewhere in the middle - which one was yours?
• Statistically speaking (and real life speaking) it is unlikely that any given surgeon will be the best at every technique that he or she undertakes.
• The bell curve applies to the days of our lives (and the lives of surgeons) - not every day is the best day - hormones and schedules ensure that a surgeon (like anybody) is at top form only part of a given day, week, month. The rest of the time, they're just muddlin' through. Now "muddlin' through" for your surgeon might be a great big step above what most people would call excellent, but still, there'll be lots of times when your surgeon is not the very best that he/she could otherwise be.
• Surgeons can catch head-colds, or be fat and pre-diabetic, or have age-related eye troubles, or have a hang-over, or... or...
• Surgeons have families that go through crises, break up, and so on. All those things take a toll on a person's performance, whether they care to admit it (to you or even to themselves) or not - besides, it's part of the surgeon's persona to bristle with confidence, remember? Was your surgeon at the police station dark-and-early this morning, bailing out his delinquent son?

And in the OR

And the bell curve applies to surgeries. When a surgeon (or anybody who works in hospitals) is about to undergo surgery on themselves, do you know what their best friend is? A Sharpie permanent marker. If a surgeon (knowing how things work in an operating theater) is about to have surgery on her left leg, she will write on it "THIS ONE!"... and she will write on the right leg "OTHER ONE!"

This is because she knows that a busy working surgeon comes into the operating room and operates on the leg (or kidney or ovary or ear or...) that the pre-surgery prep team has exposed and prepared. She knows that sometimes the documentation gets mixed or the staff gets confused and the wrong leg (or kidney or ovary or ear) gets prepped and then gets cut.

It doesn't happen often, but if you are the one it happens to...

• Not everything is always optimal with the surgeon (see previous list above)
• Not everything is always optimal in the operating room - equipment can fail or be poorly maintained, sanitation and sterilization can be sub-par, etc.
• Other important operating-room staff can be having a bad day (see amputating the wrong leg, above).
• Patient-prep before the operating room might have been carried out by overworked and underpaid nursing staff and by interns or residents at the end of 36-hour shifts (so your pre-surgery medicine might have been overlooked or might have been somebody else's).
• The patient doesn't always follow all the pre-surgery directions as closely as they should.
• If the surgery was scheduled weeks or months ago, the patient's condition might have deteriorated.
• The patient might be coming down with some illness and either doesn't know it yet or has declined to report it for fear of having the surgery delayed again, so the patient will be battling some germ when his energy is needed for surgical recovery.
• Somebody might have had a car breakdown or a brush with road-rage on the way to work this morning and still be wound-up and distracted by that event.
• Somebody might be in deep debt and facing eviction and bankruptcy, so their attention is severely divided - could that person be your anesthesiologist?
• Somebody might be in the middle of a nasty divorce and you look just like the evil-soon-to-be-ex-spouse's lawyer.
• Is your surgery scheduled for when everybody has been overworked for months and is more than ready for an overdue vacation?
• Is your surgery scheduled for when half the staff is just back from vacation and is not yet in the "work groove"? (Who just picked up hepatitis in Mexico and doesn't know it yet?)
• Surgeries are like cars - you want one that was built on Tuesday, Wednesday or Thursday, not one built on Friday when the workers had a hard week behind them and weekend escape at the top of their minds, and not one built on Monday when they're recovering from the weekend debauchery. Remember, most weddings happen on weekends. The bride and groom go away for a honeymoon, but the other celebrants bring their hangovers with them back to work on Monday. People who work in operating rooms attend weddings just like everybody else.
• Did you know that many of the bad results from surgery occur because of anesthesia? THAT is the most dangerous part of many surgeries. They are paralyzing you and suppressing many of your necessary bodily functions, and then keeping everything balanced on an edge between failure and waking up. Your anesthesiologist needs to be as attentive as your surgeon while you are unconscious. The dividing line between "minor" and "major" surgery is whether or not you are given general anesthesia. That's how important and how tricky it is. Making you paralyzed and unconscious and then getting you back again is a specialty that needs more years of extra study than the surgery itself. Worry about that.

Keep in mind that 100% of iatrogenic illnesses and infections are contracted in hospitals. (OK, that sounded silly on the face of it, but there's a practical consideration to glean from even a truism like that.)

All these things affect performance of people and equipment that are very important to the success of your surgery. How many of them do you control? Is overconfidence by the providers beginning to look like a dangerous sham? Maybe it should.

So, we think surgery (for anything) is GREAT, when it's truly the best option to save your life or your quality-of-life. But we also think that, given what can - and often does - go wrong, you should exhaust any other promising remedies first, before going under the knife. Take any overconfidence by your surgeon as exactly that... OVER-confidence. It's their job to make you feel that they can't fail.

Make your own decisions and don't get rushed into anything by a confident attitude and a brusque assumption that somebody else (who profits from your acquiescence) knows better than you what is best for you. After all, they don't have to live with the outcome - you do.

The Wager

How well do you think this conversation might fly?

YOU: Doc, you seem very confident that surgery is the way for me to go.

SURGEON: Absolutely.

YOU: And that you are the man to do it.

SURGEON: Of course!

YOU: And that if I just follow the basic directions for my own actions, everything else will go smoothly and I will have a good outcome.

SURGEON: Yes, yes...

YOU: So, since I had 161 apneaic episodes (and snored most of the time) during my sleep study, when I have a follow-up sleep study (would four months post-op be good?), I should have zero apneaic episodes and snore no more than 10 percent of the entire night. Does that sound like a good definition of success?

SURGEON: Well, er...

YOU: You see, you've been bowling me over with your confidence (in the surgical choice and in your powers as a surgeon) and your assurances that surgery will make my condition right, and you lose nothing if you happen to be wrong, and I lose tens of thousands of dollars and pieces of my throat. So I was thinking that a little wager would be in order.

SURGEON: ............ wager? ......

YOU: Yes, since all the risk is on my side, I want to move a little of it - along with some incentive - to your side. So, if I don't get the desired outcome, as validated by an independent third party (the sleep lab), then I don't have to pay your fee. How's that?

SURGEON: Don't be silly. It doesn't work that ....

YOU: Now doc, YOU are the one talking me into this and expressing 110% assurance that you can make it right for me. I'm not being silly. I'll still pay the hospital and the anesthesiologist (if I wake up alive...) because they will have done their jobs. I'll just be off the hook for YOUR fee if the independent study doesn't prove that you've done yours. You're confident enough to accept that wager aren't you?

SURGEON: ... urk!.... [head explodes]

YOU: Yeah, the guys at MHT kinda said it would work that way if push came to shove.

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