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When Doctors Say Don't and the Patient Says Do
NYTimes ^ | 10/29/02 | MARC SIEGEL

Posted on 11/01/2002 7:35:32 AM PST by RJCogburn

The woman was 93 and still tap-dancing. In her 20's, she performed for a professional touring dance company. In her 30's and 40's, she taught dance at Juilliard. For the 50 years since then, she had tapped eagerly at amateur shows and recitals.

When she arrived at my office complaining of weakness and pain in her arms and legs, her only concern was that she would no longer be able to tap out a rhythm.

I was concerned that she might be suffering from polymyalgia rheumatica, an inflammatory muscle condition common in the elderly and partly treatable with steroids. But her blood tests showed that this was not the case. The tests showed just the beefy unfettered corpuscles and the clear blood serum typical of a much younger patient.

She looked much younger than her age. Her smooth features seemed related to the years of careful physical conditioning and diet. Still, as she began to have more trouble walking, I sought an explanation consistent with some degenerative pathology or other. I ordered a set of M.R.I.'s of the entire spine. The extensive imaging discovered a bulging disk in her neck, tissue so inflamed that it encroached on the space intended for the spinal cord, the crucial superhighway of the nervous system.

There was not supposed to be a decision to make. In a younger patient, a controversy occurred when the cord was compressed, but not enough to interfere with bowel or bladder.

A surgeon might favor surgery, while a nonsurgical neurologist might say that because some of the damage to the cord was irreversible, Why take the chance of scarring and inflammation from the surgery? On the other hand, doing nothing meant living with the unremitting pain, not to mention leaving the spinal cord vulnerable to further damage.

In patients older than 90, there was no disagreement. It was hard to find any doctor who would recommend corrective surgery when the statistical risks at advanced age of a postoperative complication or poor outcome were so great.

But this time the patient herself insisted. Even when the risks, including paralysis, were explained to her, she simply replied that tap-dancing was her life.

"Can the surgery make me dance again?" she asked me.

"It's possible."

"Then I'll take my chances."

As her heart and lungs were healthy and she was in such good physical condition, I was able to find one of my hospital's top neurosurgeons to take the case.

I could not come up with a good reason to deny her this referral, though I made my reluctance plain. The statistics were not on her side. Still, given her remarkable determination, I found myself rooting for her to dance again.

The day before the surgery was scheduled, a routine blood test found a low sodium count. That meant an automatic delay because of the increased risk of seizure from low salt. Plus, the low sodium could be caused by dehydration, which would be compounded by blood loss during surgery. That sudden aberration before surgery seemed to be a warning that something else might go wrong.

I ran several tests but was unable to be sure of the cause of the low sodium. I was ready to cancel the operation. But the woman, who had already been admitted to the hospital, still insisted that she wanted it done without delay. She admitted to not drinking or eating properly in apprehension of the surgery. So I decided to treat her for possible dehydration, ordering saline solution intravenously.

The sodium condition was corrected. The surgeon saw the corrected lab data and decided that it was safe to go ahead with the operation the next day.

Afterward in the recovery room, seeing her awake and smiling and moving her arms and legs, I first considered that she might have made the right decision. The best medical decisions were made not just on the basis of scientific analysis, but on a clinical gestalt, a knowledge of an individual patient. And sometimes it was the patient who knew how to balance the risk-benefits better than the doctor.

Weeks later, she arrived again at my office, not with tap-dancing shoes, as I had imagined, but unaided, without even a walker or a cane. She was calm and pleasant, and I could see her vitality starting to return. She was already walking better and feeling stronger than she did before the operation. As if to underline her full recovery, her blood tests were all normal, including the sodium, an indication that she had truly been dehydrated before surgery. Any other cause would not have gone away for good with just saline.

"You see," she said, "we patients are not just statistics. We don't always behave the way studies predict we will."

That was as close to saying, "I told you so," as she would get, and I realized how much more self-congratulating I might have been if the roles had been reversed and I had been the one to recommend the operation.

It was too soon after the surgery to know whether she would be dancing, too soon for me even to bring up the question of it.

But when I received my invitation to her recital several weeks later, I could just imagine the justified smile on her face.


TOPICS: Culture/Society; Miscellaneous
KEYWORDS:

1 posted on 11/01/2002 7:35:32 AM PST by RJCogburn
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To: RJCogburn
Sometimes you have to be firm with your doctor and TELL them what you want done, or not done.
If it becomes a problem you may want to find a different doctor.
2 posted on 11/01/2002 7:40:18 AM PST by Just another Joe
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To: Just another Joe
YUP....what we need are more "bad" patients - patients who question, cajole doctors......they are the healthiest people.
3 posted on 11/01/2002 7:42:58 AM PST by goodnesswins
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To: RJCogburn
That is really awesome... What an inspiration.
4 posted on 11/01/2002 7:50:29 AM PST by Freedom2specul8
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To: RJCogburn
Doctors must be managed.
5 posted on 11/01/2002 7:54:56 AM PST by Mark Felton
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To: Mark Felton
as long as she understood the risk and was willing to take it.....fine...if she got infected, paralyzed, died......
well then the family would of course would not have invited him to the recital but I'm sure would have invited him to a Morbidity and Mortality conference, followed by a really cool deposition, and then some really, really, really neat meeting with the medical staff review committees and finally arbitration or trial..

I love stories like this. Cause we all know that doctors are dumba$$3@ that only want your money.

the fact is that the doctor took the risk WITH the patient. She seemed competent and should have been allowed the surgery, but I think he got very lucky.... and the patient had a good outcome.. congrats to the patient and kudos to the surgeon.

6 posted on 11/01/2002 8:12:01 AM PST by Dick Vomer
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Comment #7 Removed by Moderator

To: RJCogburn
It is VERY important for people to TAKE RESPONSIBILITY FOR THEIR HEALTH, and not hand it off to a near-stranger. Today, many people have the idea that the medical industry has their best interests at heart, just as the believe that the talking heads on the alphabet-soup networks are telling the truth. Some doctors are trained to treat SYMPTOMS. They specialize in interpreting test results and writing prescriptions.
8 posted on 11/01/2002 8:34:34 AM PST by redhead
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To: RJCogburn
Lets say that this had ended up badly, which, statistically speaking, for a 90 year old, is probably what would have happened. These doctors would have had their pants sued off.

I am all for patients taking responsibility for their own care, but they also need to take responsibility for their decisions as well. Of course, when there are lawyers involved....

9 posted on 11/01/2002 8:38:32 AM PST by Paradox
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To: Paradox; Dick Vomer
What do you want to bet that the patient was required to sign a waver?
10 posted on 11/01/2002 8:46:28 AM PST by Just another Joe
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To: Just another Joe
A waiver?

"Members of the Jury, my client, a frail 90 year old woman, was not of sound mind when she signed that waiver. How many 90 year olds would YOU trust with your life?"

11 posted on 11/01/2002 8:53:01 AM PST by Paradox
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To: Just another Joe
What if you TELL your Dr. you would rather die, what then? I believe in euthenasia. Sue me.
12 posted on 11/01/2002 8:54:40 AM PST by Hildy
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To: RJCogburn
Doctor: Does it hurt when you do this?

Me: Yes.

Doctor: Then don't do that.

13 posted on 11/01/2002 8:58:08 AM PST by Hatteras
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To: Hildy
What if you TELL your Dr. you would rather die, what then?

I don't know about anyone else but I don't need a doctor for that.

14 posted on 11/01/2002 8:59:22 AM PST by Just another Joe
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To: Paradox
How many 90 year olds would YOU trust with your life?"

Practically every one of them that I know that are not living in a 'retirement' home.
The question should be, "How many 90 year olds would YOU trust with their OWN life?"

15 posted on 11/01/2002 9:01:16 AM PST by Just another Joe
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To: Just another Joe; Paradox
Paradox is quite right. A waiver is barely worth the paper it is printed on.
16 posted on 11/01/2002 9:05:59 AM PST by Amore
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To: Hatteras
That is just what the doctor in Spain said to me - I said, "it hurts when I bend down." He said,"don´t bend down."

I think that is a universal doctor joke.
17 posted on 11/01/2002 9:22:23 AM PST by acnielsen guy
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To: drphil
" if the surgeon refuses she can shop around. Problem is, govermental health care has taken price competition out of the equation. You get the same fee if you operate on a 90 with multiple co-morbidites or a healthy 30 year old."

I agree. That is what I mean by "manage". Hire them and fire them if need be.

I don't know why I would let one man assume responsibility for my health when I would not fully trust one man to care for my car.

It takes interaction. It requires education on the part of the patient and questions from the patient. I can understand a doctor who says he "does not know" or once to try something different (because a previous course of treatment did not work) but I cannot stand a doctor who will get defensive when I ask questions.

18 posted on 11/01/2002 9:26:34 AM PST by Mark Felton
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To: Mark Felton
"once" = wants (hhhmmm...still having brain cramps mebbe I need a new doctor)
19 posted on 11/01/2002 9:28:43 AM PST by Mark Felton
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To: Just another Joe
And if things don't turn out as well as the insistent patient expects, hire a lawyer and sue the doctor. With these controversial cases, it won't be hard to find a plaintif's expert to say that the surgery was not indicated.
20 posted on 11/01/2002 9:39:56 AM PST by joonbug
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To: joonbug
Whether the surgery was indicated or not if the patient insists on it, signs a waiver stating that they knew the risks and were willing to take them, and can find a doctor willing to do the surgery it should be laughed out of any court.
Notice I say, "should be".
21 posted on 11/01/2002 9:55:50 AM PST by Just another Joe
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To: Just another Joe
One of my doctors wanted me to have a procedure done to prevent fluid from accumulating around my lungs. I looked into it,asking another doctor who didn't recommend it, a nurse, and an alternative care provider I see several times a year. I decided not to do it. Doctors are so prone to just suggesting these things without really knowing the consequences. They rarely tell you to diet (I have high blood pressure--medication! Never said a word about nutrition to me.) and they know nada about supplements. If it weren't for the supplements I'm on, I could be dead by now. I believe they've helped me far more than all the medications I've been taking. You DO have to get educated and ask around. Don't be bashful. (P.S., I'm doing much better than I was!)
22 posted on 11/01/2002 9:59:27 AM PST by Marysecretary
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To: redhead
Drs. can help maintain your health. They don't cure you. Diet and supplements can help do that. I recommend the Hallelujah Diet for anyone who has a serious illness. It can be found on the internet. We need to be careful what we eat, drink, and do with our lives. We only get one time around.
23 posted on 11/01/2002 10:01:53 AM PST by Marysecretary
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To: Mark Felton
My doctor has prescribed two medications for me that were not good for diabetics to take. One shot my blood sugars so high and for so long that I had to get another glucose monitor to get the real numbers. The old one just kept saying HI. The other one caused many problems in another diabetic woman. They really don't know what they're prescribing or how it can affect you. I brought in one paper to show him but they don't like to admit they're wrong. I don't have confidence in doctors much anymore.
24 posted on 11/01/2002 10:05:06 AM PST by Marysecretary
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To: Just another Joe
That reminds me of a friend of mine. He says the right way to choose a doctor is to go from one to the next until you find one that will do what you tell him to. LOL.
25 posted on 11/01/2002 10:06:33 AM PST by RedWhiteBlue
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To: RedWhiteBlue
The doctor IS supposed to be working for you.
At least that's what I PAY mine for.
26 posted on 11/01/2002 10:08:30 AM PST by Just another Joe
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To: Marysecretary
"I don't have confidence in doctors much anymore."

Doctors used to belong to an aristrocratic class that demanded respect and trust just for existing as part on an aristocratic elite.

Every individual doctor must earn my respect over time. It is better to enter a patient-doctor relationship wary and with some skepticism before affording them your full confidence.

"Dubitando ad veritatem venimus."
We arrive at the truth being sceptical.
-- Pierre Abélard, Sic et non?

27 posted on 11/01/2002 10:16:54 AM PST by Mark Felton
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To: Just another Joe
I am glad you added the "should be". There are elective surgical procedures performed that involve extensive informed consent processes including written materials, watching videos, taking a quiz, discussions, etc. and still they sue if the outcome is not to their liking.
28 posted on 11/01/2002 10:17:36 AM PST by joonbug
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To: joonbug
and still they sue if the outcome is not to their liking.

Only because personal responsibility, especially in the courts, is rapidly becoming a thing of the past.

29 posted on 11/01/2002 10:20:45 AM PST by Just another Joe
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To: Just another Joe
Very true and that is why doctors are reluctant to always follow the patient's request for surgery if the indications are dodgy. The patient is happy to exercise "personal responsibility" when choosing their treatment, but if the outcome is not to their liking, "personal responsibility" is replaced by "it's someone elses fault".
30 posted on 11/01/2002 10:27:42 AM PST by joonbug
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To: RJCogburn
Guess I need to get glasses. When I glanced at the first sentence, I thought it said,
"The woman was 93 and still lap-dancing."

31 posted on 11/01/2002 1:26:54 PM PST by Erasmus
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To: drphil
Any responsible doctor who feels the patient is selecting the wrong course should tell the patient that he/she should interview a different doctor for the solution. Why would you enter into a course of action that you don't feel is the correct one? Aren't you setting yourself up for a day in court?

By the way I don't have much faith in MD's anymore. I feel they promote drug use without consulting the patient as needed. It's been a long time since I had a doctor who called me at home to ask how I was feeling when he subscribed a different medication.

I have a spinal injury and four different MD's pushed drugs at me until I was an addict. Now I regularly see a chiropractor and use no drugs whatsoever on a daily basis.

By the way, a nurse suggested this chiropractor telling me that the doctor would never recommend the treatment because it would probably cost him my business.

32 posted on 11/01/2002 9:04:44 PM PST by B4Ranch
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To: RJCogburn
There are some good doctors out there, but they keep retiring or flat out won't deliver babies anymore :-( The effort to find them is just too much anymore.

Sign me,

Having my babies at home!
33 posted on 11/01/2002 11:38:31 PM PST by Marie Antoinette
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Comment #34 Removed by Moderator

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