Aligning Your Surgical Goals With The Patient’s Goals To Stay Out Of ‘Surgeon Purgatory’

“Can a nudist ever lose in strip poker?”

I had to forcibly shake my head to the question, like someone had just tried to awaken me from a deep, nearly comatose sleep when I did not want to wake up. “Really?” I shot back at Chamberlain. “You have got to be kidding me.”

No, this wasn’t a dream. We were really there. The solid steel door vibrated heavily behind me as it closed, surprisingly without much noise. It was dark and cold, and as my eyes quickly adjusted from the bright light outside the room, I could see stacks and stacks of X-ray films, magnetic resonance imaging films, and paper charts. Yes, paper charts. We must have gone back in time.

“What year is it?” I asked my compadre. “It’s 2019. Why?” he answered.

“Can’t be. Look at all these paper charts stacked in here,” I told him.

Snickering, he started to lift a few of the thickest ones. “Lift this one,” he commanded as he handed it to me. My bicep snapped into contraction.

“How many terabytes would this room take up?” I asked as I started moving across the musky room. Chamberlain did his usual in not answering my question.

He kept digging and digging. “Aha!” he exclaimed like you would expect a miner panning for gold to shriek upon finding his first real nugget.

He handed me the chart. I noticed it was not as heavy as the first one as I started looking through it. Finally, I realized where I was. I was in “Surgeon Purgatory.”

“This is the place we were talking about the other day about how surgeons and patients evaluate outcomes, and ruminate when things just don’t go quite right or as expected,” I said.   

It took me less time to get through the current chart than it does for me to log in with six different screens and four different passwords, only to be kicked out after 30 seconds if I don’t scroll or do something meaningless on our current electronic medical records (EMR) system. God forbid if I actually took a couple of minutes to look at the patient and do an examination.

“The outcome on this one looks really good,” I mused. “The patient had four failed third interspace neurectomies that all started with some alcohol injections but, finally after the denervation with a cadaveric allograft blind loop technique, the patient’s pain level went way down and she was able to get out of the wheelchair for the first time in four years.

“So, what’s the deal with this one?” I asked him. “Go to the last page and see the last history of present illness. I rifled through the rest of the chart. There it was: “The patient is extremely unhappy because she now has pain after four hours of standing and walking, and is requesting her records for another opinion and legal review.”

Again, I found myself shaking my head. “What the hell, Chamberlain?” I continued on before letting him answer. “The patient went from a wheelchair to ambulation essentially with no function to having pain after four hours of standing, and she’s pissed off at the surgeon for doing what I would consider a surgery with a great outcome.”

Rubbing his eyes, he started to answer and then just turned away. “Look at these,” he said as he flipped on a bright view box. The sudden contrast and intensity of the light in the dark room was actually painful. Side by side, he placed a before and after film of a forefoot reconstruction. The one on the left, the pre-op view, looked like some type of appendage attached to something that would wash up out of the sea at night on the beach. It was all knurled and barely representative of human pedal form. Then to the right of the lobster art was what I, or anyone who does this stuff, would consider, an absolutely great reconstruction. “Can’t be the same foot,” I proffered.

Chamberlain acknowledged what I already knew. “Oh, it is the same foot, I’m afraid.”

“Flip that light off,” I barked as I was starting to feel the toxic effects of mold and unreasonableness come over me. I went to the door and allowed egress for both of us. My colleague trailed behind. Scratching my head, I finally had to ask what that one was about.

“Well, two things here,” Chamberlain informed me. “First, it is a fantastic reconstruction, textbook stuff really. But more importantly, there was a huge decrease in function for the patient, and the patient developed pain. You see, the lobster claw, as you so delicately referred to it, was not painful. It was only psychologically disturbing for the patient.”

Once reoriented to time and place, my most knowledgeable mentor explained to me what it was that we just visited. That was “Surgeon Purgatory” and all of those cases represented what any surgeon would consider success, and ultimate success in many respects. However, the outcome from the patient’s perspective was diametrically opposed and that is really the only opinion that matters. You take someone from a 10 out of 10 on the Visual Analogue pain scale to a 2 to 3 out of 10, but do not do enough psychological digging during the consultative preoperative phase to realize that the patient has aspirations to have a complete 0 out of 10 postoperative result, and voila! You have a bad patient outcome.

“So, here are some key things for you to do prior to surgery that may keep you out of ‘Surgeon Purgatory.’ First, establish and document the patient’s current level of function and pain. Next, determine the patient’s ultimate goal. Then, maybe most importantly, you have to ‘frame’ what success is for the patient. It is different for every sole! And the patient’s definition of success really is different from yours! Take time to get to know the patient and find out what he or she did before their condition presented itself, and determine his or her desired outcome.”

This Chamberlain cat is one wise dude.

He continued, “Don’t take a serious 35-year-old athlete who has 90 percent of really great function and operate on him to at best get 10 percent more function. That does not make sense.”

“I know the answer,” I responded. “Nudists can never lose at strip poker because they have a ‘frame’ or construct, or whatever you want to call it. If nudists end up naked in front of a bunch of people, it is no different for them than how they spend their usual warm weekends with their friends and strangers. It is all perspective!” 

Chamberlain started to head off and I yelled out to him, “Where are you going?”  He turned, not breaking stride and shouted back. “I have got a poker game to get to.”