Is Compromise Something We Should Do in Clinical Medicine?

Dear Readers:

In many fields of study, compromise is the road to success. We can all think of hundreds of compromises we make every day: deciding what is for dinner, what meeting time works best for all parties, or even what the weekend plans look like. There are many decisions and viewpoints that may benefit significantly from compromise. However, in part, compromise means that you are not in the ideal position—or at least not in your ideal position.

In medicine there are many places where compromise is not good, such as delivering care with inadequate diagnostic studies, thus potentially leading to suboptimal outcomes. An example of this occurs in venous ulcer disease. There are many ulcers of the lower leg that may look somewhat like venous ulcers, but their underlying pathophysiology is not venous in origin. In addition, if those lower leg ulcers are venous in origin, we really need to know what the venous anatomy looks like so that we can decide if the patient needs a venous intervention to help heal their wound. Therefore, the compromise in this scenario might be, that since it can be hard to get a good venous ultrasound, one could just treat the lower leg ulcer as if it is venous. In the patient with a venous ulcer, data clearly show that intervening on the superficial reflux not only reduces recurrence but increases the closure rate, while even decreasing the time interval to that closure. Therefore, compromising on the patient’s care by not obtaining the correct diagnostic studies is not a tenable compromise in the developed world.

However, it is important to remember that it is not only the clinician that makes compromises; the patient often tries to compromise with their own biology. Interestingly, biology does not compromise back. Usually, the patient is trying to avoid unwanted social stigma or negative impact on daily living. The patient with a diabetic foot ulcer does not want to wear the total contact cast, though it may be the best option for the patient to heal expediently. The patient with a venous leg ulcer may wish to avoid heavy compression wraps, which we can understand, but they are trying to compromise with the uncompromising reality that they have venous hypertension. Patients try to compromise on their care for various reasons, two of which can be a lack of education and being caught in denial. 

In practice, I try to help the patient understand that biology will not bargain with them, and biology does not care if they have an upcoming wedding, graduation, or trip. When a patient starts bargaining with us to provide suboptimal care, we must consider whether it would be okay to compromise on the care we deliver. In short, the answer is no. Therefore, we need to be firmer with our patients who wish to compromise the care they receive. This compromise of care on the part of the patient is in part why “outcomes-based reimbursement” is so challenging in wound care. Documentation of this “patient-based compromise” must also be imbedded in our quality metrics.

The lack of compromise is probably one of the reasons that patients in the standard-of-care arm of prospective randomized trials do so much better than those in the general population. This is even more true when we review the per-protocol patients outcomes versus the intent-to-treat cohort. While it is true that these trials may to some degree hand select the best patients physiologically, the studies may also select the best patients mentally (ie, patient is engaged in their care and willing to submit to a protocol-driven care plan). As we move research control arms toward best clinical practices and away from just standard of care, we will push more patients to not compromise their own care and remind clinicians that compromise is not in the patient’s best interest. As we continue to deliver care to our patients, it is important that we dissuade them from compromising their own health, document those conversations in their patient chart, and in some cases, allow them the chance to compromise, in the sense that some therapy is better than none. 

John C. Lantis II, MD, FACS

Editor-in-Chief, Wounds Wounds. 2023;35(9):A8

woundseditor@hmpglobal.com