How I Decide Whether Surgery Is the Right Choice

One of the most common misconceptions patients have when they come to see a surgeon is that the purpose of the visit is just to discuss surgery. In reality, my goal is not to guide every patient toward an operation. My goal is to help patients understand their condition, understand their options, and determine what treatment approach best aligns with their lives and goals.

In my practice, surgery is one tool among many. Sometimes it is the best option available. Sometimes it is not. Most importantly, the decision to move forward with surgery should make sense in context of several factors.

What are you trying to understand when meeting a new patient?

The first thing I try to understand is how much a problem is affecting their daily life. Imaging like an x-ray or MRI tell part of the story, but are notorious for finding issues that really don't cause any symptoms. Thumb base arthritis is a classic example of this where the x-ray doesn't always correlate with symptom severity.

I also try to understand a patient’s baseline health and what recovery from surgery might realistically look like for them. Surgery may be technically possible, but that does not automatically mean it is the best choice for a particular person at a particular point in time.

Most importantly, I want to understand the patient’s goals. Some choices provide modest benefit, but are are better option for someone who is interested in a short downtime. Some patients could benefit from surgery, but work and lifestyle issues make surgery impractical and we find a work around.

Do patients sometimes come in expecting surgery?

Not everyone.

Some patients come to a surgical consultation expecting surgery to be the definitive or permanent solution to their problem. Part of my role is helping patients understand the nuances of treatment and discussing the full spectrum of options available.

In hand surgery especially, some conditions can initially be treated completely just by conservative means . We often discuss splinting, therapy, exercises, topical medications, over-the-counter medications, injections, activity modifications, or observation before considering surgery.

Carpal tunnel syndrome is a good example where we know up to a third of patients, especially with mild symptoms, who are treated with night splinting get symptom relief and can avoid surgery at least for a while. We may offer steroid injection if there are other factors such as pregnancy or acute exacerbation due to stressful hand use. When these fail to provide complete relief, or if relief is short lived, then I'll typically offer surgery.

When do you usually recommend surgery?

There are several situations where surgery becomes the most appropriate option.

Sometimes conservative treatments have already been exhausted without meaningful improvement. In other situations, surgery may be necessary because delaying treatment could result in worsening damage that becomes more difficult to reverse later.

Again - this is the case with certain nerve compression problems such as carpal tunnel syndrome, ongoing compression can lead to progressive nerve injury over time. While surgery is highly effective at relieving symptoms for many patients, delaying treatment too long may reduce the likelihood of complete recovery if permanent nerve damage develops.

There are also situations where surgery is the best available tool to correct the underlying problem and restore function when non-surgical options are unlikely to provide meaningful relief.

How do you discuss risks and expectations with patients?

I believe patients need and deserve realistic expectations. It's my job as a surgeon to deliver care and provide education on the underlying problem and the risks of the various treatments available.

No surgery has a 100% guarantee of success, and “success” itself can mean different things to different patients. Some patients achieve complete symptom relief, while others experience partial improvement. Part of my role is helping patients understand those possibilities honestly and clearly.

For example, carpal tunnel surgery is generally very effective, but there can still be variability in how completely symptoms improve depending on factors such as severity, duration of symptoms, and nerve health prior to surgery.

We also discuss the fact that surgery can sometimes solve one problem while creating another. A procedure may relieve pain or restore motion, but it can also leave behind scar sensitivity, numbness, stiffness, swelling, or other tradeoffs that patients should understand beforehand.

For example, trigger finger surgery may successfully eliminate locking of the finger, but some patients may later notice tenderness or sensitivity around the surgical scar. While this is usually manageable and often improves with time, it is important to discuss these possibilities openly before surgery rather than afterward.

Ultimately, treatment decisions involve balancing the risks of intervention against the risks of leaving a condition untreated.

Is there always one “right” answer?

Not always. The practice of medicine has been around for thousands of years and we are still working on finding the "right" answer for everyone as individuals.

Many conditions have multiple reasonable treatment options, and the best decision often depends on a patient’s priorities, lifestyle, work demands, recovery tolerance, and long-term goals.

My role is to help guide patients through those decisions while balancing several important principles:

• preserving function

• minimizing harm

• maintaining future treatment options

• respecting patient autonomy

• and helping patients make informed decisions that fit their lives both now and in the future

This process is very much based on shared decision-making rather than simply telling patients what they should do.

Does your background in both plastic surgery and hand surgery influence your approach?

I like to think so.

Plastic surgery tends to be a very principle-based specialty rather than an algorithm-based one. That type of training encourages nuanced thinking about problems and individualized approaches to treatment.

My plastic surgery background strongly informs my hand surgery practice in terms of meticulous tissue handling, attention to healing, and balancing form and function. Similarly, my hand surgery expertise influences my broader reconstructive and plastic surgery philosophy by emphasizing function, thoughtful surgical planning, and realistic goals for recovery.

What do you hope patients leave a consultation understanding?

I hope patients leave understanding their bodies and their condition better than when they arrived.

I hope they understand that there are usually multiple treatment options available, including doing nothing at all, and that each option carries its own risks and benefits.

Most importantly, I hope patients feel empowered to make informed decisions that make sense not just medically, but for their own lives, goals, and future.