Avoiding surgery on certain patients

Discussion in 'Podiatric Residents & Physicians' started by GeauxT, Dec 6, 2018.

  1. GeauxT

    GeauxT Member
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    What is your strategy for avoiding elective surgery on patients you know will be a post op nightmare?

    I had a lady in her late 40's come in yesterday complaining of a pain in both feet. She had a moderate bunion on her right foot and stage 2/3 hallux limitus on the left. Both were certainly worthy of surgical correction. She has seen 3 other podiatrists in the area, all of whom she said she "didn't like." She was on both antidepressants and anti psychotics. She has neuropathy of which no source has been found yet. She said I came "highly recommended" from her primary doctor. She also had her 80 something year old mother with her who seemed to answer more questions than the patient herself. I see red flags everywhere.

    How do you tactfully go about avoiding surgery? I certainly don't want to damage any relationship with the referral doctors in the area. My first step was a neurology referral for the neuropathy, which I figured would buy me at least a month or so. After that, I guess I'll just bombard her with conservative care until she decides she doesn't like me either...
     
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  2. GreenHousePub

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    "I don't feel comfortable performing this procedure, I didn't have a lot of experience in residency and I don't want to do you any harm. Here's the number to the local orthopedist who I have heard nothing but good things about. If you have any further questions or concerns I'm happy to see you"

    Make yourself seem like a dummy, it's the best strategy.
     
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  3. Scrantonicity

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    Haha--I dunno about the dummy thing, as word could get around real quick about you.

    I usually just exaggerate the risk of post-op complications and time it would take to heal. With this particular patient, her idiopathic neuropathy gives you an easy out.

    "I would love to correct your bunion, but the biggest downsides are the time it would take for this to heal and the risk of complications. We are looking at 6 months to a year of healing, and with your neuropathy the risk of complications and amputation are much higher. In fact, there is a significant risk in fact that the trauma of surgery could even worsen your neuropathy pain, which would make your foot permanently worse. All of these things combined make me particularly uncomfortable about doing surgery on your foot. As much as I hate to say it, you would be better off continuing to live with it and trying to accomodate for it with wider shoes, padding, etc."

    I mean, you're not lying---just being brutally honest without necessarily mentioning the behavioral health issues. No one should make you feel forced to do surgery on them. If she gets upset about that, all you can say is "I know, I hate it too. I'm sorry, but I just can't put you through that."

    P.S. If by any chance she's a smoker---you have the easiest out of all...
     
    #3 Scrantonicity, Dec 6, 2018
    Last edited: Dec 7, 2018
  4. Creflo

    Creflo time to eat
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    The most important thing is that you realize that you should not do the surgery. If you have a bad feeling, you should probably listen to your gut. You could say the risks outweigh the benefits which is a true statement. For the hallux limitus you can prescribe orthotics. For the bunion you can prescribe voltaren, shoe changes. Then if she pushes surgery, you can say that in your opinion conservative options are best, and different podiatrists have different treatment philosophies and it may be worthwhile for her to seek a second opinion, but you are happy to continue to treat her.

    I believe that one of the biggest factors in a successful surgery is patient and procedure selection. Maybe you could offer a silver instead of an Austin, for example. I did this for a hairdresser that couldn't miss much work, and she was very happy with the outcome. I'll only do a lapidus on someone who does not smoke, will rest after surgery, who shows up for appointments, who follows my instructions, etc etc.

    Another example is whether a patient answers their phone and has voicemail. If they don't answer and don't have working voicemail, I'm not going to do elective surgery on them. I want to be able to communicate with them before and after the surgery.
     
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  5. air bud

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    This is beyond stupid, are you kidding me? Why would you undercut yourself like that? As well as add fuel to the fire with Ortho???

    Wait to see what neuro says, you don't have to commit yet. Maybe you will get a get out of jail free card. Maybe not. But this patient isn't worth it. It's not worth it if trying for boarfs. It's not worth the money and itsitnot worth your mental energy. I promise whoever referred her or anyone who might know her also knows she is crazy and you will lose no status in their eyes
     
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  6. air bud

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    Again I would not do anything to like and demonstrate lack of knowledge - in regards to your 6 months to 1 year NWB. But absolutely would play up charcot risk. Neuropathy is your way out. And then just be a man and say no
     
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  7. GreenHousePub

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    Eh, to each their own. It's worked well for me over the past two years for the 3-4 patients I've had. I've even had them come back for some other stuff like orthotics in future. Referrals keep coming. Ortho's not even thinking about you anyways, we are an afterthought. ¯\_(ツ)_/¯

    Like even you said: "I promise whoever referred her or anyone who might know her also knows she is crazy and you will lose no status in their eyes"
     
  8. GeauxT

    GeauxT Member
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    This is basically what I did when I referred her. I told her that she would need to have to neuropathy worked up/treated before considering surgery. Hopefully it works...
     
  9. dtrack22

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    Kicking the can down the road with further work up seems reasonable (though pointless if you plan on saying “no” anyways) but I’m not sure why anyone here feels the need to lie to their patients. Be an adult and tell Mrs. Smith that you do not think she is a good surgical candidate and you do not believe that she will get better with surgery. Or that the chance of her benefitting from surgery is too small and therefore you aren’t willing to do the procedure. Then refer her out. Like a real doctor does.

    Or make up stuff about weight bearing status that isn’t true, or tell her you suck, or make up complications that aren’t realistic I guess...
     
  10. Scrantonicity

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    j

    OK man, I obviously mistyped...I meant to say 6 months to a year of healing, not non-weightbearing. I just fixed it in my comment. No one would believe a bunion would be nonweightbearing for that long. I didn't say to lie or make up complications...just list off what it says might happen in the consent. Anyways, thanks for catching that.
     
    #10 Scrantonicity, Dec 7, 2018
    Last edited: Dec 7, 2018
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  11. streetsweeper

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    Tough situation but someone on here once posted to be honest and ethical. If the problem is legitimate despite patient having psychological problems or neuropathy I'd take on the case if I sense that they'll be able to take care of the post op (family at home or rehab availability). I'd preface it with "I can't solve all your problems but I can take care of this very specific structural problem." My overall experiences/outcomes have been very good with this approach.

    I had a similar anecdote a few days ago. Patient came to me and the referring doctor talked about me as if I was a god. Patient came with high expectations. Very demanding and had dismissed advice from a couple other podiatrists in the region. However, I didn't think her problem needed surgery. No lying needed, just be honest. I told her that I didn't think surgery will solve her problem. She was clearly disappointed but I added " if you were my mother (or other family) I'd have the same conclusion" .. and this changed her tone into someone more appreciative. My patient satisfaction score might sting a little...but I'll sleep better.

    My 2 cents
     
  12. ExperiencedDPM

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    The answer is simple. Just be honest, is that so difficult. Over the years I’ve had many patients who gave me that “feeling”. Trust your gut and forget about who you’ll piss off and forget about the money, etc. If you get that gut feeling and ignore it, you will likely regret that decision for a long time.

    I simply tell the patient that although I believe I can successfully correct the problem, I don’t feel as if I will ever make them satisfied. If they ask why, I simply tell them. I have NEVER regretted following my gut feeling but have regretted thinking I was the one who was going to make this patient happy.

    It’s not the results. You’re results can be clinically and radiographically perfect, and they still won’t be happy.

    Just be honest. Period
     
  13. air bud

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    It's all about patient satisfaction scores...
     

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