Patients—Our Primary Responsibility

The successful management of patients with spine disorders requires wisdom, compassion, and common sense.

Wisdom represents the sum of one’s knowledge and experiences. With effort, attention, and maintenance, wisdom increases with age. Recently trained graduates, while likely to be very smart, do not have a mature knowledge base and have little experience. Practicing clinicians “know what they know” and gain experience over time but must continually add to and develop a broad and mature knowledge base to become truly wise.

We gain wisdom from our education and training. All graduates of training should have a solid knowledge foundation upon which to build throughout their professional lifetimes. Some clinicians have a more solid foundation—a better breadth and depth of knowledge—on graduation than do others. The key is to build upon and add to one’s knowledge base daily over time. This is accomplished through teaching opportunities and responsibilities (you cannot teach what you have not learned and retained). It is accomplished through daily interactions and experiences with patients, ranging from phone interactions to clinic visits to operative procedures to evening patient rounds. We gain knowledge by understanding and learning from shared experiences from our colleagues and partners (e.g., one of the merits of a monthly morbidity and mortality conference is to learn from experiences that might not have involved you or one of your patients).

We also gain wisdom from reading literature generated by our subspecialty discipline, as well as other disciplines. Review of contemporary textbooks, monthly reading of our society-specific journals, and, in particular, the study of evidence-based medicine guidelines^1,2 add to our growing, maturing knowledge base. From a technical standpoint, do not assume that because you operate three days a week, your technical skills are at their peak. Do not forget the merits of cadaveric anatomic dissections. Learn new techniques or modifications through cosurgeon mentoring experiences or through additional didactic tutoring, including formal fellowship training.

New knowledge needs to be pursued throughout one’s lifetime. Reading and writing are certainly part of this process, as are teaching and mentoring. A dedication to lifelong learning must be carried on during one’s professional career. Scientific inquiry, either in the laboratory or from clinical practice (clinical outcomes analysis) fortifies this effort. Sharing professional experiences with others by way of consultations, conferences, presentations, and societal meetings serves this purpose. Seek advice from those who have trained and/or think differently than you do. On the one hand, seek the advice of independent thinkers and actors, yet appreciate the concept of the “wisdom of the crowd” as defined by James Surowecki: “In the right circumstances, large groups of people are smarter than an elite few, no matter how brilliant—better at solving problems, fostering innovation, coming to wise decisions, even predicting the future.”³

Familiarize yourself with the concept of metacognition, which is defined as higher-order thinking that involves active control over the cognitive processes engaged in learning.⁴ One of the key tenets in the ability to control or regulate one’s cognitive processes is a thoughtful self-assessment and appreciation of one’s knowledge base and deficits. Attempt to identify your professional biases and blind spots. In addition to reading about what you know or believe in (a good thing), read about or study less familiar topics and professional areas.

Treat patients with compassion. Be thoughtful and respectful. Patients already know that you are smart, you are an expert, and you are very busy, typically well behind schedule. Offer them caring consideration for the periods of time in which you interact with them. Try to avoid characterizing them or dismissing them or their issues at the outset. Take the time to greet each patient and look him or her in the eyes. Remember the advice of Sir William Osler: “Care more for the individual patient than for the special features of the disease … put yourself in his place … the kindly word, the cheerful greeting, the sympathetic looks … these the patient understands.”⁵

Your patients will have completed information sheets while they waited for you. Your staff, nurse, or resident will have interviewed and examined patients before you meet them. Sit down at the patient’s height, and review the clinical information that has already been collected. Discuss the highlights of the patient’s complaints. After washing your hands, examine each patient yourself. Yours may be a focused examination, but it is the most expert (or should be if you are attentive), and it is what the patient both expects and deserves. Osler’s adage is insightful: “The value of experience is not in seeing much, but in seeing wisely.”⁵ Thoughtfully study the patient’s images or other diagnostic studies, and review them with the patient. Offer your learned interpretation. If it is at odds with the radiologist’s report, simply explain your interpretation without becoming defensive or derogatory toward the alternative interpretation. You are trained to be a spine surgeon, but more important, you are trained to evaluate and sort out those patients who are likely to benefit from your surgical skills. You have taken an oath to be responsible to your profession and the patients you will encounter.

Patients like their troubles less than you do, are typically frightened and ill-informed, and seek your help to resolve their conditions. Avoid caring only for patients who have simple pathology. Resist developing a “this is not my problem” or a “this is not my area of expertise” approach to patient management. Offer rational, personalized consideration once you have obtained the patient’s clinical history, examined the patient, and reviewed the diagnostic studies. Determine what is best for the patient in both the short run and the long run, even if a patient presents with a problem or pathology that is beyond your skill and experience (you might need to stabilize the patient initially).

Conversely, do not adopt a “do something, do anything” approach. There are some patients for whom surgery is not indicated or wise when all aspects are considered. For example, many patients with metastatic oncologic disease affecting the spinal column will not survive beyond 6 months, irrespective of the treatment you offer. Similarly, carefully selected patients who have persistent back pain after initial spine surgery will benefit from a spine fusion procedure, but most will not. Be judicious and appropriate in the application of your surgical expertise. And, as discussed later, remember to make informed consent a process through which you explain, discuss, and maintain an environment in which you present and outline the risks, benefits, and alternatives that are available to the patient.¹

We advise patients as if the patient were a family member (and we teach our residents to offer advice to patients in a similar manner). We believe in professional attachment, not detachment, in caring for or advising patients. Rational thinking, emotional balance, common sense, intuition, and experience most often result in sound decision making and practical, productive management choices. Do not fear second opinions; encourage them, particularly when the pathology or issues are not straightforward.

Use common sense when making patient management decisions. Common sense is the balance of your knowledge, your experience, the literature, your morality and personal integrity, your professional commitment, your emotions, your beneficence, and your compassion. Weigh all of the features and factors of a patient’s predicament. Analyze all of the issues and considerations, and decide what strategy or what combination of strategies makes the most sense for the patient. Distinguish between your desire to help the patient and your ability to help the patient. (This works both ways: Sometimes clinicians do not want to help but are able to do so. Such a situation borders on negligence. At other times, the clinician might wish to help but cannot, or no attempt to help makes any sense.) Determine which approach, if any, is the most ideal and the most likely to give the patient real and meaningful benefit. Importantly, do not fail to engage in a patient’s care because it inconveniences you, because it conflicts with your social schedule, or for financial, political, or other reasons. We do not suggest that you should become a “super doctor,” diagnosing and treating patients who have maladies that are beyond your professional focus. You are gifted, however. Strive to be the best. Make the diagnosis that others have not made or cannot make, and offer the patient advice and an appropriate referral. As Osler urges, “The good physician treats the disease; the great physician treats the patient who has the disease.”⁵ Whatever decisions you do make on the patient’s behalf, communicate them effectively and with compassion to the patient.

Seek knowledge and experience to gain a sense of the big picture of your patient’s presenting disorder. Engage, attach, and compassionately analyze your patient’s circumstances. Add common sense to develop the wisdom to effectively advise, manage, and treat. This combination will allow you to be a better, more practical, and wiser clinician and surgeon of patients with spine disorders.

Professional Responsibility

Respect, honor, and revere the values and principles of our profession. Patients are our first professional priority; our discipline and profession are our second. Recall the Hippocratic Oath, in both the modern and original versions⁶ (Boxes 204-1 and 204-2). Live your professional life by them.