Leave it to the doctor to decide

While a patient may think they know what’s good for them, it’s our job to convince them that we know better

Sue demanded to be seen as soon as she arrived from Zimbabwe. She was escorted from the airport straight to the hospital and admitted in a deluxe room, typically reserved for overseas patients, complete with wooden floors, crisp linen, a recliner for relatives, and a panoramic view of the verdant green racecourse and cerulean blue sea. Its neatness, however, was brusquely defiled by her messy way of unpacking and the acrid whiff of cigarette smoke that made the hair in my nostrils stand on end.

She shoved the cigarette packet under the pillow as soon as she saw me walk in – the kind of thing little kids do to ensure their toy is not taken away. Even though you’ve seen it ensconced, you’re supposed to pretend you haven’t. We exchanged pleasantries and I introduced myself and my team, politely suggesting we open up some windows.

She was in her mid-fifties. Her hair was short and wavy with dry streaks of white and gold. She had a raspy voice, which turned crustier when she began describing her story. “I have this agonizing back pain that shoots down my buttock and the back of my left thigh and calf,” she said, tracing her finger along the site of pain distribution. “It’s killing me. I can’t even walk for a few minutes.” She was operated on her lumbar spine 3 years ago. When the surgery didn’t make any difference, she was recommended another back operation, this time to insert some screws and rods to help rid her of her pain. She chose to come to India to get it done. “Thank you for agreeing to do this surgery; I can’t trust the doctors in Zim(babwe) anymore,” she said matter-of-fact.

One thing I learnt very early in my practice is never to believe what an unhappy patient says of their previous doctor, or, at the very least, take it with a pinch of salt. It’s a trap. It’s their often subconscious ploy to make you feel like you’re the best – which is obviously incorrect. Another thing I learnt (this one fairly late in life) was to accept reality as it is, not as one would like it to be or even as one imagines it to be. This patient’s pain was real. Her interpretation of its source was probably not, even though she had symptoms of sciatica with textbook fidelity.

After examining her carefully, I took a deep look at her MRI, scrolling back and forth on the computer, my discerning eyes scanning carefully. Apart from the tiny footprints of the previous surgeon, there was nothing on the MRI that could explain such agonizing pain. I had to squint hard to ensure I wasn’t overlooking something minuscule pinching on the nerve. The X-rays did not show any instability even when taken in extremes of movement: flexion and extension of the spine.

As artist Richard Avedon says, “All photographs are accurate, [but] none of them is the truth” – a lesson we learn over and over again from social media. The MRI was hers. The X-rays were hers. They were accurate. But did they tell the ‘truth’ about her condition? I needed to look for other causes, as I was convinced she wasn’t faking her plight (which can also sometimes be the case).

I went back to her the next day to say I was certain she didn’t need spine surgery. Her face changed colour, wondering if she had met another duplicitous doctor who was here to disappoint her. “I flew 3,000 miles to have this operation. I can’t stand for 5 minutes – my leg feels like someone’s eating into it – and you’re telling me you’re not going to operate on me? I am not leaving here without surgery. Open me up again, take a look, and see what you can fix. They tell me there could be some scarring. Even if I don’t get better, at least I’ll know I tried everything I could. I think that would be best for me.” She turned around and looked at her daughter, who nodded back in agreement at the finality of this decision.

I understood her despair and calmly asked her to lie down. I needed to examine for other possibilities. I held each of her feet in the palm of one hand. The left foot was distinctly cooler. On closer inspection, the colour too was imperceptibly different. The warmer foot was a rosy pink, while the cooler one was an ashen spectral white. I rolled my fingers to feel the contour of her pulse on the dorsum of the foot and behind the ankle: while it bounded on the right, it was entirely impalpable on the left.

“Smoking has damaged the arteries supplying blood to your legs,” I announced. “They’re crying in pain for oxygen and nourishment. We’ll have to do a Doppler and CT angiography of the legs to find a block that we can open up. I will surely not operate on your back,” I reiterated, this time with an arrogance of finality. But medicine also requires a tender balance of firmness and kindness. “Give me 24 hours,” I requested,  “and for anything we do to work, you have to stop smoking now,” I implored.

The angiogram showed a 5 cm occlusion of the left iliac artery, where it branched off from the aorta. There was severe atherosclerosis causing narrowing of the artery. We called a peripheral vascular surgeon who inserted a stent, opened up the vessel, and started her on antiplatelets. Her pain was gone the next day – not a trace of it. “It feels like I have a new leg!” she said with a smile on her face for the first time since she had arrived. “You still want me to operate on your back?” I cheekily taunted. “I’m sorry for being so silly,” she acknowledged, giving me a hug, ready to head back to Zimbabwe.

A while ago, I wanted to present this case at a clinical meeting and emailed her to check on the longevity of our procedure, so that I could be truthful about the outcome. She replied in a single sentence: “Three years, no pain; thank you for not operating on my back.” I smiled, reflecting philosophically on the truth of the adage that what one thinks one wants isn’t necessarily what’s best for you. I had learned so much myself from this one case.

40 Comments on “Leave it to the doctor to decide
  • Donna Reen says:

    One thing I learnt very early in my practice is never to believe what an unhappy patient says of their previous doctor, or, at the very least, take it with a pinch of salt. It’s a trap.—So true

    Reply
  • Minaz Ajani says:

    “leave it to the doctor to decide “- so true . Self diagnosis and self medication is so very common.

    Reply
  • Dr. Neepa says:

    Mazda, your clinical acumen is excellent. You gave her the right diagnosis, and the right line of treatment and relieved her of the pain. Nice work..

    Reply
  • Debashree Turel says:

    🤍🤍

    Reply
  • Avinash Karnik says:

    Dear Dr. Mazda
    What a fantastic and eye opening case that tells the world that operating on a patient is not always necessary and one can take a selfless decision by not taking the patient under the knife.
    I’m sure Mazda that you will serve the humanity in the right spirit through your medical practice all the way and am proud to know you. You had in the past avoided a surgery on my friend who was advised by two doctors otherwise. We need doctors of your caliber as a neurosurgeon who has a welfare of patients on a priority basis. Please take a bow first as a kindhearted man and as an excellent neurosurgeon. 🙏🏻🙏🏻🙏🏻

    Reply
  • Rita Singh says:

    U r a wizard at diagnosis.I am amazed again and again how u can understand cases so perfectly well.

    Reply
  • Maneck says:

    Very well thought of and written!

    Reply
  • Dr. gurudutt Satyendranath bhat says:

    Great writing as we have come to expect from you week after week.You stood behind your clinical skills and firmly declined to do an unnecessary procedure speaks volumes for your rational ethical approach.Kudos….

    Reply
  • Anuradha Karnik says:

    A very good article. The sign of a good doctor – belief in his diagnosis and ability to veer his patient away from his fear and anxiety. You succeeded in doing that.

    Reply
  • Anita says:

    Beautiful Beautiful 💐 Could not put my phone down .

    Reply
  • J T says:

    Very good writeup..

    Reply
  • Muhammad Ahmad Salisu says:

    Dr Mazda has said it all by using sound judgement to support his professional calling while tackling the uninformed claim of the patient in question.
    His disposition is corroborated by the legal maxim: RES IPSA LIQUITUR.
    That’s nice one!

    Reply
  • Khyati says:

    Total surrender is must ..

    Reply
  • Rustam says:

    Dr. Mazda. You are a genius . A brilliant Surgeon and the pride of your profession. Very fortunate are those that are under your care in the knowledge that they are in the hands of the best there is.

    Reply
  • Freddy says:

    Human being first….Very proud of you Dear Dr Mazda Turel.

    Reply
  • Connie says:

    Thank you for sharing your opinion doc. The realm of “knowledge” is sometimes very subjective. Until the patient flew the 3000miles to seek “knowledge” related to her back problem, she had been consulting with doctors who purported to “know” yet their knowledge in this case was not true. You provided the “true knowledge” that finally solved her problem. You did not assume what many of the other doctors assumed was true knowledge.

    As patients we need many of your kind that do not just cut and paste but that take time to look for the plain and honest truth. Now there lies our reason for travelling far and wide to search and look for those that truly give us the answers to our searches.

    May the Lord continue to guide you as you reveal these truths about our ailments.

    Reply
  • Jyoti Raut says:

    Excellent article.

    Reply
  • Manjul Tripathi says:

    Mazda bhai
    With your breviloquent and candid writings you are giving a new direction to the philosophy of neurosurgery. I am a witness to another Henry Marsh in making😌. Keep writing brother
    Manjul

    Reply
  • Marzin R Shroff says:

    In the age of “Google Doctors” most patients think they know more than their doctor
    But this case was a situation in which the patient was almost convinced she needed extreme surgery
    Well diagnosed Doc. Keep sharing your experiences every weekend.

    Reply
  • Germaine Boatwala says:

    Rarely are medical articles written with literary flair and benign wit of this calibre. It was enjoyable, also illumining. The patient, in pain and grief does want relief yesterday! But only the process of due diligence can unearth the actual cause and potent treatment for that pain. Great story, Dr Turel!

    Reply
  • Dr. Vivek Arur says:

    Very well written . Learnt the importance of keeping the open mind and not being carried away by patient’s
    Opinion .

    Reply
  • Sumit Singh says:

    Bravo Dr. Mazda. We’ve learnt to expect this from you.

    Reply
  • Dr Jayant Apte says:

    Good clinical Acumen based on experience shows in the diagnosis and firmness to stick to your opinion goes a long way in medicine . Hats off to Dr Mazda K Turel .

    Reply
  • Dr. Vivek Arur says:

    Very good clinical diagnosis & management

    Reply
  • Dr Shivkumar V Dalvi says:

    Excellent article.shows it is necessary to do the clinical exam.carefully n not be biased by patient’s insistence.Dont reoperate unless Dr is more than 100% sure.Congrats for ur coolness which helped the lady get total relief.

    Reply
  • Anjali Patki says:

    From inability to let well alone, from too much zeal for the new & contempt for what is old. From putting knowledge before wisdom, science before art & cleverness before common sense……wise words by Sir Robert Hutchison, which Dr Mazda, you have followed to perfection. Keep up the good work.

    Reply
  • Di says:

    Excellent article… well diagnosed.. doctor knows best especially if its genius Dr. Mazda! Liked the way you ended the article and the line “what one thinks one wants is not necessarily what’s best for you” 👍

    Reply
  • Cashmira Pashaei says:

    You are a great dr a kind soul and a wonderful writer. Sorry… I just can’t stop applauding you….gift to mankind.

    Reply
  • Cashmira Pashaei says:

    You are a great dr a kind soul and a excellent writer. Enjoy reading your articles, very knowledgeable.

    Reply
  • Herois Kambata says:

    The Doctor knows best. Google and wife come next. Shows how important it is to keep an open mind while coming to conclusions and making decisions.

    Reply
  • Adi Engineer says:

    It shows that a good doctor has to have a brain that is sharper than a Lancet and a cool headed disposition to arrive at the right diagnosis. Or else much cost and agony is involved without any gain. With the commercialisation of medical treatment this is hard to find.
    Bravo Doc Mazda.
    Adi Engineer.

    Reply
  • Ericson says:

    “I smiled, reflecting philosophically on the truth of the adage that what one thinks one wants isn’t necessarily what’s best for you.” ……so true Dr. Mazda! Thanks for your kindness always.

    Reply
  • Zarin Bahmani says:

    Bravo Dr Mazda Turel. Enjoy every article that you write with humour, and immense humbleness.

    Reply
  • Haresh Jumani says:

    Sir Managed beautifully
    Also case presentation with good phrases .
    While reading the case dr Shashi Tharoor pict came in front . Good language and command on words
    Superb Sir

    Reply
  • Pooja Hardik Gorasiya says:

    Dear Dr. Mazda,
    This was one of the best articles I have read from your collections..
    Thank God there was no need for the surgery…. You are truly amazing!
    Here i learnt, that in some cases patients ONLY require good guidance as prescriptions, than surgeries.
    May you always be blessed with good health and happiness.

    Reply
  • Poonam Nowzadick says:

    Thank u Dr Mazda for sharing your opinion.
    Good job..keep it up
    May god bless u and stay safe

    Reply
  • Vinod Ahuja says:

    Excellent article interspersed with a dash of humour and of course clinical acumen. Thanks

    Reply
  • Kash says:

    Wonderful article as always! Such an insight into life as a surgeon and more importantly as an intelligent, honest doctor who truly cares for the wellbeing of his patients!

    Reply
  • Dr. Nisha Savla says:

    Congratulations …Dr. Mazda,
    The decision of not treating the patient without arriving at proper diagnosis requires courage and confidence which is as important as knowledge for the proper management of the patient. Clinical checkups are more important than any investigation to avoid misdiagnosis…a true message from your article..to doctors as well as to patients…

    Reply
  • Vrushali Telang says:

    What a brilliant piece ! I do not have a medical background but your writing makes me want to know more about the world of surgeries

    Reply

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