When surgery is not the right answer... but the patient thinks it is
A surgeon can wear many hats. "Doctor," "anatomist," and "surgeon" should seem fairly obvious. But what about "salesman"? You might initially recoil at the thought, but I can think of at least two situations where that's applicable.
The first, and arguably less common: there is a subgroup of patients that have a bad problem, but for multiple reasons are vehemently "anti-surgery" or "anti-hospital" or are just afraid. Despite this, you as a surgeon may know that fixing their unstable fracture, releasing their trigger finger, or decompressing their irritable and unhappy nerve would improve their quality of life with a low complication risk. This is, of course, assuming the patient has failed a legitimate attempt at conservative treatment.
Even in those cases, a balanced perspective needs to be offered - patients must be educated about potential risks of surgery, ESPECIALLY (from a CYA standpoint) patients who get talked into having surgery. Imagine if a complication occurs, and they feel you "talked them into it" and didn't fully explain the risks. What could you possibly say?
If you want to know whether your explanation is sound, you might scrutinize it a lot more clearly if you preface it with "Well, Your Honor...". Not that "CYA medicine" is necessarily good medicine. But imagine how much stronger the logic probably is if your rationale was, "Well, Your Honor, the patient exhibited signs and symptoms classic for severe cervical myelopathy with high potential for irrecoverable loss of function if expedient surgical decompression was not performed, so I found it prudent to do so and after I explained the risks and benefits the patient agreed" sounds a whole lot better than, "Well, Your Honor, she was in pain and I hadn't filled my block time, so I offered her surgery."
Call it the "WYH test." Again, not that medicine should be practiced defensively, but I think this can be a useful exercise every now and then to ensure you aren't stretching indications.
There is, of course another situation in which a surgeon can justifiably act as a salesman. And I think it's more commonplace (or if it's not, it probably should be), but it's one we don't think about. It's when we need to talk the patients OUT of surgery and INTO something more conservative.
For example, I saw a patient recently who had a particular problem that, it was abundantly clear, would not improve with surgery. Her complaints were non-anatomical in nature. She was tender everywhere. Her complaints varied from visit to visit. She was witnessed in the exam room easily lifting to her mouth a fairly large soft drink using her "injured" hand that reportedly was so frail it hurt with any sort of activity. She had what some clinicians call "TBD" ("Total Body Dolor"), or "Undhier Syndrome" (it hurts hier, und hier, und hier, und hier...").
[As a side note, I have also seen cases of "Undhier by proxy" which is the simultaneously fascinating and terrifying situation in which a caregiver (usually a parent) brings the patient to multiple different specialists and talks over them, answering all the physician's questions and advocating that they need surgery (again)...]
We took her seriously, performed a full exam, even ordered advanced imaging. But it was clear that the thing she wanted most, surgery, would not help her. What she needed instead was some time, a little bit of therapy, a lot of counseling, and a healthy dose of grit. But if I simply told her that, she'd have stormed out of the room crying (she ended up crying anyway but thankfully did not storm out).
Unfortunately a lot of these patients come to a surgeon thinking they can be put to sleep for a bit and fixed, when that's simply not the case. They need to become active participants in their care and work toward healing, and set realistic expectations. Sadly, some don't seem to want to do that - they came to the doctor because they are not able and/or willing and/or interested in trying to solve their problems on their own (even with professional help) and want someone to do it for them. Something is broken inside of them, but it's not something that cold steel or sutures will fix.
Not to belittle the suffering these patients experience, but these are also painful encounters for a surgeon. Surgeons are fixers. Surgeons get to the point. We want to figure out what's wrong and propose a solution we feel will work, then implement it. When we don't know the diagnosis or know that surgery is not the answer, or when we know the diagnosis but the patient doesn't want to hear it, we are frustrated. We went into medicine to diagnose and fix. We did not go into medicine to hand out Kleenex to sobbing patients who take up 45 minutes of office time for an imaging-results visit that was only allotted 10 minutes, when we're already behind schedule and drowning in Epic clicks (great article I recently read).
We're also simply NOT THAT GOOD AT THIS! We simply aren't therapists, and our abilities to even handle a Kleenex box are typically marginal at best. Obviously we're all different and some surgeons will be better at "wearing the therapist hat" this than others, but on the whole, empathy is a pretty lousy skill set for us. You can argue that we should work to change that, but until you figure out a way to re-wire human personality, consider me a skeptic.
These encounters also contribute heavily to burnout, a claim I base on the popular theory that burnout is a product of emotional exhaustion, depersonalization (a cynical/instrumental attitude toward others), and a sense of personal ineffectiveness. That these encounters (patient desperately wants surgery, surgeon knows it won't help them) imbue a surgeon with personal ineffectiveness and emotional exhaustion is basically a given; I'd argue they're also very depersonalizing when you consider the language we start to use to describe these patients (from "Chronic pain patient," to "malingerers," "Munchausers," and of course "TBD", "Undhier by proxy" etc)
Nevertheless, we all still need to see these patients (unless someone out there has figured out how to filter such patients out?), and we need to efficiently deal with these "tough encounters" so they don't derail the whole day. Also, theoretically it would be nice to help the patients if they are open to non-surgical help.
They key is in how you do it. You don't want to just blithely dismiss them and have them cursing you out in the waiting room. I mean, maybe you do? But you probably don't. The last thing you ever want to do in these situations is just give in and operate because the patient is begging you to (if you know it won't help).
The "sales hat" is hard to imagine wearing here. But put that surgeon's hat back on over top of it, and you can wield a powerful tool while maintaining integrity and being brutally honest. "Listen, I'm a surgeon," I've heard many say. "At the end of the day, I make money by operating. I also enjoy it. What I'm telling you is that I do not think an operation is going to help you. I could just offer you the knife, it's an easy procedure to perform, but I know you wouldn't be any better, and I could even make you worse. A surgeon is telling you that you don't need surgery - when that happens, you need to pay attention to that."
You of course need to preface or follow that up quickly with an explanation of what you think MAY help them, typically therapy, or seeing a different kind of doctor (psych?) or just giving something more time.
This is where the "sales hat" really comes into play. Instead of saying "therapy," try "A few formal sessions with a certified (insert specialty) therapist who can work directly with you, one-on-one, to try to figure out solutions and possible treatment modalities." Rather than "do nothing" or "waiting", present it as "allow the body to sort this out on its own, naturally, as it often does in situations like these." The placebo effect is a real and powerful thing, and if you can harness it to help your most difficult patients, you're doing it right.
As far as how to get through to some of the more recalcitrant patients when surgery is a bad idea... I've heard many approaches similar to this:
"There are three possible outcomes of treating this without surgery," you can start. "One, it gets worse - which is unlikely. Two, it stays the same -which is a possibility. Three, it gets better - which is also a possibility. But with surgery, my professional opinion is there's a strong possibility you won't improve. And a chance you could even be worse off. And then, an unlikely chance you'd get better. Typically, if all we did was wait, there's not much downside. But if you have surgery, and it was the wrong answer, and you got worse... we can't always un-do that."
Some add: "And furthermore, if you did get better, remember there's a reasonable chance you could've gotten better by leaving it alone also. So the only difference is a scar, pain, time off work, and hitting your annual deductible."
Then you could also mention that you would encourage them if they don't believe you, to get a second opinion. And you'd be happy to give them some names. And that probably there are surgeons out there who would offer surgery for this problem... but you'd caution against it. At the end of the day, you can only do so much. If they want to go down the street and get cut open, they will do it. You have no control over them.
It's hard. The temptation is high to just book the case anyway... "the patient is coming to a surgeon looking for answers," you might tell yourself. "They came in here wanting surgery, I can do the surgery, and if I don't do it, someone else will anyway, so what the hell, right?"
"Right?"
"...Your Honor?"
The first, and arguably less common: there is a subgroup of patients that have a bad problem, but for multiple reasons are vehemently "anti-surgery" or "anti-hospital" or are just afraid. Despite this, you as a surgeon may know that fixing their unstable fracture, releasing their trigger finger, or decompressing their irritable and unhappy nerve would improve their quality of life with a low complication risk. This is, of course, assuming the patient has failed a legitimate attempt at conservative treatment.
Even in those cases, a balanced perspective needs to be offered - patients must be educated about potential risks of surgery, ESPECIALLY (from a CYA standpoint) patients who get talked into having surgery. Imagine if a complication occurs, and they feel you "talked them into it" and didn't fully explain the risks. What could you possibly say?
If you want to know whether your explanation is sound, you might scrutinize it a lot more clearly if you preface it with "Well, Your Honor...". Not that "CYA medicine" is necessarily good medicine. But imagine how much stronger the logic probably is if your rationale was, "Well, Your Honor, the patient exhibited signs and symptoms classic for severe cervical myelopathy with high potential for irrecoverable loss of function if expedient surgical decompression was not performed, so I found it prudent to do so and after I explained the risks and benefits the patient agreed" sounds a whole lot better than, "Well, Your Honor, she was in pain and I hadn't filled my block time, so I offered her surgery."
Call it the "WYH test." Again, not that medicine should be practiced defensively, but I think this can be a useful exercise every now and then to ensure you aren't stretching indications.
There is, of course another situation in which a surgeon can justifiably act as a salesman. And I think it's more commonplace (or if it's not, it probably should be), but it's one we don't think about. It's when we need to talk the patients OUT of surgery and INTO something more conservative.
For example, I saw a patient recently who had a particular problem that, it was abundantly clear, would not improve with surgery. Her complaints were non-anatomical in nature. She was tender everywhere. Her complaints varied from visit to visit. She was witnessed in the exam room easily lifting to her mouth a fairly large soft drink using her "injured" hand that reportedly was so frail it hurt with any sort of activity. She had what some clinicians call "TBD" ("Total Body Dolor"), or "Undhier Syndrome" (it hurts hier, und hier, und hier, und hier...").
[As a side note, I have also seen cases of "Undhier by proxy" which is the simultaneously fascinating and terrifying situation in which a caregiver (usually a parent) brings the patient to multiple different specialists and talks over them, answering all the physician's questions and advocating that they need surgery (again)...]
We took her seriously, performed a full exam, even ordered advanced imaging. But it was clear that the thing she wanted most, surgery, would not help her. What she needed instead was some time, a little bit of therapy, a lot of counseling, and a healthy dose of grit. But if I simply told her that, she'd have stormed out of the room crying (she ended up crying anyway but thankfully did not storm out).
Unfortunately a lot of these patients come to a surgeon thinking they can be put to sleep for a bit and fixed, when that's simply not the case. They need to become active participants in their care and work toward healing, and set realistic expectations. Sadly, some don't seem to want to do that - they came to the doctor because they are not able and/or willing and/or interested in trying to solve their problems on their own (even with professional help) and want someone to do it for them. Something is broken inside of them, but it's not something that cold steel or sutures will fix.
Not to belittle the suffering these patients experience, but these are also painful encounters for a surgeon. Surgeons are fixers. Surgeons get to the point. We want to figure out what's wrong and propose a solution we feel will work, then implement it. When we don't know the diagnosis or know that surgery is not the answer, or when we know the diagnosis but the patient doesn't want to hear it, we are frustrated. We went into medicine to diagnose and fix. We did not go into medicine to hand out Kleenex to sobbing patients who take up 45 minutes of office time for an imaging-results visit that was only allotted 10 minutes, when we're already behind schedule and drowning in Epic clicks (great article I recently read).
We're also simply NOT THAT GOOD AT THIS! We simply aren't therapists, and our abilities to even handle a Kleenex box are typically marginal at best. Obviously we're all different and some surgeons will be better at "wearing the therapist hat" this than others, but on the whole, empathy is a pretty lousy skill set for us. You can argue that we should work to change that, but until you figure out a way to re-wire human personality, consider me a skeptic.
These encounters also contribute heavily to burnout, a claim I base on the popular theory that burnout is a product of emotional exhaustion, depersonalization (a cynical/instrumental attitude toward others), and a sense of personal ineffectiveness. That these encounters (patient desperately wants surgery, surgeon knows it won't help them) imbue a surgeon with personal ineffectiveness and emotional exhaustion is basically a given; I'd argue they're also very depersonalizing when you consider the language we start to use to describe these patients (from "Chronic pain patient," to "malingerers," "Munchausers," and of course "TBD", "Undhier by proxy" etc)
Nevertheless, we all still need to see these patients (unless someone out there has figured out how to filter such patients out?), and we need to efficiently deal with these "tough encounters" so they don't derail the whole day. Also, theoretically it would be nice to help the patients if they are open to non-surgical help.
They key is in how you do it. You don't want to just blithely dismiss them and have them cursing you out in the waiting room. I mean, maybe you do? But you probably don't. The last thing you ever want to do in these situations is just give in and operate because the patient is begging you to (if you know it won't help).
The "sales hat" is hard to imagine wearing here. But put that surgeon's hat back on over top of it, and you can wield a powerful tool while maintaining integrity and being brutally honest. "Listen, I'm a surgeon," I've heard many say. "At the end of the day, I make money by operating. I also enjoy it. What I'm telling you is that I do not think an operation is going to help you. I could just offer you the knife, it's an easy procedure to perform, but I know you wouldn't be any better, and I could even make you worse. A surgeon is telling you that you don't need surgery - when that happens, you need to pay attention to that."
You of course need to preface or follow that up quickly with an explanation of what you think MAY help them, typically therapy, or seeing a different kind of doctor (psych?) or just giving something more time.
This is where the "sales hat" really comes into play. Instead of saying "therapy," try "A few formal sessions with a certified (insert specialty) therapist who can work directly with you, one-on-one, to try to figure out solutions and possible treatment modalities." Rather than "do nothing" or "waiting", present it as "allow the body to sort this out on its own, naturally, as it often does in situations like these." The placebo effect is a real and powerful thing, and if you can harness it to help your most difficult patients, you're doing it right.
As far as how to get through to some of the more recalcitrant patients when surgery is a bad idea... I've heard many approaches similar to this:
"There are three possible outcomes of treating this without surgery," you can start. "One, it gets worse - which is unlikely. Two, it stays the same -which is a possibility. Three, it gets better - which is also a possibility. But with surgery, my professional opinion is there's a strong possibility you won't improve. And a chance you could even be worse off. And then, an unlikely chance you'd get better. Typically, if all we did was wait, there's not much downside. But if you have surgery, and it was the wrong answer, and you got worse... we can't always un-do that."
Some add: "And furthermore, if you did get better, remember there's a reasonable chance you could've gotten better by leaving it alone also. So the only difference is a scar, pain, time off work, and hitting your annual deductible."
Then you could also mention that you would encourage them if they don't believe you, to get a second opinion. And you'd be happy to give them some names. And that probably there are surgeons out there who would offer surgery for this problem... but you'd caution against it. At the end of the day, you can only do so much. If they want to go down the street and get cut open, they will do it. You have no control over them.
It's hard. The temptation is high to just book the case anyway... "the patient is coming to a surgeon looking for answers," you might tell yourself. "They came in here wanting surgery, I can do the surgery, and if I don't do it, someone else will anyway, so what the hell, right?"
"Right?"
"...Your Honor?"
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