Put Down the Xray and Talk
Forget about house calls…Dr. Neel Anand, Director of Orthopaedic Spine Surgery at the Cedars-Sinai Spine Center in Los Angeles, would be happy if orthopedists would just examine their patients.
For a number of reasons, we have reached the point where imaging tests are ubiquitous and random. Some days it seems that all orthopedists do is look at tests.
If you are going to be a medical detective, says Dr. Anand, you need to use all the tools available to you…even if they are seemingly basic/old fashioned/not sexy. “Just because you see something on an Xray doesn’t mean it is the source of the problem. Our job as orthopedists is to put together all of the clues and correctly determine what is causing the patient’s symptoms. But all the signs need to point in the same direction…the clinical exam must correlate with what the technology is telling you. You should not, once you have found something on the MRI, then try to make it match with your findings from the clinical exam.”
Getting Back to the Fundamentals
Getting ahead in the field should not mean getting ahead of oneself…or getting ahead of the patient. Dr. Anand: “Orthopedists have more responsibility than ever, and I’m sure we’re busier than ever. But that doesn’t mean we can forget the fundamentals, including the fact that we are doctors because of the patients. They probably don’t know their diagnosis, but they are certainly the best ones to report their symptoms. These days it is normal for residents to look at the imaging before seeing the patient, and, as they walk into the room say to themselves, ‘OK, she’s got stenosis at T3, T4, so I will do a decompression.’ Then they find that the patient has other symptoms. If the doctor doesn’t do a detailed exam, then the patient ends up being operated on at more levels than necessary.”
Which, of course, sounds not just unethical, but seems like something that would interest a lawyer. “The fallback is the radiologist, ” says Dr. Anand. “He or she reads the films and, for example, writes ‘spinal stenosis at T3, T4’ in the report. Then the doctor finds something else during the clinical exam. In the event of a lawsuit, however, the defense attorney can say that stenosis was in the report. A good prosecutor, however, will essentially say, ‘Well, Dr. X, didn’t you go to medical school as well? This is your patient.’”
Thus for many reasons a touch of the old fashioned is in order. “Over time the importance of history taking and the clinical exam has been relegated to background. In the past we had grand rounds in which the doctors would go from patient to patient as a team taking the history and discussing the management and care of the patient. Today we sit in radiology rooms, throw films up and talk about them, as opposed to discussing the whole patient.”
“The value of the history and physical has also slid into the background in residency training, ” continues Dr. Anand.
When the history is presented on the podium, in most cases the resident doing the presenting has just taken the information from the chart. This misses the fact that the patient has recently gone through a divorce, has major psychological issues, or that he had similar symptoms six years ago that resolved themselves.
Recalling a clinical situation he once encountered, Dr. Anand notes, “I know of a case where the patient presented with classic back pain accompanied by leg pain. The majority of leg pain is related to just one nerve, so any pain down the leg has to follow the pattern of that nerve (the L4 nerve). The patient had seen three orthopedists, had a block, and the MRI was reported as normal…but no one had bothered to examine him. The fact that the block had improved his pain meant that there was indeed a problem. It turned out that he had an extra foraminal disc—and yet people had written him off as histrionic.”
But if it’s not in the patient’s head, it may be in his neck. “You may have someone with cervical myelopathy, who presents with bizarre symptoms such as dropping things, a change in handwriting, and stumbling. A well trained spine surgeon will be comfortable doing a neurological exam in order to fully assess the situation.”
“Let’s take another case, ” says Dr. Anand. “You have a 65-year-old woman with multiple levels of stenosis or degenerative changes, all of which is noted on the report. If you talk to the patient, you will find that she is active, and in fact walks five miles a day. For more than six weeks she has had pain down to her foot, to the top of her foot to the great toe. This is clearly related to the L5 nerve—she has no symptoms in her other leg and is otherwise healthy. All she needs is a block at L5, not, as some would preemptively say, a fusion or four level decompression.”
Continuing with the all too frequent back pain theme, Dr. Anand notes, “Back pain is usually mechanical and comes from loading, i.e., sitting for long periods of time, lifting, etc. The patient may be fine in the mornings, but gets up from a sitting position and feels pain. The same patient now tells me that his buttocks hurts, meaning that a pinched nerve is the likely culprit. But a lot of patients don’t differentiate between their back and their buttocks. Buttock pain needs to be differentiated from axial central back pain, as it usually indicates radicular pain and a pinched nerve, as compared to axial pain which is pain from the disc or facets.”
Learning Good Social Skills
While you didn’t go to medical school to learn how to be a good human, having a clinical practice may indeed require that you learn those skills anyway. “It may sound mundane, but you must have good social skills. We are dealing with people who are in pain, angry, and who may feel that they have been given the run around. Even though you may feel like walking out the door, you have to listen to their stories. Just accept that a full understanding of the person’s situation means that you will have to give of yourself…and give your time.”
Dr. David Helfet, Chief of Orthopaedic Trauma at Hospital for Special Surgery, concurs. “There is no question that a patient’s history and examination are still the most important aspects of the evaluation. No matter how much people try, we are not supposed to be treating an Xray. And Xrays are only part of the picture because while they define a bony injury, they don’t define a soft tissue injury. You could actually be dealing with a nerve injury, vascular injury, a muscle or tendon injury, none of which will show up on an Xray.
“Most of my senior colleagues and I are proponents of ‘old school’ orthopedic education, i.e., you talk to the patient, examine the patient, and only then review the imaging. This trend in medicine to jump to the technology means that people are looking at the bloodwork, scans, etc., and are in fact spending more time reviewing this information than talking to and examining their patients. Technology has unfortunately taken over healthcare.”
Laying out what could be a confounding situation, Dr. Helfet states, “Let’s say a patient presents with knee pain…you take a knee Xray, find some arthritic changes and jump to the conclusion that the patient needs knee surgery. If you examine the patient, however, you learn that the knee itself doesn’t have pain but that it is actually emanating from the hip.”
The wavelengths on the Xray are sometimes less important than being on the same wavelength with the patient, says Dr. Helfet. “Mr. Jones comes in, says he’s had an accident, and that his hip doesn’t feel right. The doctor reviews the Xrays and says, ‘Well, I don’t see anything, ’ but doesn’t examine the patient or doesn’t adequately examine the patient. Maybe it’s a case where the hip subluxes or impinges and almost pops in and out of the joint. You have to take the time to go through all of this with this patient. Sometimes I run two or three hours late, but believe it or not patients don’t mind…they do mind if they wait two hours and then you spend only a few minutes with them.”
To those whose starting point is a legal one, Dr. Helfet notes, “Don’t practice legal defensive medicine—practice good medicine. Then you don’t have to worry about litigation. You can easily justify your decisions and actions, and have a history of communicating well with patients.”
“We have a noble profession that is sometimes dirtied by a few bad apples. Truth be told, we have a contract with every patient—an ethical and moral contract—one that they expect us to fulfill.”