Balancing Our Hippocratic Oath With Risk Management Concerns In Problematic Patients

Stephen Barrett DPM FACFAS

There is no surgeon who would not readily agree there is nothing more important than a great patient outcome. Call it that “karmic euphoric goodie” of receiving thanks — sometimes unspoken but powerfully demonstrated — from patients by seeing them relieved of the condition for which they sought your expertise.

In talking with my colleagues over the years, the discussion will often focus on the fact that the best surgery for that problem patient would have simply been not to do the surgery in the first place. Easier said than done. Imagine yourself sitting in the treatment room, facing the patient and saying, “I’m sorry. I just don’t feel comfortable operating on you. Your mindset will not permit the optimal outcome." This is difficult and sometimes humanly impossible for people of our emotional ilk.

As surgeons, we feed off the ability to help our patients by relieving their pain and improving their function. Put most of us on the shrink’s long black couch in a poorly lit room and strip off that veneer of the politically correct surgeon psychobabble rhetoric that spews forth from us reflexively and the truth will come out. The therapist would likely find that the core of our being is ultimately altruistic and in many, if not most, cases runs counter to pragmatism, rational risk management and surgical decision making.

Well, what if we could increase our pragmatism (think risk management here) and stack the odds in our corner? Vegas does it. So do insurance companies as they have actuaries to calculate the odds very precisely of damn near everything. Combine that with the pool of premium payers and you can see why the insurance business for the most part has been remarkably successful for the stockholder over the last 200 years. Then when insurance companies do have that occasional technical snafu, the government bails them out.

What if we could get some “actuaries” on our side? These would be wise, experienced, graybeard soothsayers whispering in our ears through our wireless Bluetooths, who can tell us when and when not to take that questionable patient to the OR. The voice might say “Don’t accept her as a patient, you sucker!” or “No, you can’t because of the fibromyalgia or the depression, stupid.”

Now hearing the little voice resonating louder in your fuzzy noggin, you are looking around the ceiling of the treatment room, wondering why the air vent suddenly is morphing into a replica of cell bars from San Quentin and they are closing in on you.

“Look at the chart, dude,” says the soothsayer. “She is a worker’s compensation patient and she has a lawyer. Be careful.”

“Hey, soothsayer,” you reply back in mental sotto voce, “This one is a no brainer. I can make her better, much better. This is a simple problem.”

You never hear the final answer from the soothsayer as you are filling out the surgery scheduling form. “No you can’t. She doesn’t gain by getting better.” It is my opinion that despite all our carefulness in surgical planning, complex treatment plan decision making, ad nauseam preoperative patient counseling, and any other variable of surgical risk management, nothing supersedes their mindset. If the patient has something to gain by not getting better (longer time off work, sympathy from the inattentive husband, larger settlement) no matter what you do surgically, they aren’t getting better.

Pertinent Insights On Pinpointing The Source Of Pain (If There Is One)

Now here are some nuggets that can help you listen better when the soothsayer speaks.

In a recent guest editorial in Practical Pain Management, Dr. Sarkozi writes about fibromyalgia and the fallacy of believing that pain can come from nowhere.1 He eloquently contends — and I believe he is right — that pain has to have some peripheral etiology such as degenerative joint disease, ligamentous injury, fasciitis, peripheral nerve injury or entrapment, or maybe a combination of some or all of the above. I can now see your cerebral gears churning out the list of names of your surgical patients who had the diagnosis of fibromyalgia and you are wishing you had paid attention to that little voice in the Bluetooth.

Guess what? According to Sarkozi, 91 percent of patients who present to your office with the diagnosis of fibromyalgia do not have fibromyalgia.1 You really should read this article. It will give you a much better insight into how to appropriately manage and perform needed surgical intervention in these patients. In fact, I think we all should read this informative publication, as there is something great for the lower extremity surgeon every month.

So what is the point here? There are buzzwords or phrases that have been ingrained into our “computers” when it comes to patients for whom we should avoid performing surgery. These buzzwords or phrases may include “fibromyalgic,” “patient on antidepressants” and “those in litigation or seeking worker’s compensation.“ However, there are many folks we can still help who have been mistakenly categorized or mislabeled. Now the difficulty factor has reached exponential heights in regard to balancing risk management with our Hippocratic Oath. How do we pull off this delicate balancing act?

First, spend time with the patients in the preoperative phase. Look at the patient’s facial expression while you are examining or talking with him or her. Does the patient only “flinch” when you ask him or her if it hurts in a certain area? What does the patient do when he or she is distracted by discussion while you are pressing on the same vital area of “pathology”?

Does the patient hurt everywhere to the same level? Recently, I had a patient who presented with extreme incision pain, which she graded pain with palpation the same in three different surgical sites. Really, do I have to believe that all of the sites hurt exactly the same? Couldn’t one hurt a little less? Did the patient have to report all the surgical sites as being over the top in terms of pain? Last week, the patient had no pain and was doing well. This week, the benefits stopped and the patient had to go back to work. It is funny how this works.

Second, if things do not seem right, see the patient at another time and listen to your “gut.” It is often right. What is the patient’s presentation like this time? Look at the use of diagnostic lidocaine blocks as your best friend in these nebulous cases. If you are able to relieve the patient’s pain with a focused infiltration, then you have an important diagnostic indicator, which may help you decide to operate on that patient. This is strongly indicative of a true peripheral pain generator and not centrally mediated sensitization.

If you have a real squirrelly patient, have the patient back for a confirmation diagnostic block and use bacteriostatic saline. Now you are dialing in on the pain generator.

Even though Dr. Sarkozi has demonstrated in detail that pain has to come from a peripheral generator(s), if the prefrontal cortex has ideations of tropical beaches with cool, umbrella-adorned adult libations only to be interrupted by the monthly journey to the mailbox to collect the “benefits” check, that pain level “3” in the patient without secondary gain is a “10” in our postoperative problem child.1

Finally, keep reading and learning all you can about the central nervous system, psychology, social interaction and anything you can dig up that deals with personality types and disorders.

In Conclusion

We manage a lot of patients with chronic pain and make most of them better. However, don’t hesitate to call in the psychiatrist, pain management physician and rheumatologist. Enlist a team because there are many sad patients who are not being treated because they have been poorly or inaccurately labeled, and unfairly so many times. This is such a complex topic that in order to digest even a small morsel of it would require years of mastication.


1. Sarkozi J. Fibromyalgia, chronic widespread pain, and the fallacy of pain from nowhere. Practical Pain Management. 2011; 11(1):74-77.

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