Can You Heal Everyone?

Jarrod Shapiro, DPM PRESENT Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

Is it possible to heal everyone? This may sound like a silly question, especially to those new to podiatric training.  It doesn’t take long, though, to realize the obvious answer:  No.  It’s not possible to heal everyone.   Now, this isn’t simply an elementary question; I think it has greater ramifications that are worth considering.  In fact, for young physicians such as me, it is often difficult to come to terms with the idea that we will not always be successful in treating our patients.

In my locality, I see a common complaint from a specific type of patient: the “foot sprain.”  Often I’ll receive a follow-up ER consultation on the patient who sprained her foot, had negative radiographs, and complains of pain “all over my foot.”  My examination finds diffuse, nonspecific pain, no edema, ecchymosis, or other signs of injury.  Obviously, this presents a difficult situation, knowing the significant morbidity associated with an undiagnosed Lisfranc injury.  In fact, at times I’m forced to obtain an MRI to rule out this injury (after weightbearing radiographs, of course).  Typically, I see a protracted course of recovery with the patient asking repeatedly for pain medication.  Can this person be healed?

	Today's Premier Lecture is A Pre-Operative History and Physical for the At-Risk Podiatric Patient presented by Gregg Sherman, MD

Or what about the diabetic patient with neuropathy and a HbA1c of 9 complaining of burning sensations?  You can try boatloads of Lyrica and Neurontin, but without gaining control of this patient’s blood sugar, they’ll continue to have symptoms.

Patients such as these are sobering and humbling for physicians.  These are the patients – and we all have them – that cause us to cringe when we see them on our schedules.  Perhaps this is the reason hallux valgus surgery is so popular a topic in podiatry.  This is a concrete, identifiable pathologic entity with a clear difference between the pre- and postoperative appearance.  If done correctly, surgery is curative and eliminates symptoms.

Here’s my version of “treatable” pathology: a distinct, focal area of pain with an identifiable etiology, in an otherwise stable patient.  I know; it's a rarity.   This is the patient I know I’ll be able to treat.  What can we do then about the other extreme?  Here are some of my thoughts about screening for the challenging patient.  Write in with your methods to handle these patients.

1. Identify the “difficult” patient: vague questionable or multiple complaints, an unclear history with diffuse nonfocal musculoskeletal pain.
2. Beware the associated diagnoses such as fibromyalgia, anxiety and depression and their associated medications.
3. Caution with the multi-drug allergy patient.  I’ve seen patients with 8 or more supposed allergies.  Most of these are probably not true allergies, but rather adverse drug reactions.  What this shows is a long history of various medical treatments over a long period of time – an at risk patient.
4. Red flag: the patient who outright requests pain medication. 
5. An even redder flag: the patient who says for example, “Vicodin?  That doesn’t work for me.  Percocet works a lot better.” 

With these thoughts in mind, it is still incumbent upon us to make every effort to heal our patients.  Although we always try to first identify the specific etiology of pain before beginning treatment, it may not always be possible.  This is where basic patient care concepts become important.  For example, PRICE therapy is always in order for lower extremity soft tissue injuries.  Additionally, a low threshold for ancillary tests and second opinion consultations may be helpful.

To close, there’s one other issue this type of patient brings up.  Many of us see patients previously examined by our colleagues, and it may be easy to assume your colleague is a poor doctor because he or she couldn’t successfully treat that difficult patient.  Keep in mind that difficult patient may not provide an accurate story of your colleague’s treatment or quality.  Reserve judgment, for you may soon be that other physician.  Remember, you can’t heal everyone.

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Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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