When good doctors leave patients unhappy

Every patient is equally precious, the effort to heal is also equal. But not every reaction is as sunny as you imagined it to be.

Doctor saheb, aa operation thi mane kai pan faaydo nathi thayo,” said Mr Shah when he visited me for a follow-up three months after I had operated on his lumbar spine. Pre-surgery, his bones had degenerated and the thickening of the spinal ligaments pressing down on his nerves, left him with severe pain and a tingling in his legs when he walked. This condition, we call, lumbar canal stenosis. His vertebrae also had an abnormal movement. I discussed the options with him: a slightly larger surgery, which would require some screws and rods, or a smaller, minimally invasive one, where we’d simply release the pressure on his nerves by drilling the hypertrophied bone and biting off the compressing ligaments.

Given that he was 77, had osteoporosis, uncontrolled diabetes, and varicose veins, he opted for the latter—and rightly so.

The operation went off well, but after temporary relief, he was back to square one. He’d call me every few weeks. “Sir, you said, with a smaller operation, I’d have 70 to 80 per cent chance but I’m not even feeling eight per cent better.” He said he had approached me for a consult because his neighbour, whose spine I had operated on, did very well. He wished he had gone to a more “senior” doctor.

I saved his number on my phone thus: Mr Shah—unhappy lumbar spine.

When patients don’t do well despite the doctor’s best intentions and efforts, it’s gut wrenching. We try and analyse, in our head and often in the heart, if we should have done something differently. I wonder about a possible glitch in process that could have delivered a less-than-satisfactory outcome. Would I offer the same options to another patient who came to me with the same problem? Have I been truthful and transparent in decision-making? What do I do to rebuild the trust the patient had in me before he agreed to surgery?

I explored the regular route of pain-relief medication, continuous physiotherapy, and even recommended the larger operation. I suggested that he take a second and third opinion. But, he received conflicting advice that confused him further.

He decided never to have surgery again.

The spine is a complex part of the body. The pain generators could be in the muscle, bone, ligaments, or the nerves. In fact, the cause of the pain is often a combination of these. In my opinion, the success of any surgery lies in choosing the right patient and operating when the radiology matches the clinical symptomology. Following this dictum, over 90 per cent patients do well, but there will be a handful who will leave you miserable and drained, but they also keep you grounded. To see their name show up on your phone display is demoralising, but you have to give them your best each and every time. You have to work with unhappy patients and find alternatives to help them. You have to give them more time than you would to those who walked away happy.

Spine patients tend to be unhappy owing to multiple reasons: a complication in the primary surgery, the development of a post-operative infection resulting in prolonged hospital stay, and agonising antibiotics. Or because the next level adjacent to the one operated on started undergoing new degeneration. National and international meetings are routinely held so that surgeons can discuss these issues.

Several months after a streak of successes and perfectly performed surgeries on the brain and spine with excellent outcomes, I operated on Mr Daruwala, 83. He had a problem similar to Mr Shah, and his symptoms were not adequately alleviated either. “I hate to tell you, but I don’t feel any better. I would be lying if I said I’m okay,” he confessed. He felt he should have consulted me earlier, or that it was his pre-existing neuropathy that was interfering with the healing. “I pray that Khodaiji [generic term for God among the Parsis] blesses you. May you continue to help the community and society.”

I turned red in the face. I was unable to tell if such a reaction from a patient was a harder blow than someone directly suggesting that I had used them as guinea pig. Should I be relieved that this gentleman had taken the onus of the outcome on himself, or was he simply being kind to a fellow Parsi?

When I tried to find the answer, Philip Roth’s words came to mind: All that we don’t know is astonishing. Even more astonishing is what passes for knowing.

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