The name trickled through my head for a minute. I couldn’t quite place her at first — then something caught.
“She have really pale skin and dark red hair?”
“Yes, that’s her!”
My awesome PA was grinning away; now she knew she could go back to her patient with the comforting thought that her doctor was coming to see her — a nice thing for a lonely old lady in the new world of Daily Care Teams and hospitalists-du-jour.
Victoria*, a patient from years before had been admitted through our Emergency Room, unable to walk. They had made darn sure she didn’t have a broken hip, CT scanned everything they could, then put her upstairs in a bed on the medical service, awaiting “placement.” The medical people had a pretty good idea what was going on; Victoria had arthritis — of her spine, her hips and especially her knees. And it had finally caught up with her; she just couldn’t walk because of the pain. But it was unlikely they would permit her to have the orthopedic surgery she needed to fix it — not at this point anyway, anymore.
Much experience has shown that it’s just not a great idea to do total knees on patients who come in through the ER. There usually are many other things going on with them that makes their post-op course long and dangerous. And expensive. Generally way more expensive than the one-lump-sum of money that Medicare gives the hospital when “Knee Replacement” pops up on the billing record. This isn’t written anywhere but everybody knows it.
I stifled the sinking feeling of having to give the dreary speech again. It’s the one we give patients we’ve told to have a joint replacement, again and again, but who were too scared of the operation, and then, when they are fully incapacitated, like Victoria, and ask for the surgery, are too sick, or too old, to have it. It’s basically “You had your chance but I can’t really help you anymore, sorry.”
She was surprisingly ok with it. Her mood, in fact, was quite bright for someone stuck in a hospital bed, finding out that she wasn’t going to take more than a few steps, with a walker, ever again. I looked her up on the computer. Not that sick, really. Her labs were ok, her knees were terrible, as was her back, but the rest looked well enough for a total knee. Some, (maybe most) of her pain was related to her spine — an enormous and oft unspoken issue in the world of knee replacements — but, bottom line, if this lady had fallen and broken her hip we certainly would fix it. And that operation poses about the same level of risk as a knee replacement. So — if you would let me fix her hip to keep her walking, how about giving me medical clearance for a total knee? But something kept me from saying this to the medical people.
Anosognosia. That was what Steve, the neurologist who came to see her, called it. It’s something like not being able to recognize or acknowledge one’s own illness. One of the smartest docs I have known, he gave me and our PA’s a perfect little 5 minute lecture on it in the doctors’ lounge. The big danger with it is falls; patients just don’t register “I can’t walk anymore,” so they get up, head for the bathroom and crash. It’s classic for schizophrenia but he had seen it with strokes. Hmm. So we looked at her head CT again. And there it was.
Some little arteries to a small, but important part of Victoria's brain had quietly clotted off. No paralysis, no slurred speech, only this odd little disability, not quite “getting” that your knees don’t work. This would have been the “something” that made getting over a knee replacement much harder, longer and more expensive. The stroke might actually have been the reason why she had landed in the ER in the first place; we couldn’t tell when it had occurred. But it was one of those reasons why it would have been messy and expensive post-op, and we had now found it pre-op, so there would be no-op.
A lot of big questions swirl around cases like Victoria’s. How hard to push elective surgery on people approaching “too old” age? To what degree should the financial risk to your hospital or medical risk to your patients cause you to withhold otherwise beneficial treatment? And should you even try to fix a problem for a patient who can’t understand what’s wrong? Answering big questions like these takes everything a doctor has; education, experience, emotional involvement, interaction with other docs — effort in other words. And lots of (unreimbursed) time.
There is no one who can take this job off our hands — though some try. “Forget the philosophy and leave big issues to us” is often the message we get from hospital administrations. “You just keep punching those codes into our computers and we’ll make rules to use when it gets complicated. We’ll form committees, have meetings and give you guidelines.”
Don’t buy it. Victoria’s case, like many others, was complicated, and took many specialties to close, but it made one thing clear; you can be too old for a new knee. How old? That’s one of the hard question that only doctors can answer well. As streamlined and efficient as our practices get, good clinical medicine remains a time-consuming, ideological and very personal business.
Scott Haig has been an Assistant Professor of Orthopedic Surgery at Columbia University for over 20 years. He has written extensively for Time magazine, published two professional books and has taught classes in Old and New Testament Studies since 1994. He remains in full-time private practice. He is a 2018–2019 Doximity Author. All patient names have been changed for patient confidentiality.