Navigating The Nuances Of Risk Management

I used to play a game called Risk with a group of friends during the early years of my practice. We would gather at somebody’s home or office, bring pizza and beer, and start the game. Risk is a game where you try to conquer the world with little plastic armies, using dice and strategy to gain continents and countries. As the night wore on and the beer and pizza were ingested or thrown at other players, our “risk” tolerance grew. A strategy I enjoyed was irritating another player by slinging insults about his profession and then conquering his countries. My friends/opponents returned the favor by making disparaging remarks about podiatrists that often caused me to lose a few countries. If I believed I was going to lose, I would form alliances with other losers to take out at least one possible winner. This scheme almost caused a mild mannered English teacher to punch me out one time. He was new to the game and did not understand the lack of rules. This game was an easy way for a young doctor to learn to cope with and manage risk. Players who were reckless could lose all their countries fast just as players who were too risk adverse were sure to lose the game. These risk concepts have helped me maneuver through 33 years of podiatry practice. I have tackled risky clinical situations using the patient as a co-player to help achieve a favorable outcome. A patient who truly understands the risk in a treatment plan is more apt to be compliant than one who goes into a procedure with blind trust. A risk-informed patient is also less apt to blame the doctor when things go wrong. This is possibly a factor in allowing me to enjoy 33 years of practice with no malpractice claims. A doctor who is too risk adverse is not effective in patient care. That is the doctor who processes patients all day and avoids any treatment with even the slightest risk of failure. I pity these folks and wonder how they can face themselves in the mirror each morning. Outcome-based medicine will be hell on physicians who are too careful. Age has a lot to do with risk tolerance. At 61, I frequently analyze my motivation for selecting conservative treatment over definitive therapy. If I determine that I am being too careful so I will not be called out of retirement in a few years to defend a malpractice claim, I get a consultation from my young partner. I embraced risk in my youth. It is a wonder I made it to adulthood. I once saw a television show in which a guy raced up a ramp on a motorcycle, became airborne and jumped across a bunch of trucks, landing safely on the other side. I was 10 years old and only had a rickety old bicycle but wanted to try flying like the motorcycle daredevil. There was a hill in the town where I grew up that had a steep road that descended three blocks. There was a stop sign at the bottom and a cross street that created some risk. I decided that hill was going to be my venue for the bicycle flight. I made a ramp out of an 8’ by 4’ sheet of plywood and a sawhorse. I chose a slow afternoon midweek when there was less risk of hitting a car on the cross street. Stopping for the stop sign was not an option. My old bicycle had a bad bearing that caused the front wheel to wobble at higher speeds so I “borrowed” my sister’s Schwinn Phantom, which weighed about 90 pounds. I set up the ramp and pushed the bike three blocks up the hill. I turned at the top and listened for traffic. They did not have bicycle helmets in those days so I aimed the heavy Schwinn and started to pedal. I picked up speed rapidly and was probably doing 25 mph as I approached the ramp. I was too close to the ramp and going too fast to stop with the coaster brakes when I spotted an old Dodge headed toward the intersection. The hood ornament was a ram. I hit the ramp and the old Schwinn became airborne but not enough. I came down on the hood of the old Dodge and bounced to the pavement. Pieces of the ram and my sister’s bike light scattered. I was scraped and bruised. The old guy driving the Dodge almost needed CPR but that had not been invented yet. That ride taught me a few life lessons about risk that have served me well in podiatry. My sister is still mad. Dr. McCord is a Diplomate with the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.