Telling It Like It Is

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

Recently, I had a couple of patients praise me, saying they respect that I “tell it like it is.”  I was surprised at first when I heard this because I’ve always thought of myself as a diplomatic person, less prone to blunt and abrasive statements.  I was aware at the time that this was meant as a compliment; the patients appreciated honest advice.  So, I wonder: is it right to “tell it like it is?”  Should the hard truth always be the way a doctor speaks?

I don’t think a black and white answer will suffice, except to say that a physician should try to be as honest as possible while helping to attain successful results for his patients. 

As I mentioned before, I do quite a bit of wound care and hospital consultation work.  As such, I’ve had a reasonable number of patients to whom I’ve recommended transmetatarsal amputations.  Unless it’s a clear-cut case of gangrene or an emergent surgery, convincing a patient to have this procedure can be difficult.  More than once, I’ve watched a patient’s eyes glaze over for a minute after I tell them that they need this procedure.  This is a case that requires a mixture of tact with a generous helping of honesty thrown in.  They learn the risks of not having the surgery (essentially limb loss or death), the alternatives (more proximal foot amps or leg amputation), and the benefits (continual ambulation on the limb and improved life expectancy).  One tactful tool is not using the word “amputation” at the beginning of the conversation.  I use euphemisms like “remove the front of your foot.”

On the other hand, you can’t be evasive, even if you’re trying to spare your patient emotional pain.  Early in practice I had a patient with a gas-producing foot infection that I I&D’d.  The patient’s sister later became upset with me because I did not use the word “gangrene” when I discussed the infection with the family.  The sister felt she had not been given the entire picture.  Telling her there was gas in the foot was not enough information for her to appreciate the problem.

As physicians, the hardest part of the job is not the technical aspect, but rather the emotional and psychological components of our patients.  Every patient is different, requiring different approaches.  This is part of the “art of medicine” that takes time to develop.  What’s your approach?  Are you brutally honest with all patients?  Do you take a modest approach?  What works for you?

When all else fails, fall back on the golden rule.  Ask yourself this: How would you want to be spoken to by your doctor if you were the patient?


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

LETTERS TO THE EDITOR

***Bunions DO come from shoes***

Numerous anthropological studies done over the last 25 years demonstrate that there is a low level [4 - 7%] inherent incidence of bunions, hammertoes, etc. in societies prior to their introduction to western style foot wear. This increases to the rates we see in industrialized, westernized societies of 75-85% of foot deformities.

Whether or not the deformities are painful, as well as their development, is an interplay between nature [genetics] and nurture [shoes].

Despite what you may have been taught, shoes DO contribute, if not cause, bunions.

H. David Gottlieb, DPM
Chief Podiatry Surgical Resident
Veterans Affairs Maryland Healthcare System
[email protected]

Editor’s Response:

A convincing argument you pose, Dr. Gottlieb, in spite of the fact that you missed the overall point of the editorial.  Sometimes you have to simplify things a bit for readability.  In spite of my inherent distrust for anthropological research (that particular field of “science” has very questionable methods) I’ll take your figures at face value.  I wonder, though, what populations were studied?  Are they societies with a low penetrance of certain genes?  We see in practice that certain groups of people have a higher incidence of this disorder.  How many families have you seen where multiple members have bunions?  If there’s not a genetic component to these folks then educate me on what it really is.  They’re not all wearing the same shoes I hope!

I actually do agree with your statement above about the interplay between genetics and shoes.  We know from the podiatric biomechanical research that certain “foot types” predispose individuals to various pathologies (genetics) and that shoes may worsen the condition (environment). 

--Jarrod Shapiro, DPM


***Surgical cases and board certification***

I just joined someone as an associate for a one year contract.  I still have not had medicare or any private insurances contract yet.  Therefore I am told that I can only be the primary assistant in the operative report as well as the hospital booking in order for my boss to get paid.  My question to you is will I be able to use those cases toward board certification or do I need to be the surgeon in the operative report in order to have those surgical cases be considered even though I will be the one who does all the surgery?

Sincerely,
Khanhmei Wong, DPM
[email protected]

 

LETTERS TO THE EDITOR

***Surgical Cases and Board Certification***

It's going to take at least few months to be credentialed with Medicare and the private insurance companies, but that doesn't mean you can't be the primary surgeon. My assumption is that your charges are being billed under one tax ID (the senior doc's practice), and you are applying to be credentialed as a provider within this group.

As long as your senior doc is an assistant surgeon, you can be the primary. I don't think the payment will be affected. (He does have to cosign your notes, and be present for the surgeries). And for boards, you do have to be the primary surgeon. (I'll be sitting for them this year). Hope that helps.

David Baek
[email protected]

***Tell it like it is***

In response to your discussion about "tell it like it is". I agree with everything you have said but would like to add a pearl. When I have a patient that obviously needs some form of amputation that is not emergent, I will often review the science behind everything and the need for amputation and add in "We will give it a good try but if I get a sedimentation rate or X-ray that shows worsening signs of infection, then I have no choice." I will then send the patient for the study and the majority of time the patient feels as if there has been a defined objective threshold set rather than my subjective decision. I will then inform the patient of their sedimentation rate of 100 and they will then TELL ME "OK doc then I guess we need to do this surgery, I'm ready." I have found the key to this discussion is explaining the results before the test is ordered. If the case is stable then I may wait a week or so between the conversation and acquisition of the study, assuming it will not harm the patient.

—Anonymous
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