Monday, May 24, 2010

Consultations

Recently Dr. Debra Benzil (Women Neurosurgeons: Hearts and Hands) wrote a post suggesting doctors are often their own worst enemies.  As I continue to read through Dr. Robert Goldwyn  essays, “The Operative Note: Collected Editorials” (published in August 1992), I came across this one which suggest the same. 

I contend that his essay could apply to consultations for many different medical and surgical issues in how we physicians treat our patient and each other.  The bold emphasis is mine.

 

Consultation for Breast Reconstruction

The woman who has just heard that she has breast cancer faces not only the prospect of deformity and death, but also the quandary of having to decide among various treatments:  mastectomy – radical, simple, or segmental; node dissection; chemotherapy; or irradiation – alone or in combination.  Should this patient later want breast reconstruction, she must sort through another set of alternatives.  A few years ago, the choice for patient and plastic surgeon was relatively easy – an implant or nothing.  The advent of musculocutaneous flaps has allowed more latitude and, in may instances, superior results.  Even the implants have changed and now exist in a bewildering array:  saline- or gel-filled, in various sizes, shapes, and thicknesses, as well as the expander type.  My purpose here is not to list the indications, advantages, and disadvantages of each or to advocate one over another.  Numerous articles in this Journal have already done so.  This editorial is to make two pleas:  for each of us to take the time to explain to the patient the different methods for rebuilding the breast and the reasons for our specific recommendation, and for each of us not to denigrate the plan or person of another plastic surgeon who may have suggested something different to that patient. Results, though improving, are still not ideal and should not foster dogmatism.  The fact that the number of plastic surgeons has increased makes it easier for patients to obtain additional opinions.  In my own practice, I have heard such statements as “Dr.  ____ says that the flap from the abdomen is the only way to do it.”  Or “Dr.  ___ said that implants should never be used if you can avoid it.”  and “Dr. ___ told me and my husband that it is rarely necessary to use a flap because an implant can do the same thing more easily.”  One wonders whether that surgeon knows  how to do a latissimus dorsi or rectus abdominis flap.

I realize, of course, that patients misquote doctors; nevertheless, I am sure that much depends on what door a patient enters.  One surgeon may be in hsi Radovan expander phase; another in the flush of his first rectus flap; or a different surgeon may be fossilized, unwilling to try anything other than an implant.

Advising a patient about breast reconstruction involves the same principles as counseling in other areas of medicine.  What are the objectives and what methods are available for attaining them?  Am I capable of providing that treatment?  If so, should I proceed?  If not, I should refer.  In all these deliberations, the patient must be an informed participant.  Involving the patient and helping her choose a course of action is not the same as making the patient decide on her own.  The doctor who lists the serval ways of reconstructing the breast as a waiter would recite the entrees for the evening abrogates his or her responsibility.  The patient did not come to the surgeon to flounder in the sea of indecision while the surgeon sits comfortably in a nearby lifeboat.

Since reality is seldom perceived beforehand, photographs of average results of breast reconstruction, showing scars in the recipient and donor sites (if a flap is to be used), are helpful.  So is having the patient speak to or perhaps, see another patient who has already been through the ordeal.  One has to make clear in the record and to the patient that this does not imply guaranteeing a similar result.  In fact, on occasion, I have referred a patient to someone who is unhappy with the result if I sensed the new patient was screening out information about what could go wrong. 

Breast reconstruction is a challenging aspect of our specialty.  With several thousand plastic surgeons working in the world, ingenious developments will be forthcoming.  Tolerating ambiguity is necessary if we are to advance.  Is there unanimity in how to repair a cleft palate or how to treat cancer of the tongue or breast?  Breast reconstruction has come of age; there are now several ways of doing it.  Despite this variety, I expect that surgeons of the next generation will do better for patients than we can now.  Perhaps the need for breast building will have disappeared if an alternative to mastectomy proves effective and safe.  In the meantime, we must remain sympathetic to the patient, who bears the greatest burden. We should not make her lot more difficult by behavior that is unprofessional toward colleagues and damaging to those whom we are supposed to serve.

3 comments:

Gizabeth Shyder said...

Well put. If we get this message out there, the world might be a better place.

DBenzil said...

Thanks for the mention-the passage is lovely and obvious the message applicable well beyond breast reconstruction.

rlbates said...

DBenzil, the mention is well deserved. Thank you.