Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

It's a Red Flag: Walk Away

As I sit writing this blog I can't get the lyrics of Kenny Roger's song, The Gambler, out of my head:

You've gotta know when to hold ‘em
Know when to fold 'em
Know when to walk away
Know when to run….

I had an experience this past week that made me want to run away. I'll tell my story mostly as a warning to all those young, fresh-out-in-practice podiatric surgeons who want to cut everything they see. I've seen too many patients in my short five years of practice that have undergone surgery who, for one reason or another, should never have been touched with a blade. Don't be that surgeon.

Tonight's Premier Lecture is
Emergency Care in the
Practice of Podiatry
by Adam Thau, MD

Ok, here we go.

I was covering clinic the other day at one of our affiliated county hospitals. My student presented a 40-something year-old female patient with rheumatoid arthritis who wanted to have her left forefoot reconstructed due to chronic pain in the forefoot (your typical forefoot RA pain and deformity). She'd had a prior triple arthrodesis on the right side by a local orthopedist and was doing reasonably well on that side. Her left foot, she related, had become increasingly painful and wanted surgical treatment, since shoes didn't help. She had no history of ulceration or infection.

Sounds pretty standard so far, but this is where the train falls off the tracks.

As I started asking more questions, I found out a couple of potentially significant details. For example, the patient lived completely alone two hours away from the hospital. She had no friends that could help her postoperatively. She was on a number of medications for her rheumatoid arthritis and sundry other medical issues.

The train then not only went off the rails, but exploded when we started discussing my concerns. When I mentioned that I would speak with her rheumatologist, she became frustrated. She complained that she'd had this problem for years and was tired of waiting. She didn't understand why I would have a problem with her lack of personal postoperative support. My response was that I had concerns about complications after the surgery. What possible complications would there be? she asked flippantly. I could have mentioned any of a number of complications that would have been worsened by her lack of support, but responded with the worst case scenario: "You could have a blood clot in your leg that could go to your lung and kill you." Unfortunately, she had no response at all to this. Instead, she continued to complain about her situation, clearly demonstrating a sense of entitlement that added insult to injury. I argued that I would want to get to know her better and that it would be a crazy doctor who does elective surgery on a patient that he doesn't know. What do you need to know? she asked. Clearly her sense of reality and mine were completely divergent.

I recommended she see someone else for another opinion. I shook her hand and wished her all the best with her future treatment. I remained professional but firm during our confrontation, but of course left frustrated. But imagine how I'd have felt when she shows up for her postoperative appointment with a ballooned-out foot due to cellulitis, fixation popping out of her skin, and a nonunion. The patient doesn't like me, but at least I'll sleep well. Besides, what patient wants a doctor they can bully into doing surgery on them?

I've personally learned this lesson the hard way in some cases, and if there's one thing I hope my experience teaches anyone, it is to evaluate your patients carefully. Some patients require surgery no matter what. Think of the acute trauma patient. In others, though, especially the elective cases, you as the surgeon have the choice. Before you do surgery, ask yourself one question: is this patient a safe surgical candidate? If for some reason - medical, psychosocial, or otherwise — you can't answer with a clear "yes," then walk away. Politely explain your concerns and offer to send the patient to another physician. You'll be happy with your forethought. Know when to walk away, know when to run.

What do you think? Have you had a similar experience? How do you decide which patients are poor surgical candidates?