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.

Disclaimer:  this information is for your education and should not be considered medical advice regarding diagnosis or treatment recommendations. Some links on this page may be affiliate links. Read the full disclaimer.

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About the author:

Howard J. Luks, MD

Howard J. Luks, MD

A Board Certified Orthopedic Surgeon in Hawthorne, NY. Dr. Howard Luks specializes in the treatment of the shoulder, knee, elbow, and ankle. He has a very "social" patient centric approach and believes that the more you understand about your issue, the more informed your decisions will be. Ultimately your treatments and his recommendations will be based on proper communications, proper understanding, and shared decision-making principles – all geared to improve your quality of life.

24 comments on “Treat Patients as People… Not Diseases

  • 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!

  • 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

  • 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

    • 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

  • 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.

  • 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!

  • 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

  • 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.

  • Thanks for writing this. I’m a patient recovering from a tibial plateau fracture and torn meniscus, and have been recovering for 7 months; while I can walk with a limp, I can’t walk up and down stairs without a cane, and my insurance company has denied me further therapy citing I should be able to do this eventually at home myself. I have been desperately trying to get my doctor to appeal this decision in order to get an expedited response to have my therapy reinstated. To date, he hasn’t returned any of my phone calls and the office assistant sat on this request doing nothing for 2 weeks. I have been out of therapy for 5 weeks now and need to know how I can help myself progress because it’s unlikely that it will be restored before my next Dr.’s appt. .given these circumstances. After surgery, doctors must be accessible to their patients, because if they don’t fully recover, then the surgery has failed. We are not just a body part to be fixed, but human beings and the whole person has to be fixed.

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