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.
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:
I hope you continue to keep teaching this…I know I will!
Greg Smith MD says
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.
Howard J. Luks, MD says
Greg… I appreciate your comments and thank you for stopping by!
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.
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! :-)
Name Dann Byck says
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.
Howard J. Luks, MD says
Dan, good hearing from you! I hope all is well.
What a lovely blog page. I’ll surely be back again. Please hold writing.