When You Have To Veto Elective Surgery

I always like to spend a few minutes getting acquainted with patients who are new to my practice. I start by reading the face sheet on the chart before entering the examination room. This tells me where the patient lives and works, and the reason for the visit. It also lets me know about the patient’s general health. A new patient came to my office a few months ago. The chart told me she was 46 years old, had come from a town about 70 miles from my clinic and had bunions. Most of the medical questions were left blank. It was obvious she didn’t like filling out forms. I don’t either so we had something in common. She was reading People magazine when I entered the room and didn’t seem inclined to put it down right away. She kept turning pages and concentrated on the magazine so I decided to skip the introductory chat. I asked, “How can I help you today?” She turned another page and said, “You tell me. You’re the doctor.” This response from a patient always brightens my day. She finally put the magazine down and snarled, “I want these bunions taken off as soon as possible. My insurance runs out next month.” She opened People again and started thumbing through pages. There was a strong odor of cigarette smoke on her clothing. Her bunions were the smallest thing about her. She must have weighed nearly 300 pounds. I have learned over the years that an obese cigarette smoker is a deep venous thrombosis (DVT) waiting to happen after foot surgery. I asked how she happened to come to me. There were a dozen good foot and ankle surgeons between my clinic and her town. “You were on the list my insurance company gave me.” She went back to the magazine. I went through the neurovascular and biomechanical exam while she looked at the pictures. “My assistant is going to get some X-rays of your feet,” I explained. “Why?” she growled. “You can see I’ve got bunions and I want ‘em off.” To a new young foot surgeon, this case would seem like a slam-dunk. The patient had good insurance and was demanding a procedure. To an old guy like me, a lot of caution flags were flying. The patient had bypassed a lot of good surgeons to come to a small town for no apparent reason. She didn’t share much of her health history and was an overweight smoker. I knew there was no way she would end up on my surgery schedule. I value my career and her life too much. The X-rays showed minimal deformity and no sign of a bunion. I pointed that out to her. Her complexion went from red to purple and she got mad. “I demand to know why you aren’t willing to fix my bunions,” she said. “My mother had hers done and they turned out perfect.” I explained her feet were almost normal and the surgery wasn’t indicated. I also explained she would be a high risk for complications due to her weight and smoking. This really set her off. “You’re discriminating against me because I’m big and smoke cigarettes,” she said. “I’m going to report you to the medical board.” “It’s the podiatry board, ma’am, and I’ll give you the phone number,” I responded. “Be sure and spell my name right.” She continued to rant about her right to have bunion surgery and told me I was just as dumb as the other four podiatrists she had seen recently. None of them would schedule surgery for her either. This made me feel good about my colleagues. I calmed her down and explained the dangers of DVT and complications in healing we see with overweight smokers. I also explained we like to try conservative non-surgical treatment before operating on any patient. I also explained elective surgery is a two-sided issue. She can elect to have it done or not and I can elect to do it or not. I decided to end the visit on a positive note. I said, “Let’s get together and evaluate your bunions next fall. I would like you to try to lose some weight and to become a non-smoker.” She seemed to soften a bit and told me she would try on both issues. I said I looked forward to our next visit and started out of the room. There was another person in the room during the visit. The patient’s 14-year-old daughter looked up at me and quietly said, “Thanks.” Dr. McCord (pictured) is a Diplomate wtih the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.