Ask Leslie

How do you know when it's time to make a decision about a complicated surgical procedure? 


Question: I have a meningioma (a benign brain tumor). I've watched your show, read your book and followed your suggestions. At this point, I've consulted with five neurosurgeons, found an expert to perform my brain surgery, and lined up a quarterback to help me out. But I still don't feel sure I want or need surgery. My options are: watch and wait; have brain surgery; have stereotactic radiosurgery. All the surgeons I've consulted with say that because the tumor is attached to the main vein that runs through my brain, radiosurgery would be too risky. I've been doing the "watch and wait" thing for 7 years and the tumor has grown slightly. If I decide to proceed with brain surgery, is it better to go to a teaching hospital where residents are likely to do parts of the procedure, or to a private hospital where I know a neurosurgeon will perform the whole thing? What can you suggest that might help with my decision?

Leslie: The key question with regard to surgery is: How much experience does your surgeon have with the removal of meningiomas in the exact location where yours is located? 

Any time you have a complicated surgical procedure (which, of course, yours is), it really must be performed by a specialist who has studied it meticulously and has deep experience in performing your exact procedure. You need to be comfortable asking a doctor about his or her volumes.

And very often, the surgeons with the most experience are found in an academic setting. The potential downside is, yes, you will have residents doing aspects of the procedure. But, in general, the benefit of having a highly skilled neurosurgeon doing your surgery in a rigorous and technologically advanced hospital environment more than counterbalances any measurable risk of having residents performing the more mundane and less serious aspects of your surgery—such as the craniotomy (opening and closing), which is not nearly as technically demanding as the actual removal of the meningioma.
But, remember, it doesn’t hurt to ask your surgeon to be the one holding the knife the day of your procedure. Here’s a passage right from the book that describes how you might start this conversation:

    Dr. _, I’ve got the highest respect for your practice and your accomplishments. This is a complicated and sensitive surgery. I frankly have concerns about it. I’ve met with several physicians, but I knew after meeting and speaking with you that you are the only one I want doing my surgery. I realize that we’re in a teaching facility, and you have fellows you need to train. What I’d like is to make sure that you’re the person who actually does the surgery on me. Would that be okay with you?

If this is really difficult for you, you could ask your trusted primary care physician to make the request. 

But let me pause for a minute, because you specifically expressed concerns about whether you should be doing surgery at all. You say that your surgeons counseled you against stereotactic radiosurgery (a highly targeted type of radiation therapy used to treat tumors of the brain), but were these physicians radiosurgery experts? If not, I'd encourage you to reach out to an expert for an opinion.  

There are several ways to do this, including: 1. Type "radiosurgery" into Expertscape and you'll get a list of top experts on the procedure; 2. Look at the websites of the largest academic medical institutions near you, and search out radiosurgery experts in the neurology departments. You can also try calling the offices of the top experts, explaining your situation, and asking if you can send your medical records in for a second opinion. They may be open to consulting with you over the phone.

Finally, I want to tell you that you’re doing a wonderful job of asking questions, getting expert opinions, and seeking out more information. Bravo, you! This is your life and your body. And no matter what you ultimately decide to do, you should feel good knowing that you are in charge. I hope you have a thoughtful quarterback helping you through this time, giving you the support you need.