Why Surgery Is A Bad Wager For Some Patients

Slowly swirling the amber liquid in the crystal glass, with the nearly non-viscous fluid gracing the edges, I found myself turning inward, becoming increasing contemplative. As the liquid, provided “free” while I sat at the roulette wheel, enveloped the melting ice, I found myself wondering why we as surgeons have not been able to figure out how to game the odds like those savvy dudes who run the place where I happened to be being gamed myself — Vegas. Really, those Vegas cats know how to manipulate outcomes so they always come out on top.

“Who loves ya, baby?” I’ll tell you who loves you. Vegas loves you. In fact, they love anyone with a heartbeat and an open line of credit. They especially love those who have a hot nucleus accumbens. (If you don’t get that one, start looking up psychological studies on gambling.) The folks at Vegas know so much about human behavior that collectively, they may be the most esteemed psychological institute in the world.

As surgeons, we really don’t know that much about the human psyche. We may know the human body but fixing that is easy compared to trying to figure out what happens between the ears of our patients. That is where the “game” is really played. I do know that after spending time with the folks at Painweek, maybe the world’s largest multidisciplinary pain management meeting in the world, I know a lot more and I think I may just be able to start running my own little Vegas-style “surgicino.”

What do I mean by this? Outcomes, baby! (For those of you old enough, picture Telly Savalas as Kojak sitting with us at the bar having this discussion. I know he died in 1994 but for blogging sake, just pretend, will you?)

So I am sitting there swirling my honey bourbon when along comes a follow surgeon who happened to look just like Kojak. He also happened to be a general surgeon who specializes in pelvic pain—a world-renowned one in fact. (Out of 2,000-plus attendees, there was only one podiatrist registered (me) so my chances of meeting up with one of my brethren to discuss these incredible “knowledge nuggets” that were blasted through our craniums like asteroids burning their way toward earth, ultimately becoming imbedded into our cortices, was pretty small.)

Dr. Kojak, who apparently had zero regard for my contemplative state, immediately started engaging me in conversation. Savoring the downslide of my last sip and sucking up my desire to decompress, I gave him my full attention (as much as a card-carrying ADHD sufferer can at least). As being a nerve surgeon is my primary passion, I knew I would glean some translatable information from his pudendal arena to my pedal one.

“The biggest mistake I made early in my career is that I truly believed that I could help every patient,” Dr. K whispered to me while looking around to see if anyone was listening to our conversation. The paranoia was a bit unnerving. It’s not like this was CIA stuff or anything. He stepped on the words that were about to come out of my mouth.

“You just can’t and never will. But the hard part is that we have it in our core to do just that. We do what we do to help even those who don’t want help.”

“Amen to that,” I told my bald-pated comrade.

Dr. Kojak slid on his bar stool a little closer — to the point where he was now violating my physical comfort space — and his breath reeked of a Cuban that probably had been stashed away for decades in a closet growing some type of toxic brown mold. “You want the scoop, dude?” he smiled demonically.

Now I’ll admit I did want the “scoop.” (I thought about replying to him by saying, “give me the dope” but I was damned sure he would have pulled out a syringe and plunged it into my jugular.) I capitulated. “Okay, I’m all ears.” (That was a lie as I had some dilated and offended nostrils from the tobacco stench.) “Enlighten me.”

“You want to game the system? Here’s how.” Dr. Kojak was on a roll now. His eyes were wide and words were eloquently flowing out of his mouth like he was reading a teleprompter.

“First, how long have they complained about their problem? It is well known that higher levels of preoperative pain are more likely to have higher levels of postoperative pain. If they catastrophize, punt them and punt them quick.” Dr. Kojak pulled no politically correct punches. “If it is a long time, then that’s a huge warning sign, and if they magnify the symptoms, magnify the words, ‘I’m sorry. I just can’t help you’ on your way out the clinic room door.”

Finally backing his mug away from mine, he continued. “Second, have they had surgery(ies) in the same spot you are thinking about going into again?” Dr. K smiled as if this never occurred in many of our cases. “Fibrosis begets fibrosis, and fibrosis begets atherosclerotic plaque in the coronaries of the surgeon.”

This was becoming really fascinating. “Next thing you have to ask yourself as a surgeon is how invasive is the planned surgery? If you can plan something minimally invasive, do it and don’t look back if it will do the job. Unlike Christmas time with the kids and family, less is more. Much better odds for sure.”

“That makes sense,” I said to myself. “Give me some more,” I implored.

“If they smoke and have a big BMI, run like the plague,” he said. I got the smoking part but so what if they liked big German cars?

Recognizing Red Flags In Patients Seeking Surgery

So what are we to make of this conversation as surgeons? First, there is no way we can effectively treat everyone and that the ultimate outcome is decided in the patient’s cortex. From a surgeon perspective, it can be the most eloquently performed surgical case from A to Z, but if there is something that the patient does not like, for whatever reason, we have failed.

Take for example a patient I saw recently. She had a very straightforward nerve entrapment, which I knew I could easily decompress in my sleep (very assuredly in hers with anesthesia). I eliminated 100 percent of her pain with a simple diagnostic lidocaine block. Voila! It was a no brainer. Decompress the nerve and gain a victory for the patient and the surgeon.

Hold on, folks. Maybe it was not so simple. I come to find out I was the 25th doctor she had consulted. No red flag there, right? Then after spending a good chunk of time explaining the surgery, perioperative management and what was involved, she asked me if I would answer one more question. Feeling pretty confident and good about my potential to truly help this patient, I replied, “Of course,” even as I was making my way out the door of the treatment room.

She said, “When will I be able to go back to my full-time employment, which requires 12 hours straight on my feet, six days a week?”

My head rotated faster than one of those anorexic figure skaters doing a spin that would blow out any normal cochlea and I had to fight back an external Tourette’s syndrome. Politely, I explained that she should go see doctor #26 as there was no way I could or would help her.

Now the fact is, folks, if you got into medicine for the same reason most of us did, to help people and make a decent living doing it, it’s hard to “just say no,” when you know that you have a solution. However, as the saying goes, “you can only help people that want to be helped.” I will take it a bit further and add “and are willing to but with a modicum of effort themselves.” As for me, dear brethren, I would rather spend my time stacking the deck than rolling the dice.

Pure and simple, just as Vegas has taught me. I couldn’t win that one so why place a wager?



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