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.

Sir William Osler offered sage advice about our personal integrity and our professional careers: “The greatest leverage you can create for yourself is the pain that comes from inside, not outside. Knowing that you have failed to live up to your own standards for your life is the ultimate pain. If we fail to act in accordance with our own view of ourselves, if our behaviors are inconsistent with our standards—with the identity we hold for ourselves—then the chasm between our actions and who we are drives us to make changes. One of the strongest forces in the human personality is the drive to preserve the integrity of our own identity.”⁵

Box 204-3 summarizes the most important things to remember for successful surgical management.

Minimizing Litigation Risk

No matter how wonderful a person and communicator you may be, there will be some patients who don’t understand you, are put off by you, or do not like you or your attitude on a given day. The key is to keep these perceptions to a minimum. Patients are troubled and often scared; many are less cerebral and less well-educated than you. They have been kept waiting (weeks for the appointment, possibly hours to see you in the clinic), and they are usually hungry. They don’t really care that you may have had an emergency last night (hence you had less sleep), that you have patients who are critically ill in the hospital (you are worried), or that you have a “monster clinic” (you are behind schedule and are stressed).

Given all of these possibilities, consider the following ideas to establish and improve the doctor–patient relationship and hence to foster more effective communication and better care. Take time to greet patients and the family members who accompany them. Introduce yourself by your given name (e.g., “Mark Hadley,” not “Dr. Hadley”) and smile at them. Sit down. Do your best to record and recall their first names and where they are from. Try (in a short time) to appear friendly, relaxed, as humble as possible, and not rushed (giving them whatever time they need). Apologize for being late or behind schedule (most will appreciate this). Interact with them as if they were family members, dear friends, or neighbors whom you are counseling on your backyard patio. Be mindful of any barriers in language or culture.¹¹ Do not discourage questions. After the chat and interview, get up, wash your hands, and perform the essential elements of the examination yourself (put your hands on the patient). Spend time and review the images, explaining your interpretation without criticism of the radiologic interpretation or any poor work that was completed or attempted. In conclusion, offer your diagnosis and a treatment plan. Again, answer questions that arise. For patients with a diagnosis that you do not specifically treat, offer the appropriate referral. Above all, do your best to explain yourself and your thinking, and offer a potential treatment.¹² Stay calm, even if the patient or family members challenge or attempt to provoke you.

Do not offer surgery based on imaging (exceptions may be trauma, instability, or cancer). Rarely will you see a patient in the clinic who truly needs an urgent procedure. Discuss medical management, and when appropriate, send the patient away to pursue it. Patients should leave your clinic with a follow-up appointment if surgery is an option, should medical treatment fail. Patients typically do not want surgery. Most favor a comprehensive attempt at medical treatment before they will consider surgery. Failure to first exhaust medical therapy can be an extremely contentious medicolegal topic if your patient just meets you, goes straight to surgery, and has a poor outcome.¹³ The more interactions you have with a patient before a surgical procedure, the better the patient can get to know you and form a favorable personal impression.

From a medicolegal perspective, when a bad outcome occurs, patients are far more likely to consider legal action against the unknown, aloof, surgical “expert” than against a surgeon they have come to know, who has made an effort to understand them, and whom they like and and respect.¹³ While one cannot successfully win a suit only because the surgeon “acted like a jackass,” the “jackass” surgeon is much more likely to get sued in the event of a poor outcome.

Obtain appropriate informed consent. This is a topic that could, and does, fill many articles and books; it is of central importance. After your examination, and after the establishment of a plan of care, if a procedure is called for, remember that informed consent is a process.⁷ It should include notes in the clinical chart that reflect your conversations with the patient. In these conversations, you should describe the essential elements of the operative procedure to be performed. Offer a rough idea about how long the procedure will take to complete once the patient is asleep and positioned. Describe the potential complications associated with the operative procedure (e.g., difficulty swallowing and/or speaking, hoarseness, fluid collection or blood clot, cerebrospinal fluid leak, arterial injury, nerve injury, and/or spinal cord injury are possible complications for an anterior cervical discectomy and fusion procedure). On the other hand, you do not need to spend time reviewing every possible complication or every potential anesthetic complication, but do not shy away from potentially major adverse risks, including death, paralysis, or stroke. Honestly describe your experience with the specific procedure over the course of your career, using general terms. Specifically write the name of the procedure on the consent form, and in the margin, handwrite a list of major potential complications. Invite questions. Patients must sign the consent form and initial the list of the potential complications on the form. You should sign the form as well (Fig. 204-1).

FIGURE 204-1 Appropriate informed consent.

Informed consent has long been a major topic of debate. Patients and family don’t often recall the details of the informed consent discussion.¹⁴ They argue that the preprinted forms are too long, too hard to read, too confusing, and too much like a business contract that they signed without reading or fully understanding. Specifically writing the procedure description and creating a list of potential complications associated with the procedure in the margin in ink and having the patient sign and initial it can diffuse a great number of these arguments should questions be raised following a poor outcome.

Greet each patient and his or her family in the preoperative holding area as they present on the day of their scheduled surgery. Shake hands and use the first names of the patient and the spouse or other family member(s) present. Remind them that you are present, fit, and committed to doing your very best. Mark their surgical site yourself; remind yourself of the procedure you have proposed, including side and level. Smile and show both compassion and optimism. (This is yet another important opportunity to calm and bond with the patient, to show your personal attachment and humanity.)

Personally perform the TIME-OUT once the patient is prepped in the OR. Personally confirm the localization of the operative procedure. Personally perform the essential elements of each operative procedure (this is the personal and professional contract you made with the patient). If an unexpected, untoward event occurs during surgery, deal with it as effectively and as definitively as possible. This could mean requesting a colleague to come in to assist you. (Do whatever you would want a similar surgeon to do in the same circumstance if the patient were your family member.) Careful, thoughtful, definitive treatment of the complication at the time of the untoward event often minimizes its potential ill effects; reduces the likelihood of a later, subsequent procedure; and typically reduces patient and family consternation.

Speak with the patient’s family immediately after the procedure. We typically do this by telephone before the patient is awake. Call or have your resident or assistant call the family again once the patient is awake and can be properly examined. Assess each patient personally before he or she leaves the recovery room (unless the patient is recovering in the intensive care unit). Then make rounds at the end of the OR day, greeting each family and assessing each patient in his or her hospital room.

Dictate your operative notes within 12 hours of the operative procedure (the same day). Delayed dictations raise a number of medicolegal questions if an untoward event should occur. The family’s attorney will check the timestamp on that note, and if it is not relatively contemporaneous, hard questions and harder implications will follow. Be honest, but do not “wear a hair shirt.” Take responsibility, both in your dictation and in your subsequent care of the patient. Should your patient have a complication or poor result after an operation that you performed, assume general responsibility. It is okay to express regret over the outcome and to be sorry that the patient has had a complication, particularly when this is followed by your commitment to help the patient in any reasonable way thereafter. However, be clear in these statements, and ideally, have someone with you.

Do not hide behind an “I don’t know” excuse; on the other hand, do not speculate if the cause of the event is indeed uncertain.¹⁵ Do not abandon the patient. See more often and spend more time with patients who have unexpected outcomes or complications. Too often, surgeons distance themselves from patients who have experienced a complication. This confuses the patient and family and leads to questions about the surgeon’s professionalism, character, commitment, and expertise. If you have a patient with an untoward result, it is far better to have his or her family members know that the surgeon did all he or she could, spent more time rather than less, truly cared about the patient, and regretted the bad outcome.

At the same time that you assume general responsibility, do not blame others or your equipment or devices. You are the surgical expert, the surgical team leader, and the focal point of the family’s attention, and they expect you to be professional, candid, and informative about the situation. Do not make excuses or displace blame or responsibility. We do not recommend that the surgeon get too detailed in the spoken description of the events that led to the complication. Conversely, do not omit important information that should be included in the report (or in the medical record). Choose your words carefully and wisely. (For example, you might say, “During the dissection I ripped the dura” rather than “The dura was attenuated by the stenosis or scar” [or whatever occurred]. Say something like “I used blunt and sharp dissection techniques and observed a rent in the dura. I repaired it by [however you treated it] to avoid nerve root entrapment and the potential of a cerebrospinal fluid leak.”) Do not speculate; whatever you say at this early juncture will be hard to explain later if the facts turn out to be different than you initially thought. And by all means, if you believe that you actually made a mistake or if you are of the informed view that someone else’s actions fell below the expected standard of care, advise your risk management or other legal advisor immediately so that all aspects of the matter may be reviewed and so that both you and the patient and family will be advised properly.

A neurosurgeon recently asked me (MNH) to review a vertebral artery injury complication (a known complication of this operation) that his patient had experienced during an anterior cervical discectomy procedure. I decided that I could not support the surgeon’s care for a variety of reasons (e.g., “urgent” operation for a routine radiculopathy due to a disc herniation at C5-6 of 3 weeks’ duration, no medical management, poor informed consent, appearance of abandoning the patient after the operation) but primarily because he described “working, dissecting around a diseased vertebral artery” in his operative report. This was recorded in his dictation, his discussion with the family, and his deposition. Unbeknownst to the surgeon, the patient had had a cervical CT angiogram 6 months prior to surgery (the patient had been hit in the anterior neck by a baseball, with echymosis and swelling). The CT angiogram revealed no evidence of a carotid artery injury and showed normal, nondiseased vertebral arteries without vertebral artery or vertebral body anomaly (normal caliber, position, and course). Had the surgeon done other things differently (see preceding comments) and had he described the operative event more accurately (e.g., “I worked laterally at the C6 level to fully expose the medial uncinate process to better expose the disc herniation and underlying nerve root. I suddenly encountered brisk arterial bleeding …”), this unfortunate event may have been defensible.

Sometimes complications occur late. Be responsible to your patients in the postoperative setting after discharge from the hospital. Have a consistent paradigm in place by which you or your staff address patients’ worries and concerns, observe their function and incisions, remove their sutures, and follow their healing and recovery process. Assess your patients with internal fixation and fusion constructs with radiographic follow-up as appropriate to be sure the construct is intact and the internal fixators remain in the appropriate position. Be as attentive postoperatively, particularly in the first 3 months, as you were preoperatively.

Think twice before criticizing other physicians and surgeons who may have advised or treated the patient before you. Rarely are you going to have all of the facts necessary to render a fully informed opinion about prior care. Resist the natural human response of appearing astounded over a patient’s plight and treatment. Patients do not always describe the physician–patient interaction in the same way the physician would. What a patient reports to you about the other doctor’s words, actions, and deeds might not be entirely accurate. You were not present during those earlier interactions. You were not asked to provide an opinion on the patient earlier, before the current circumstances. Assess the patient’s present status without criticism. Do not add fuel to the fire, and resist the urge to be a “Monday morning quarterback.” Recall with humility that all clinicians (you included) have patients who have not been helped as intended or hoped.

One final medicolegal point: Resist the temptation to participate in the medicolegal arena simply for monetary gain. Patients who are the victims of negligence and/or malpractice (plaintiffs) deserve the advice of expert surgeon clinicians. Surgeons who have been accused of negligence and/or malpractice (defendants) deserve the advice of expert surgeon clinicians. A small number of “experts” in our field supplement their incomes substantially by serving as medicolegal experts. Many of these clinicians advertise their interest and availability to serve these purposes. Many are involved in numerous proceedings at any one time. It is not unusual for experts to become so involved in the outcome of the medicolegal proceedings that they misspeak or offer opinions beyond the collective wisdom of their specialty (egregious testimony). This, in our opinion, is wrong both professionally and from a personal integrity perspective.

A number of professional organizations have attempted to address this issue. Recommendations and guidelines have been generated¹⁶ (Box 204-4). We would advise you to avoid the temptation of undertaking this “work” simply for the extra income it might offer; doing so produces incentives that are at odds with rigorous adherence to the guidelines and our duties to patients and the legal system. Instead, follow your professional common sense, vigorously maintain your adherence to the guidelines’ protocols, and serve as an expert when you find a truly compelling, ethical reason to become engaged.