Staying Within Your Boundaries

Jarrod Shapiro, DPM PRESENT Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

One surefire way to lose a medical malpractice lawsuit is to have an unexpected complication after a surgical procedure on which you have no training. Surgery is a complex undertaking with many chances for complications, and lack of experience is difficult to defend. Is it ever reasonable to go beyond one’s training? How do we obtain further skills if we never go beyond our residency education? When is it safe to push our boundaries?

The other day I had a new patient visit with a 32-year-old man who’d “fallen” 20 feet, sustaining a severe closed, comminuted intra-articular calcaneal fracture.  He’d clearly require surgical repair. However, I have little experience with this type of fracture.  I related my lack of experience to the patient, explaining that I would refer him immediately to another physician.  The next day the patient called my office to tell me that the other surgeon would not see him due to insurance issues (he didn’t have any), and would I consider doing the surgery anyway?  Obviously, this would be a good case:  interesting, challenging, beneficial to the patient, and a good case for the rearfoot boards.  I turned him down.

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It seems a very common theme for podiatrists to boast about their busy practices and giant surgical case loads.  I’ve listened to others brag about their complex trauma cases, wound cases, and reconstructions, always wondering if they were being completely accurate.  In this climate of “my practice is better than yours” where the grass always seems greener on the other side, I can understand where someone might be tempted or pressured to go beyond their experience and take on a case outside their training.  We all want to look like the world-class surgeons we see at the conferences.  However, this does not justify placing a patient at risk due to an inexperienced surgeon

So is it ever permissible to go beyond our boundaries? If not, how do we ever progress and stay current?  We know, for example, that many of our general surgery colleagues completed their residency training prior to the universal adoption of laparoscopy.  Clearly, these surgeons received extra training (as do we at our cadaver ACFAS courses) and performed those first cases outside of their original residency training.                

The answer, then, must be a clear “yes.”  We should go beyond our residency training, but in a responsible manner.  Here are my thoughts about responsibly doing surgery in new territory:

1. Don’t do the surgery alone if you have no training in the procedure.
2. Don’t do the surgery if you’re not willing or able to deal with the consequences.
3. Ask for help from a colleague who is experienced.  For example, looking back, I could have asked for help from the local orthopedic surgeon with whom I have a good relationship.
4. Always be honest and up front with your patients.   If you have little experience with a procedure, tell your patient.  Don’t let this information surface during a lawsuit.
5. Continue to gather as much continuing medical education as possible. 
6. Practice medicine to the best of your abilities and not how your bragging friend practices.

We can all imagine the scenario if I had taken on this case solo.  Likely inadequate correction and result with all the potential complications of ORIF of the calcaneus (dehiscence, infection, nonunion, neuritis, tendonsis, arthritis, etc.).  As much as my ego doesn’t want to admit my limitations, this is best for the patient.  Remember, first do no harm!

Is it ever reasonable to go beyond one’s training?  What’s a podiatrist to do?  Comment in on our etalk! Join in on an array of eTalk Topics taking place on PRESENT Podiatry, or create one of your own.

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

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