Skip to comments.When Doctors Say Don't and the Patient Says Do
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.
"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.
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.
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....
"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?"
Doctor: Then don't do that.
I don't know about anyone else but I don't need a doctor for that.
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?"
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.
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?
Only because personal responsibility, especially in the courts, is rapidly becoming a thing of the past.
"The woman was 93 and still lap-dancing."
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.