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Health Matters: Difficult choices for conservative versus surgical care

Conway McLean, DPM, Journal columnist

You have to admit, there’s a certain panache to being a surgeon. Society reveres the healer who wields a blade. Think Benedict Cumberbatch in Dr. Strange. Brilliant, handsome, wealthy and arrogant, he was the epitome of a hot-shot surgeon. Isn’t this the image that comes to mind for most people? Maybe not so much the handsome part, but how about the rest?

Surgery is viewed by some as a certain cure. Unfortunately, this is sometimes not the case. The list of complications possible that can result from a surgery is extensive. Those readers who have signed a pre-operative consent form may have had this list read to them. It is intimidating and includes failure of the operation to provide relief, infection, painful scarring, recurrence of the problem, and a host of others, even death. Clearly, conservative care should be the first option.

But what is a physician to do when they are surgically oriented, and their training is concerned with performing surgery? When an individual presents with a painful problem, but insufficient conservative care has been attempted, is a recommendation for surgery appropriate simply because it is the doctor’s area of expertise? It happens frequently: someone presents to a physician, not certain what their practice orientation is, and a recommendation of surgery is given.

Many people assume this is because the only treatment option is operative. Indeed, various conditions demand surgical intervention. Some would offer appendicitis as a good example. Actually, conservative care for this malady has been studied and found to be a good option in many cases. Thus even this problem has validated, effective non-surgical treatment.

The internet makes it less likely for a patient to have no idea how their malady is best treated. It is now easier than ever to study one’s diagnosis thanks to the internet. Predictably, some of the problems with this approach should be obvious: the world wide web is saturated with inaccuracies, misleading statements, as well as outright lies. Additionally, it is common for someone to visit a physician with some complaint, but leave the doctor’s office with no clear idea what their problem is. Getting a diagnosis can be challenging.

Patient education is a tricky thing. Many don’t want to know any of the important details; they only want their physician to resolve the problem. In my experience, it is more common for the patient to want this kind of critical information. But then, everyone is different, including physicians. Some seem not to want to bother with that sort of information. Others dispense diagnoses casually, giving out only the most general labels, similar to telling a patient they have knee pain because there is some arthritis. This specifically means the joint is inflamed and nothing else, although there is generally a reason the knee structures have degenerated so. The real cause is often never discovered.

One example germane to this discussion is heel pain, aka plantar fasciitis. This ubiquitous condition varies greatly in its presentation and the pain produced. Many will obtain relief by doing stretches and using pre-fabricated arch supports. Others end up getting custom, precision foot orthotics. When properly prescribed, these have an excellent success rate, negating any need for surgical intervention. According to many experts in lower extremity musculoskeletal function, because this type of intervention has few side effects, surgery should not be performed until orthotic therapy has been attempted.

In this same vein, what about the heel pain patient who presents to a physician for their pain and is shown their x-ray, revealing a bone spur. When the doctor says it is the problem and the spur must be removed to get resolution of the pain, many will believe this piece of advice. In truth, the spur found on the bottom of the heel bone is not a weight bearing structure. This is a common finding on the radiographs of many people, including those who have never had a day of heel pain in their life. This specific bony prominence is not a weight bearing structure and causes no pain. The pain is from the inflamed arch ligament. Removing this spur tends to cause post-operative problems. When plantar fasciitis doesn’t resolve with conservative therapies, we don’t even touch the spur. Thus, pointing to a spur on x-ray and claiming the patient needs surgery is inappropriate. This cliché is apropos: we don’t treat x-rays!

Surgery is not a magic bullet: there is always the potential for problems afterward. It is not always the best option. Unfortunately, many view operative intervention as an instant cure. But all surgical procedures have the potential for complications. None are devoid of all repercussions. You are cutting into the human body, and possibly damaging a plethora of structures. This is one of the most obvious explanations for the move towards minimally invasive procedures; why cause more trauma to the more superficial structures than is necessary, if still able to achieve the surgeon’s goal to the target tissue.

Our integument, aka skin, is a fantastic barrier to most residents of the microbial world, eg germs, virions, bacteria, etc. An operation, by its very nature, must, in some way, violate this boundary. Although post-operative infections are less common than they once were, they still occur. In orthopedic medicine, where various implants are placed in the human body, infections are a tremendous problem.

Biofilm formation is the most common reason. This is a term referring to a coating which develops on a device placed inside the human body. These films are composed of a variety of different bacteria and the tough, resistant material they produce. They are encased in this amorphous mass, sheltered and protected. Once they grow on an implanted device, be it a new hip joint or a metal rod securing a broken bone, these films are extremely difficult to remove. And they tend to grow.

The health care industry is de-valuing surgery, with reimbursements for many procedures dropping steadily. In contrast, payments for office visits, ie conservative care, has been noticeably increasing, as per the intent of CMS, the governmental agency which runs Medicare. Although surgery was once quite financially rewarding, this is no longer the case. A surgically-based practice now has a tougher time of things, what with the expense of a medical office increasing steadily and dramatically over the last few decades. The cost of staffing a medical practice has also gone up. Being a surgeon (depending on the specialty, naturally) is not as lucrative as it once was.

Every physician providing operative intervention for a problem is going to be informed and knowledgeable of the treatments available. Most conditions have conservative and surgical options. I am not for a moment saying there always is always a conservative one, for all problems. If there is one though, and it has a chance of resolving the problem, shouldn’t it be attempted?

Upon receiving their medical degree, physicians take an oath to, above all else, do no harm. This should necessarily include exhausting conservative measures, whenever and wherever possible. To do otherwise is to break the Hippocratic oath. This should be contrary to the ideals and goals of modern-day practitioners of medicine. If a condition can be resolved conservatively, those measures should be pursued, regardless of who is treating. If surgery is recommended to you, be certain the non-operative interventions appropriate have been attempted prior to giving your consent. Your health and welfare are at stake.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.

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