Treat Patients as People… Not Diseases

Author: Howard J. Luks, MD- Posted in: Orthopedic Social Media 24 Comments

Are we defined by our laboratory and MRI findings….

We as physicians are commonly trained to treat disease, not patients.   Another way of looking at it is that we are trained to think mechanically.  If “X” is present, administer “y” and if  “A” is broken, we must fix it.   Orthopedic surgeons in particular are frequently trained to treat MRI findings and not necessarily how to incorporate patient values, or the tailor a treatment plan based on  how a disease effects a patient’s quality of life.  Many  surgeons are  not typically considering the patient’s underlying emotional status and the influence that this will have on the patient’s ultimate recovery.  At risk patients have significant anxiety and other psycho-social issues that affect their ability  with regards to medical decision making and recovery from medical intervention.

Research has shown that *at risk* patients are agnostic with respect to socioeconomic background, age, or gender. The at risk patient has significant anxiety, perhaps low-grade chronic depression and certainly diminished coping skills.  In order to put in place or create an environment that ensures successful treatment of a disease state, it is imperative that the surgeon identify the at risk population preoperatively. This will enable us to put the proper mechanisms  in place in order to insure a proper setting or environment for functional improvement in the postoperative setting. Identifying an at risk patient does not necessarily mean that the patient should not consider a proposed procedure – – – instead it should alert the physician that a multi-modal approach with the inclusion of social workers or psychiatrists and psychologists may be necessary.

Participatory Medicine, Patient Values and the Master Surgeon

I’ve always stated that great surgeons know how to perform  most procedures well within their area of specialty. More importantly they know how to deal with complications as they arise and work towards the best situation possible to improve the likelihood of success.  I’ve also been quoted as saying is that a master surgeon approaches patients as people,  and not diseases. A master surgeon incorporates patient values, and can identify the at risk patient and institute measures to effectively manage and treat those patients both pre-and post-operatively and perhaps more importantly they can identify the at risk patient who should not be indicated for surgery.

For many patients it is impossible to separate the emotional and physical aspects of recovery from surgery or other disease states. There is frequently a mismatch between a patient’s subjective complaints versus the surgeon’s thoughts on objective impairment. It is the psychological issues and the coping skills of the patient that perhaps lead to this mismatch. Cognitive behavioral therapy and other non-conventional treatment modalities may prove to have a crucial role in aligning these issues.

What this boils down to is the art of patient – physician communication. It is incumbent upon the physician to have a clear sense of what the patient understands about their disease and to engage them further to improve their level of understanding. We can go further and  provide the patient with information, booklets, or links to a website  the patient can then review in the comfort of their own home or with other family members.

Those of you who frequent this blog understand that I am a strong believer in shared decision-making principles. I believe that a patient should clearly understand  their diagnosis,  the future implications of their disease, what the treatment alternatives are and what the risks of either nonoperative or operative treatment are and how the choice of surgical or nonsurgical management might affect them.

The *Personality* of an Injury (or disease state) …

I’ve spoken before about the low touch- high technology approach to orthopedics that is far too prevalent in our society. Not only does this lead to over testing and over treatment – – – it lends itself to  ignoring the quality-of-life impact the disease/injury in question is having on the patient. When surgery is considered, this leaves many patients at risk for poor functional outcomes simply because the surgeon may not have recognized or addressed the non-physical  functional needs of the patient.  Orthopedic surgery cannot simply be defined as fixing a broken part, without the clear understanding of how our intervention affects a patient, and the fact that how a patient reacts to surgical or nonsurgical management, is simply not mechanical.

We need to treat our patients as people and not as disease states.  We need to treat patients and not MRI findings. It is no longer advisable, nor perhaps acceptable, to look at a patient as possessing a mechanical issue and not consider the impact of whatever intervention we recommend on their lifestyle and quality of life.

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24 Responses to “Treat Patients as People… Not Diseases”

  1. Reply Ryan Madanick, MD says:

    Thanks, Howard, this is SO very important, especially in procedure based fields like surgery. In my practice, I see too many patients who have had antireflux surgery who still are symptomatic or can’t tolerate the side effects. The problem is that often their doctors treated the pH-study…not the patient.

    I recently tweeted something very much like this:
    https://docs.google.com/leaf?id=0ByRfWmxlYdoYZmM4MmMxNjMtMjBjNy00YmY1LThlOGMtMzc4YTJiZDljZTZk&hl=en_US

    I hope you continue to keep teaching this…I know I will!

  2. Reply Doctor Marketing Insights from the Four Seasons Hotel and a Master Surgeon | Medical Marketing Blog says:

    [...] in point, his recent post, Treat Patients as People…Not Diseases, where he tells us, “We as physicians are commonly trained to treat disease, not patients. If [...]

  3. Reply Greg Smith MD says:

    Howard,

    Thank you for this excellent piece. As a psychiatrist, I certainly work every single day with illnesses that profoundly affect the lives of people who suffer from them. It would be easy to just add another medication or perform another test, but the patient must be actively involved in those decisions at the top or we’re all doomed to failure. I too believe in shared decision making ( not just the old informed consent that we all cut our teeth on). Went to a Dartmouth summer conference on this topic in mental health a few years back with Robert Drake and it was excellent.
    Thanks for your good work.

    Greg

  4. Reply Melissa (DrSnit) says:

    Love this. People matter. I’m so glad you are reflecting on HOW MUCH we vary… amazing how some surgeons can have the same, “skill” yet vastly different *results* because they recognize that ultimately people are not machines. It is the connecting of both patient and healer (and yes- HEALERS remember the art of medicine require them to both teach and doctor) that matter.

    Cheers!
    Melissa

    • Reply Howard J. Luks, MD says:

      Melissa…. Thank you so much for your kind words. Decision making in health care is not a straightforward or easy process… hopefully many will start to incorporate more shared decision making principles, identify the *personality of an injury*, manage expectations and utilize a more patient centric approach—when applicable.

      Thanks again… so glad to have you stop by! :-)
      Howard

  5. Reply Name Dann Byck says:

    Howard,
    Well done piece on how important it is to lose ourselves in our patients not the technology they assume is the final word. I will have this conversation virtually every day with patients. They come in with a MRI and I feel obliged to let them know that regardless of the scan report I will treat them as a person and together we will develop the treatment plan. Agree, outcomes improve when both doctor and patient are engaged in a common goal.
    Maybe you can speak to the difficulty in breaking through the anxieties many patients feel when they are in a specialist’s office and how most will not remember many of the salient points due to the ‘Oh my God!’ factor.

  6. Reply clare2136 says:

    What a lovely blog page. I’ll surely be back again. Please hold writing.

  7. Reply Julie says:

    What a great post. I think every doctor who reads this should forward a copy to every doctor he or she knows.

  8. Reply MRI Over-Utilzation in Athletes ... and *Us* Too! At what Cost? says:

    [...] because of the finding. This nails home another concept I have discussed on here on many occasions. We treat patients, we do not treat MRI findings. We need to understand the personality of an injury and how that injury is presenting itself in you, [...]

  9. Reply Do Labral Tears Require Surgery? - Howard J. Luks, MD - Chief of Sports Medicine and Arthroscopy says:

    [...] Dr. LuksDo Labral Tears Require Surgery? Once again is critical to keep this in mind. Physicians should endeavor to treat patients and not their MRI findings. A recent article in the New York Times show that nearly 90% of professional athletic had MRI [...]

  10. Reply Alex says:

    I, as a chronic ortho patient (with ON in multiple joints) have been fortunate to find a group of orthos in Vail Co who are not the ” if all you have is a hammer everything is a nail” type of folks” each Dr I have worked there ( they mostly focus on one joint and have their own teams, but share a similar ethic and philosophy) and truly practices integrative/ participatory medicine. PT is the first protocol, and they have an integrated team there. They work with the patient, some call on Sundays and say hey call my cell and let me know how you are doing. Sadly I have to travel 1900 miles one way to get this treatment and I am not a famous athlete…just another person! It is a wonderful safety nest to have!

    Howard, I would like to see/ read more of the things you would do/ an outline of how to address the non functional needs of the patient…what in your opinions should Drs do!

  11. Reply Partial Anterior Cruciate Ligament ( ACL ) Tears - Howard J. Luks, MD says:

    [...] to light the fact that patient centric orthopedists — orthopedists who are treating you as a person and not your MRI finding will base the decision on whether or not you need surgery on your actual complaints, not strictly on [...]

  12. Reply Meniscus Tears- Is Surgery Necessary -Howard Luks, MD Westchester NY says:

    [...] — then why would one consider surgery a necessity? Again, physicians need to learn to treat the patient, and not the disease.   How are mensical tears treated?If you have knee pain, you are referred for an MRI fairly [...]

  13. Reply blogs | Pearltrees says:

    [...] For many patients it is impossible to separate the emotional and physical aspects of recovery from surgery or other disease states. There is frequently a mismatch between a patient’s subjective complaints versus the surgeon’s thoughts on objective impairment. It is the psychological issues and the coping skills of the patient that perhaps lead to this mismatch. Cognitive behavioral therapy and other non-conventional treatment modalities may prove to have a crucial role in aligning these issues. What this boils down to is the art of patient – physician communication. It is incumbent upon the physician to have a clear sense of what the patient understands about their disease and to engage them further to improve their level of understanding. Treat Patients as People… Not Diseases – Howard J. Luks, MD – Chief of Sports Medicine and Arthros… [...]

  14. Reply Keyon says:

    Great post. Thanks for sharing this with us.
    I love what you said about pre operative and post operative
    planning. It is important to have plans in place both before
    and after surgery, and to provide the necessary resources for
    patients who will need them.

    Sincerely,

    Keyon R. Mitchell, MSW

  15. Reply Katrina Lane, LPC says:

    Treating the diagnoses and not the patient is unfortunately not limited to the medical field, however it is more prevalent there. Although in the mental health field the patient’s emotional and psychological state is considered, the values and wishes are sometimes neglected. Sometimes they are put on multiple medications to treat symptoms, but not explained how they can be addressed with therapy. Also often even with therapy there is a reluctance to explain the limits and how much therapy would be needed for a desired outcome. Also, although cognitive behavior therapy is effective, there are some people that it might be more helpful to integrate the effective strategies of cognitive behavioral therapy into another approach because the patient may not respond to cognitive behavioral therapy alone.

  16. Reply Treat Patients as People... Not Diseases - Howa... says:

    […] Are we defined by our laboratory and MRI findings…. We as physicians are commonly trained to treat disease, not patients. Another way of looking at it  […]

  17. Reply Name Linda says:

    I have learned so much from your writings and much more than my doctor explained to me. I was a RN before I became disabled due to illness and not injury but doctors fail to take this into account for my “quality of life”.. Four weeks ago, I had a fall and landed on my lateral aspect of R knee. I want to share w/ you what I wrote to a couple nurse friends. Any advice would be welcomed. Thank you again for your article.
    ” I am really getting concerned about my knee. I feel I have no other medical people to turn to because the doctor is not’ taking me seriously. The more I read (have to be my own advocate) the more I realize that this may really be serious and I am not getting the proper care from the ortho doctor. All the indications for arthroscopic surgery are there especially the length of time and not getting better, quality of life and safety issues. It is now 4 weeks and I am not better. Even the steroid injection had only about a 10% positive affect, if any. I continue to have numbness down into my toes and when pain is bad my entire foot (on Wed., and Fri. following PT) although the ortho doc told me the foot and toe numbness wasn’t related and to see my PCP. I beg to differ w/ her. Why would I ever want to use a walker, use chairs to get around, use a wheelchair at the doctors office, and not walk?
    I think the word “blunting” on the MRI stands for the flap tear. She did tell me I had a flap tear (I didn’t understand at the time but recall her using the word “flap”). The four criteria to be met for surgery are there. If you have some time , look or skim through the following. Also, might help in your practice with ortho patients.”

    • Reply Howard J. Luks, MD says:

      Flap tears can be bothersome.. especially very unstable tears that move around a lot. There are many other variables that influence a surgeons’ decision to operate… so it might be time to find another Ortho you feel comfortable with. Kudos for taking charge :-)
      Howard Luks

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