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This is a question I get regularly. Sometimes it is framed as a rhetorical question, but othertimes it is real; surprising as that may seem. People often need help with difficult decisions. The problem is of course that no one can really make such a decision, other than yourself. Only you know the impact of the problem on your quality of life, your relationships, and what your risk tolerance and tolerance for pain, recovery, and downtime is. Only you know what your financial position is; will it for instance be better to pay out of pocket for a treatment that has no downtime so that you can immediately return to work for instance, or will the recovery time away from work not affect your finances, future standing in your work or whatever project you might be busy with. Are you aware of, and do you accept that even if you choose surgery, that it might not be a complete solution nor the last surgery you might need for this problem?

Nobody can make these decisions except yourself, maybe with the help of your family.

However, what I as physician can, and must do, is assess the problem you present with, make a proper and correct diagnosis (this is absolutely key), and explain to you what is going on, how it might affect your health and welbeing, and what you could expect going forward. I find it incredible that some patients are surprised or taken aback when they are told they will have an examination. Really? Are they used to having problems diagnosed without being examined? What a sad testiment that is!
I next then have the duty and obligation to discuss the available, reasonable and appropriate treatment options with you and make you understand the implications of these choices - keeping in mind the limitations of my knowledge of your personal life. I need to explain the potential for cure (much more likely though - 'improvement') of your problem or symptoms, but also, the risks. You cannot give informed consent if you don't understand the risks. For surgery this could sometimes be a long discussion, especially if mesh is involved, as it sometimes must be. For laser procedures, the risk part is usually a very short discussion. Often there is simply not time to discuss these issues properly and I will sometimes have to stop and defer such for another appointment. Nobody is served by half a discussion of surgical risks...

In Canada, because of familiarity with our single payer Medicare system (erroneously considered 'free' by many patients), many patients are not used to consider out of pocket pay for medical procedures that are not covered by the Medicare system, or the government. It is true that billing for Medicare-covered treatments are illegal, except for unexplainable exceptions (private MRIs come to mind). However if there is no Medicare coverage or fee code, and no government funding - it is then up to individual practitioners to make difficult decisions whether to invest and take the financial risks inherent in making such treatments available. The inevitable result is of course out of pocket expense for patients who choose these treatments which in many cases include exciting new technologies. Of course there is a higher level of oversight also involved, in that these do need to be Health Canada approved, and in the case of Class 4 lasers, College regulated, certified, and registered. Unfortunately there are unregistered laser machines out there, that are not regulated and not inspected and maintained regularly.

Before I made the financially very significant decision to invest in high end laser equipment, I had consultations and discussions with the College of Physicians and Surgeons of Alberta, including with the registrar of the College, to discuss these issues, including the elephant in the room - the possible perceived bias when treatment recommendations are discussed and financial factors are involved. The advice I received was very straightforward, and I consider that part of any medical professional's ethical behaviour:

Be honest. Don't judge.

I am not going to pre-judge whether someone will or won't be interested in something depending on who pays. I am not going to deny information to someone who might not be in a position to take advantage of every possible treatment available, and I will NEVER push someone to a treatment option only because of finances. The difficulty comes in when I truly believe a certain choice is the superior one. I may guide, suggest and recommend, but it must remain a personal decision. I do surgery. I am good at it, since I focus on a limited niche (the same is true of my colleagues who do the same) and enjoy the challenge and reward of a successful result. However, I have also now invested heavily in the very latest laser technology, PRP technology etc. and find the reduction of risk, pain and downtime and the incredibe results we are getting from these, extremely satisfying as well.

These are options and choices. You have to make the decisions.

One thing is however almost universally true: It is better to start with more conservative treatment than to jump to surgery. Surgery is NOT the easy way out. Surgery has risks. People sometimes think that 21 century medicine has overcome surgical risks. Let me be very clear... it has not. Risk is inherent in every surgical intervention and will NEVER be completely eliminated. Risk can be minimized by careful and appropriate procedure choice, managing medical conditions to be as optimal as possible on the day of surgery and by choosing a surgeon with experience. There is no doubt that high volumes and experience improve outcomes and reduces risk. This doesn't mean that trainees necessarity have a higher complication rate - but that's only true if they are under direct supervision. Inexperienced new surgeons in independent practice however definitely do.

New, conservative options have opened up exciting pathways to improving symptoms and pelvic floor problems without the risks of surgery. For instance laser procedures have become extremely popular for exactly this reason, worldwide. Yes it is true that laser procedures will not cure every problem, and might not always be enough; but you will not know whether it might have been enough, or might delay or make surgery unnecessary if you don't give it a try. What these new laser procedures are extremely unlikely to do, is cause a serious complication. You'll be going about your usual and normal life while we wait to see what the laser treatment's effects are. It takes time, but that might be the best decision you've ever made.