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When a Doctor is Like a Relief Pitcher

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I recently saw a post on a social networking site from a surgeon titled, "How Often Are Surgeons Performing Sham Surgery?"

It was a case report of a patient who had a diagnosis and attempted treatment for a nerve entrapment that required a revision surgery. At the time of revision, it did not appear that the nerve had been previously decompressed at the first procedure. The author questioned the primary surgeon's motivation for not referring the patient elsewhere and invited feedback.

I found myself questioning the motivation in posting this type of piece in a very public forum. It wasn't to stimulate an academic discussion about the technical challenges of the procedure. It wasn't to talk about the placebo effect in surgery, the research applications of actual sham surgery, or the need to ensure and maintain competency. It was about being the hero, saving the day, and bragging about it.

I learned about this in a parking lot once. It was New Year's Eve, and I wanted to be home already.

It was dark. A woman was coming across the wet pavement waving her arms. She wanted to give me a hug. I didn't know why. I had just amputated her husband's leg.

The story was convoluted and meandering, but he had a blood clot in his leg and was on a blood thinner that paradoxically led to him having more clot which slowly cut off the circulation to his leg. He had called into the clinic a few days before saying that his leg was more swollen but was told to just keep an eye on it. He showed up at the ER several days later because it had gotten worse, but it appeared perfused and he was sent home. He came back the next day, and the leg was much worse; it was hugely swollen, and the foot was cool. The ER called up to the office.

I had just finished the afternoon clinic and it was about time to go home. This only happens at the end of the day.

In the end, all the king's horses and all the king's men were not able to reperfuse his leg again. Over the next several weeks he came to terms with the inevitable and was prepared for the eventuality of an amputation. 

Of all the things we do in orthopedics, amputation is one of the hardest because the psychological impact on the patient and the surgeon is something you never really get used to even if you do it a lot – and I don't. Most of the time, patients know deep down when a leg should be removed. It is infected, has a tumor, or has lost blood flow and is dead. But still, we lament the loss of a leg because if locomotion is freedom then amputation implies imprisonment. In the case of arms our hands represent expression and without them, we somehow lose our voice. 

But that day in the parking lot, his wife gave me the best compliments on my focused, calm, demeanor and my willingness to do what needed to be done. While I appreciated her kind words, I knew that I could not claim credit for her relief. It made me uncomfortable to accept her praises knowing that I had done my duty competently but not exceptionally.

I realized there, in the rain, that it was not about me. I was not the hero who stepped in and saved the day. But when things go badly it is often the second one on the scene that plays the role of the hero. As in baseball, the reliever who gets credit for the save while the starter who flagged in late innings is doubted. It's not completely clear in medicine, it rarely is, that one thing caused the next. In this case, there were things that could have been done better along the way, but once they were bad and the patient knows they are bad, it is the next person who steps in who appears to turn the tide. 

As humans, we subconsciously trend our lives all the time. For that patient, the moment I walked in and we made the decision to amputate was when things started to get better. Somehow humans are incredibly skilled at blinding ourselves to how bad things have gotten. Maybe this is protective. It helps us cope with living life where we are. Somehow, intrinsically, he knew that the leg was not coming back and so as it were, I was doing something good by removing it. 

I don't know if that relationship can ever be had by the first doctor. He will forever be associated with a downward spiral and I don't think he or she ever gets a fair chance to change that image. It is just how the mind must reconcile these weighty matters.  Regardless of the circumstances, we have to create a narrative for the dramatic events in life, and in each story, there is a good guy and a bad guy.

Sometimes the patients with the worst outcomes can be the happiest. Whether it's a neglected suprascapular nerve compression or an amputation. But in desperate cases, what patients really want is the end of something, the end of waiting, the end of suffering, the start of healing.

Sometimes we are lucky enough to wear the white hat and the white coat.

Brian Gilmer, MD is an orthopedic surgeon in Mammoth Lakes, CA. He is a 2018–2019 Doximity Author.

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