When A Patient Pursues Surgery With Another Surgeon

William Fishco DPM FACFAS

I received a phone call from a colleague, who was upset because a patient whom he worked up for surgery went somewhere else to have the surgery done. He happened to be in the hospital where he saw his patient’s name on the surgery scheduling board having surgery with another surgeon.

I hear this type of scenario all of the time (and it is not just with podiatry). It sort of goes like this … I evaluated the patient and her X-rays. I recommended surgery with six weeks of non-weightbearing postoperatively. The patient went somewhere else where the surgeon said, “I can do the surgery so you do not have to be non-weightbearing after surgery.”

We all know that the hardest part of recovery from foot surgery is a lengthy non-weightbearing period. The pain from surgery is just about gone in a week but six weeks of negotiating crutches or being in a wheelchair is really tough. If I were a layperson and I were in a similar position, why would I not choose to have the surgeon perform the procedure that would seemingly make it easier for me?

After all, in its day, that was what the big hoopla was all about with the endoscopic plantar fasciotomy, right? Who would turn down Band-Aid surgery, which would allow you to walk out of the surgery center in your sneakers? So if the endoscopic plantar fasciotomy is superior to all other surgical treatments for plantar fasciitis, why aren’t all foot surgeons choosing that technique for surgical treatment of plantar fasciitis?

Listening To Your Gut Instincts When Recommending Surgery

I am going to share with you what I told my colleague and what I would tell you in a similar circumstance.

1. If you thoroughly explain to your patient why you recommend a non-weightbearing procedure (such as a base wedge osteotomy or Lapidus fusion for bunion surgery) and all the patient hears is “non-weightbearing for six weeks, blah-blah, blah-blah, blah-blah,” you really do not want that patient in your practice. You also do not want to operate on that patient who will be challenging you or who simply will not listen to you.

2. In bunion surgery, for example, what is your most common self-criticism that you have postoperatively? Is it the scar? No. Is it overcorrection? No. Is it your screw or pin placement or fixation strength? No. Is it undercorrection? Yes.

We all feel like we could have attained better correction in some fashion for whatever reason. Maybe the toe is still leaning towards the second toe or the toe is not straight enough. Maybe there is some residual bump left or maybe you could have had a little more intermetatarsal angle correction.

What is the bottom line? If you are compromising on the procedure selection for your bunionectomy (or other surgical procedure) so your patient can walk on it afterward, then you are just creating problems down the road for you and your patient. Getting a perfect result is hard enough when you select and properly execute the appropriate surgery.

3. You are the boss. Pick your battles. Don’t be bullied and don’t settle. You do not need the case that badly. You are busy enough. Is it really worth getting upset over the lousy $500 that you would get reimbursed for that surgery? Do not let patients tell you what they want or need. You are not forcing anybody to have surgery. Your job is to evaluate patients, tell them what is wrong and give them options to address it. Your patient has every right to get other opinions and frankly, I encourage it. A patient who has more information and truly understands what you are recommending will be a more complaint patient.

4. I am sure you all have had patients come back to you after surgery elsewhere. More often than not, they are back in your office because they were not happy with their results or the way they were treated in some fashion. Otherwise, why would they come back to you? This is a case in point that if you do the right thing for the right reason, you will always be busy and successful in practice. Remember that you cannot afford to get less than desirable results because in this business, your reputation means everything.

When Referring The Patient Is Not A Bad Idea

5. E. Dalton McGlamry, DPM, always said, “If all you have is a hammer, then everything is a nail.” My advice to my colleagues is that if you do not do a particular procedure that you feel is in the best interest for your patient, then either learn how to do the technique or refer it to someone who does. Personally, I do not do arthroscopic surgery because I was never trained to do it. Frankly, I do not want to learn and experiment on my patients. When I have a patient who would benefit from ankle arthroscopy more so than an open arthrotomy, I refer it to a colleague who is capable of doing a good job.

Another example that I see with a fair amount of frequency is with heel pain. Every year, I will evaluate about six failed endoscopic plantar fasciotomies for the treatment of heel pain. After I examine these patients, more often than not, there is obvious nerve entrapment of the first branch of the lateral plantar nerve. I personally do not know if the other surgeons do not know how to do the nerve decompression technique with the plantar fasciotomy or they do not know how to assess for nerve entrapment. Obviously, if you are getting failures, you need to figure out why and change what you are doing.

Final Notes

I hope this information helps you. I just felt compelled to write about this because it is so commonplace that I hear scenarios just like this from my colleagues from all over the country.

Just remember that you are the boss and you ultimately have the final say in what treatment the patient should have. Just because you “can” do surgery does not mean you have to. Let’s face it. Most of what we do is elective surgery. So use all of your experiences with your knowledge of patient management, surgical outcomes and, probably most of all, your “gut” instincts to give you direction

Comments

Nice article and insight. Could not agree more.

Funny, the endoscopic people claim 90-95% success. Like you, I see a lot of the remaining 5-10%, ALL WITH NERVE ENTRAPMENT.

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