Dr. X paged me while I was operating so I called him back after I was done.
Dr. X: I have this patient in room 321, I did a [spinal] fusion on him the other week. He fell and now he can't move his legs. We got a CT scan and it showed a T3 fracture. So I want to extend his fusion. I need you to explain to him and his mother, who's an idiot but she's his legal guardian, that he may have a spinal cord injury and could be paraplegic and then I need you to get consent for the surgery. Oh, and make sure they hold his heparin tomorrow.
Oh. OK.
Just to recap, that means I need to go talk to some patient who I've never met and know nothing about and tell him that he may be paralyzed for life. Then I need to explain to him that he needs more surgery. I need to convince him and his mother. I've never met this guy before. I don't really understand what's going on. I have nothing to do with any of this.
Seriously people, do your own damn dirty work.
So I went to talk to the patient. He seemed a little slow in that he was having a conversation with the phone while it was ringing, but he definitely understood what I was telling him. As in, I walked in and asked him how he was, he said he was terrible because he couldn't move or feel his legs, I said we wanted to do surgery to fix the broken bone in his back and he said "Oh G-d no, not more surgery. I'll do anything but that." Then he started crying. Because I have no tact, I pushed forward and I said we wanted to also look at his spinal cord while we were operating because there was a chance that whatever it was that was causing his paraplegia could be reversed. The thing is though, that's probably not all that accurate. So I had to say that there was a good chance if he was paraplegic now, he would always be paraplegic. I think my exact words were "It's likely that you will spend the rest of your life in a wheelchair."
He understood that.
Then, because his mother was his power of attorney, I had to call her to get permission for the surgery. She understood what was going on after I told her that he might never walk again. She said 'it sounds like he might not be able to walk again even if he has the surgery." I said that was true. She said she was still OK with him having the surgery. So I got consent, called the primary team to tell them the plan, and made sure he was appropriately pre-opped. The whole thing took about an hour.
See, this really does not sit well with me and I was actually pretty pissed about the whole thing. I know I tend to be more anal than most people when getting consent because i don't want a surgeon who can't sit down with me for two minutes and explain the surgery and the risks and benefits and I get that not everyone is like that and it's fine, but I really think it's inappropriate to have someone else deliver bad news to your patient. I mean, I don't think anyone enjoys telling people that they'll never walk again (and this is my second time in a week and really, the experience has not improved with time) but I feel like if you're the one who has the relationship with the patient, you should be the one to tell him. I don't think it's fair to the patient or to me to stick me in this position. I don't know anything about the patient or his history, so I really can't answer any questions. He doesn't know anything about me, so why would he trust my opinion on anything?
The patient said "I wish I'd never had the first back surgery." It was hard to argue with that logic so I slunk out of the room while he and his mother cried together over the phone.
It's really hard being a surgeon sometimes.
I'm sorry, but for the life of me I cannot see why you agreed to do this in the first place. You are feeling pissed because you were dumped on by a coward. Considering that this was not your patient and you knew nothing about his case, it was not your responsibility to discuss outcomes and follow-ups. When you take on a patient, you are invested in that person's care from start to finish. Would it be that we could make the blind see and the lame walk each and every time, but we live in the real world where not everything turns out sunshine and daisies. Dr. X sounds like a first class weasel and a poster child for unprofessionalism.
ReplyDeleteGeez Fizzy, this week's blogs are putting me pretty low. (And I am one of your readers who realizes Dr. Orthochick and Dr. Fizzy are two different people - but Fizzy, since you are the curator, I am addressing you. … We are doing lots of unnecessary and futile interventions on old people. We are doing multiple back surgeries on people better off without. I am an MS2 and if you post one more downer I am quitting. (I am pretty much joking here). … I am curious if Dr. Orthochick actually thinks a second surgery could be of any benefit. If she does not I think this was more of an ethical than a professional conundrum. I'd like her to comment on that if possible. … And despite my complaint here - I love this blog and I enjoy both of your perspectives.
ReplyDelete@Anon2: Recent research suggests that early surgery after a spinal cord injury may result in improved outcomes. There's no surefire way to know in advance unless imaging shows the cord is obviously very badly damaged or transected (cut) on, in which case meaningful functional recovery is less likely even after inflammation subsides. If the spinal column is unstable, then surgical fixation is generally advised.
DeleteAnd while I'm sure you were joking, consider that MS-2 is still plenty early to choose a different, more rewarding path. The pessimism you may feel after reading Fizzy's 2 downer columns is nothing compared to the relentless pessimism that pervades our current medical system. Every day brings more bad news for doctors and more burnout & disillusionment among our best & brightest. No joke.
I hate to break it to you, anon, but tomorrow's column is going to be a serious one too, although one particularly personal and important to me. As it was mentioned above, medicine is depressing. When I was an intern, I cried after every call. I tried to keep this blog light, but occasionally I do have something important to say. :-)
DeleteWhile I agree with the commenter who said you were "dumped on by a coward," good for you for stepping up and doing what needs to be done.
ReplyDeleteThis is not of course unique to surgeons. As an ER doctor specialists will often ask me to consent their patients for them. And on a daily basis, I see patients and families who do not know their diagnosis, even though it is obvious that their doctors must know.
The most common diagnosis by far for this is "failure to thrive." At least once a week, I hear the story that grandma or grandpa is declining, not eating, and losing weight, and the primary, GI, neurologist (!), etc., cannot tell them why their 103yo demented relative is losing weight. The answer, of course, is that they have FTT and they're dying. That really shouldn't be my diagnosis to make, or break to the family, but there you are.
Sometimes as physicians we have to step up and do the hard stuff other people -- including our colleagues -- duck. You have every right to be pissed, but I'm glad you cared for the patient.
Surgeons have demanding schedules that can make it difficult for the attending of record to have a conversation with a patient at a specific time as they're in surgery a lot of the time! But in cases with bad outcomes, regardless of reason, it's more important to make the effort. You don't want to leave patients or families with the unpleasant memory of, "And the surgeon never even came to talk to us!" I have heard that a lot from patients. While sometimes this is true, other times patients are asleep when the surgeon visits or they don't recall post-op visits due to grogginess or confusion from pain medication. Since families only visit part-time and frequently in the evenings, they often miss physician visits and wrongly assume that the surgeon never stopped by, which makes them very angry.
ReplyDeleteI also wonder - out of curiosity - is there a point at which a back surgery should go from being an Ortho job to a neurosurgery job? Wouldn't this be such a case?
ReplyDeleteThere are turf wars between ortho and neuro about spine cases. Neurosurg does the spinal cord stuff (intradural tumor and the like) and ortho does the deformity stuff (adult scoliosis and the like) but everything else is dealer's choice
DeleteThis is sad, and I'm sorry you got dumped on. I also had a surgeon who had everyone else do the dirty work. With his personality and some of his gems, I can understand why.
ReplyDeleteThis is residency! We have done many things even worse for our attendings!
ReplyDeleteI have been consulted (by ortho) to have a hospice conversation with a family following a hip surgery that went badly. When the family asked me why the orthopaedic doctor wasn't the one having this conversation with them I said the phrase mentioned above, "Because he's a coward." Admin actually backed me up when the ortho complained about it to them.
ReplyDelete