What To Do With Those Patients Who Weigh On Your Mind

Those of you who follow my blogs know that I usually write on an educational topic, typically surgery. This time, I think I will lament about some of the stresses and difficulties of our job.

Recently, in the same week, I had two longtime patients come in and ask if I could do a below-the-knee amputation for them. Obviously, they think I can do that because in their minds, I am a general “do it all” surgeon. Of course, I have to tell them I can’t do that and would have to refer them to an orthopedic surgeon to do the amputation. They were disappointed because they only wanted me working on them.

The first patient is a 40-something guy on whom I tried twice to do an ankle fusion, which failed. He has diabetes and Charcot-Marie-Tooth disease. He developed non-unions and ultimately had Charcot breakdown. Certainly, I gave him the option of another fusion attempt. He had enough and was looking forward to an amputation.

The second patient was a 30-something female who developed an aggressive hemangioma of the intrinsic muscles of the plantar foot. I removed it and it came back. I removed it again and it came back. She went somewhere else to have a third surgery by another surgeon and the hemangioma ultimately came back. She did not want to try again, and was adamant about getting rid of it once and for all.

These are tough cases that make you feel like a failure but sometimes you just cannot fix everything. Sometimes, you do the best you can and it just does not work.

For example, I have a patient who had a severely deformed foot from rheumatoid arthritis. He could barely walk and had bones literally popping through the bottom of the foot. I did a first metatarsophalangeal joint fusion, lesser metatarsal head resection and hammertoe repair of the second through fifth toes. This was standard stuff for his condition. Anyway, he still has some pain and is determined to find out why. He is seeing everybody in town for an opinion. He calls almost daily to tell me that “Dr. X” said I cut the bone wrong or “Dr. Y” said you probably cut a nerve, and so on.

The bottom line is that even though we are not typically dealing with life or death medical care, our jobs are demanding and stressful. If you are like me, you take everything that you do to heart. It is difficult to tell a patient there is nothing that you can do for him or her, or you did the best you could and this is the end of the road.

We have a few foot and ankle orthopods in town and I see some of their patients as I am sure they see mine. I always chuckle inside when the patient tells me her orthopedic surgeon told her he “did excellent surgery and you don’t need me any more.” The patient replies, “But doctor, I still have pain,” and the orthopod’s answer is, “You will need to see a pain management physician. Here is his card.”

I do not know if I could ever pull that off but maybe there is something I should learn from that.

I call it the “Rule of Five.” At any one time in your practicing career, you will probably have five patients who are weighing on your mind. Maybe it is a postoperative infection, a non-union, Charcot arthropathy following a “simple” procedure or even a run of the mill ingrown toenail that is not healing after a matrixectomy. It is rare that the Rule of Five is not in effect. When it is, this is a time to celebrate. When things are going great, patients love you, you can do no wrong, you are the hero and the day flies by because everybody is having fun.

Then it becomes the “Crazy Train” phenomenon. Your good times are about to derail. Another problem, complication and/or stressful situation is just around the turn. We just have to face it. That is the nature of our jobs.

Sometimes the best advice is from Kenny Rogers: “You got to know when to hold ‘em (and) know when to fold ‘em.”