by Jarrod Shapiro, DPM

Now that I'm actually boarding cases, I'm seeing in very clear perspective the personal risks associated with surgery. The risk I'm talking about is not only from litigation. Keep in mind the medical risks to your patients. Remember, "first do no harm."

Here's an example. I had a 60-year-old new patient the other day present to me with a painful HAV that she wanted surgically corrected. Her past medical history, though, was significant for a myocardial infarction 10 years previously. She had weakly palpable pedal pulses. I identify 3 primary issues regarding risk in this case. First, the heart attack. It's been longer than 6 months, so it's not an immediate contraindication to surgery. However, I'm crazy if I don't get cardiology clearance first! Second, her weak pulses require at the very least arterial dopplers, if not more, and potentially a vascular consultation. Third is primarily a legal risk issue: she's a new patient. If something went wrong with the intraoperative or postoperative course, she'd have an easier time suing me because she doesn't know me; she wouldn't have a personal connection to me. As a result, I have all new patients return to see me at least a second time before I'll consider operating on them. I tell them it gives them a second chance to get to know me and feel comfortable with their surgeon. Invariably they always return with more questions the second visit.

Let's talk about litigation for a minute. I've spoken with experienced docs who feel that if a case goes to court, the plaintiff's attorney will destroy you if, prior to surgery, there was not a "reasonable" attempt at conservative care. What's reasonable? 6 months of conservative care (considered the standard)? Less? More? Short of a deep space abscess, for every condition, there is always non-operative treatment that will relieve symptoms and/or work toward a cure. This may consist of debridement, medication, padding, orthotics, etc. It may also include your recommendation for a change in behavior, ie. limit wearing of style shoes, limit activities like dancing in style shoes, limit walking on hard surfaces. Remember to document your attempt at conservative care!

As residents we often walk into cases with little appreciation of the work-up required preop. I urge all of you to remember there's a person attached to that foot and ankle. Review their medical history thoroughly preop and don't do surgery on anyone you have a bad feeling about. I want to have a ton of cases and get board certified as fast as possible but not at the expense of my patients or my career! Medicine requires an intimate knowledge of the entire patient for optimal outcomes. Remember, you're more than a technician; you're a physician.

This program is supported by an education grant from
Dermik Laboratories.