By Clare Crawford-Mason

When my gynecologist's office called me and asked that I come in as soon as possible, I knew this was not good. But I could not have imagined the bizarre and dramatic odyssey I was beginning - or how frighteningly close several trusted doctors were to sending me to unnecessary, expensive and painful surgery.

And there's no way I could have known how the deceased management guru with whom I'd collaborated for more than a decade would provide an essential piece of advice.

I had had my biannual in-office biopsy 10 days before. The procedure was done to determine whether my small daily dose of estrogen was causing cancer. While estrogen taken for menopausal symptoms can increase a women's risk of uterine cancer, adding progestin can reduce that risk. But the progestin made me too irritable, so I quit it.

When we met to discuss my biopsy results, my doctor said a lab report showed atypical cells in my uterus, a condition considered a precursor, or even an indicator, of cancer. She wanted me to immediately schedule a hysterectomy - a major surgery in which the uterus is removed.

I am 65 years old and have avoided all surgery since I had my tonsils out at 6. I asked if there were any alternatives. No good ones, she said. I could choose to have a D&C, she allowed - dilation and curettage, an extensive scraping of the uterine lining.

This is a relatively minor procedure, but if results revealed more atypical cells or cancer, I would need a hysterectomy anyway. And, she reminded me, if I had a D&C I would not be able to take estrogen afterward. I would still have my uterus and, therefore, would need to be tested for atypical cells and cancer regularly.

I said I would like a second opinion; she gave me two doctors' names.

I met one a week later. He read the lab report and told me that I had a 1-in-4 chance of having cancer already - and should have the surgery immediately.

Somewhat impulsively, I reminded the doctor that the fifth leading cause of death in American hospitals was medical mistakes. I asked if he would read the biopsy slide that showed my cells to be abnormal. He said he would have a leading pathologist read it with him, and if there were any question, he'd take it to others.

Meanwhile, I faxed the lab report to my internist. She called the gynecologist and suggested that maybe I could have a D&C, and then they could watch me for a while. But they agreed that I should not take estrogen anymore unless I had a hysterectomy.

The internist referred me to another doctor, to whom I faxed the lab report. (I should note that all these doctors saw the written lab report; no one had seen the biopsy slide except the lab technician, who had interpreted the slide and written the report.) This doctor left a message on my answering machine saying he saw no nonsurgical alternative.

I read books and scoured the Internet for the implication of atypical cells. Not much controversy: a possible precursor and indicator of cancer.

I finally asked my internist what she would do in my situation. She said she'd have the hysterectomy. I decided to follow her advice.

Are four doctors wrong?

It took two days of telephone calls to get the biopsy slide sent from the lab to the doctor who had agreed to provide a second reading.

Two weeks passed. I did not hear from this doctor. I called his office and kept missing him. On the day before surgery, I spoke to my surgeon/gynecologist and she agreed to track him down.

That day, I went to Sibley Hospital in Washington to preregister for the operation. The woman taking my information followed the usual questions with, "At Sibley, you are not just a patient, you are a consumer, a customer. Let me explain what that means."

I laughed and said she did not have to explain. I was familiar with the concept of pleasing the customer, having worked for years with the late W. Edwards Deming, the legendary management analyst who developed the philosophy of customer-driven management and continual improvement. An NBC program I had produced in 1980, "If Japan Can, Why Can't We?," had introduced his ideas in the West. His work eventually reached corporate America and became adopted as Total Quality Management.

Over 10 years I had interviewed him for a library of videos and two books about his ideas, including the concept of making decisions based on data.

Somehow deep in my subconscious, this encounter at the hospital must have triggered an important question, though I did not realize it at the time.

Less than 24 hours away

I returned home. Surgery was less than 24 hours away. I took a long walk with my husband and then did some stretching. As I started mourning that I was not going to be able to stretch in the coming weeks, a thought or a voice - I can't remember which - came to me.

"Would you really make a decision about something as important as this with a single data point - just one reading of one slide?" Dr. Deming seemed to be asking me.

With trepidation, I walked downstairs to speak with my husband. "I don't think I can have surgery tomorrow," I said. "I just heard from Dr. Deming, and he wanted to know why I was making this major decision with information from just one data point."

But the second reading of the slide was still not available. I called the surgeon/gynecologist; she said if she couldn't reach the other doctor, she would do just a D&C the next day. By now, I imagined the second reading, if it got done at all, as being done on the fly. I assumed the doctor would just confirm the obvious and recommend the surgery.

At that moment, I decided I would ignore whatever he said and have only a D&C.

I went out and returned home to find a phone message from the second doctor.

"Don't have a hysterectomy unless you want one," he said. "That slide was over-read."

He called back later and said to go ahead and have the D&C - but based on the slide as he saw it, he expected no problems to be discovered during the procedure.

I had the D&C. The biopsy done on the cells taken during the procedure showed no atypical cells.

A Lesson Learned

I asked my gynecologist what the lesson of all this was.

"It is a good example of the importance of managing your own medical care," she said.

This surprised me. I thought she was managing my medical care. But of course, she was right. Doctors can only give you advice. And the advice can be no better than the information upon which it stands.

Incidentally, my gynecologist had said that if the lab reader of the suspicious cells had not reported them and I had had cancer, my survivors could have sued.

Later, I realized that I had been saved from unnecessary surgery because of my work with Deming. I had been able to see the system - the intangible connections among the doctors, lab and slides, and multiple possibilities. In contrast, the doctors saw only a series of single events: probability of cancer, possibility of lawsuits, cost of surgery and so on.

Being a competent patient these days is a new and baffling challenge. You have to ask impolitic, and sometimes impolite, questions. You have to monitor your care in the system from beginning to end. You have to prod the various parts to communicate with each other.

You have to be focused on your optimal goal - your health - because not everybody else in the system is certain to be.

The Seattle Times