Who Deserves Your Care?


by Jarrod Shapiro, DPM
Joined practice July 2006 of
John K Throckmorton, DPM, PC
Lansing, Michigan

Recently, I had an experience that's had a somewhat profound effect on me. A local PCP called, asking me to see a patient of his whose feet were in very bad shape. I agreed to see her, of course. As a new physician, I don't refuse a consultation.

For brevity's sake, I'll skip the ancillary details and focus on the meat of the situation. During the consultation visit, I met an extremely spry 92 year-old lady who looked more like 62 years-old with dry, stable, minimally painful gangrene of her hallux and third toe that appeared more atheroembolic in origin, nonpalpable dorsalis pedis, posterior tibial and popliteal pulses, as well as dependent rubor. Radiographs were negative for osteomyelitis. She'd been seen previously by two local vascular surgeons who thought she was a poor surgical risk. I instituted treatment which consisted of educating the patient and family (who wanted intervention), local wound care, protection, arterial dopplers and pulse volume recordings (which showed significant vascular occlusions) as well as consultation with a third vascular surgeon. The first two vascular surgeons were older and didn't know much about the less invasive endovascular techniques.

Now, here comes the problem. I called the referring physician to discuss my plan of care and was surprised to hear he wanted me to do only minimal care, that she was too risky for any surgical procedures because she may suffer from " infections." In essence, he was consulting her out to get her off his hands. This was a conundrum, because I wanted to treat this patient, so I decided to treat her to the best of my ability to the extent her health allowed. We're currently pending a CT angiogram with possible Silverhawk atherectomy.

So here's my question to you? Who deserves (or qualifies for) your treatment? When do we wash our hands of patients and tell them there's nothing to do? Do we discriminate by age? How about psychological diagnoses? I recently saw a stable schizophrenic patient with very painful bunions that needed surgical correction. Does this patient deserve my care? What about insurance coverage? Does an uninsured person deserve less care than a patient with excellent coverage?

Here's my take on this. Everyone deserves our treatment, BUT (and it's a big but!) we live in the real world. You have to consider every patient and every case very carefully, and you have to do what you think is right after weighing the risk/benefit ratio. You're the doctor; it'll be your judgement on the line. This may or may not be evident to you during your residency, but you have enlisted into a very complicated profession. My 92 year old is sharp and capable of making her own decisions; she's an informed patient. Doesn't the benefit of a minimally invasive endovascular procedure outweigh the risk of wet gangrene she'll develop at some point?

What about the 103 year-old patient with severe dementia and bed-bound, nonambulatory status and 1st metatarsal head osteomyelitis with a painless ulceration? Yes, this is one of my patients too. I'm treating her with comfort measures only; what benefit will she receive from surgical debridement and the risks that come with it? How about the schizophrenic patient? I'm going to treat her very carefully and only after discussing her case with her psychiatrist and PCP and instituting conservative care for a while to get to know her better. Every case is different and has to be evaluated individually.

What about the patient with medicaid? You'll find that, in practice, you won't get paid much for these patients. If fact, many physicians do not accept this insurance at all. This is an important consideration. Remember, you're also running a business, and it won't survive on charity. I compromise on this one a bit: I'll see uninsured or medicaid patients in the hospital and occasionally in the wound clinic, but not in the office. It's not great, but this compromise is the best I can do under the circumstances. How useful is an unemployed podiatrist?

These situations may feel removed from where you are currently as residents, but as soon as you hit the real world, they'll be part of your daily practice life. Count on it. What do you think? What decision process will you make when treating patients? What about universal health coverage? Pro or con? Write in; let's get some discussion going.

Talk to me.



Jarrod Shapiro, DPM
PRESENT New Docs Editor
[email protected]