July 24, 2024 • 48 mins
In this episode, we delve into the topic of ethical considerations in orthopedic surgery. Departing from our usual focus on surgical techniques and physical therapy, we explore the delicate balance between patient autonomy and fiduciary responsibility.
The episode features a special guest, Dr. Claudette Lajam from NYU, a distinguished joint replacement surgeon and professor in the Department of Orthopedic Surgery at NYU School of Medicine. Dr. Lajam shares her insights from a recent article in the Journal of Bone and Joint Surgery, discussing ethical challenges such as declining surgical interventions for high-risk patients and the importance of informed consent.
Listeners will gain valuable perspectives on medical ethics, including beneficence, nonmaleficence, patient autonomy, and justice. The conversation also covers practical aspects like the role of risk calculators, the impact of obesity on joint replacement outcomes, and the importance of communication in patient care.
Join us for an engaging and educational discussion that sheds light on the ethical dimensions of orthopedic practice, offering valuable takeaways for both medical professionals and patients.
Follow us on (X) and Instagram @theskcpodcast, visit our SKC Podcast YouTube and Facebook pages, or email us at theskcpodcast@gmail.com
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Music.
(00:14):
And tonight's episode is going to be another interesting discussion,
a little bit of a different topic, as we're not necessarily discussing specifically
a surgical or physical therapy topic.
We're talking more about ethical considerations and things like that in orthopedics.
And we'll talk a little bit more about that topic here in a bit.
But I'm excited about our guests that we have tonight.
And I think it's going to be interesting content for all of you that are listening.
(00:36):
If you want to hit us on social media, we have Twitter and Instagram at the SKC Podcast. podcast.
We have a Facebook and YouTube channel as well for the Shelburne East Center podcast.
If you need to contact us, which we'd love to hear any questions you have,
you can send that to theskcpodcast at gmail.com.
If you want to catch any of our previous content, you can find us on any podcast
avenues at the Shelburne East Center podcast.
(00:58):
Leave us a five-star review if you like what you hear and check out our previous episodes.
And speaking of previous episodes, before we get started tonight,
just wanted to go over the recap for last week. We talked with Dr.
Catherine Harper from the D.C. area.
It was a great conversation. We talked about intraosseous medication delivery
for total knee replacements, and it was really a cool topic,
and it's one that I have not really had any experience with.
(01:20):
And learning from Dr. Harper was really fascinating in terms of what they're
looking at from a research perspective and what kind of outcomes they're getting with that.
So go back and check out last week's episode on intraosseous medication for total knees.
Tonight, we're discussing an article from the Journal of Bone and Joint Surgery,
another JPJS article from their orthopedic form section, where we talked about,
(01:40):
where we found ethical considerations of declining surgical intervention,
balancing patient wishes with fiduciary responsibility.
And the first author on that, Dr.
Claudette Lejeune is here tonight from NYU.
She is a joint replacement surgeon from NYU.
She's fellowship trained, actually we've learned now in talking before we started
(02:02):
here year that we did the same fellowship at Insull Scott Kelly.
She did residency at Mayo Clinic before that fellowship. She's now a professor
in the Department of Orthopedic Surgery at NYU Grossman School of Medicine.
She is also the Director of Quality and Safety in the Division of Adult Reconstruction,
and she is also the Quality and Safety System Chief for Orthopedic Surgery.
So, Dr. Lejeune, thank you for joining us tonight on the Shelburne Center Podcast,
(02:25):
and we're glad to have you here to discuss this topic.
Well, thank you so much for having me, Scott and Rodney, this is really an important
topic and it's very interesting to me.
So I really appreciate your giving me the opportunity to discuss it with you today.
Let's jump right in. How did you get interested in this topic?
How did you become a part of this, the generation of this manuscript?
And how did you become an expert on this to write for all of us to read about?
(02:47):
Well, you know, I'm sure a lot of us have been faced with these situations where
we have patients who are very, very high risk for surgery.
And we then perform surgery and then something really bad happens and then we
look back on it and we say, wow, okay, maybe we could have offered them something
else or maybe we could have declined or we could have done something else.
(03:10):
And now that it's oral boards time, a lot of our young surgeons are thinking
about those things right now.
So I think it's absolutely appropriate because indications are the most important thing we do.
We can be skilled surgeons. We can be technically amazing.
But if we don't select the correct patients to operate on in terms of risk benefits,
balancing the risks and the benefits of the operation, I think then that's how we fail.
(03:33):
And that's how we should train our young surgeons is to make sure they understand
when operating is the right move and when it's not the right move.
So the genesis of this paper came about because, as you said,
I'm the system chief of quality and safety for all of our sites,
and I see everything that goes wrong.
(03:56):
So when something goes wrong, I see it.
And Joe Bosco, who is our vice chair of clinical affairs and former president
of the academy, he and I discuss them frequently.
We discuss these cases and say, oh gosh, should they really have done this at this time?
Now, obviously hindsight is 20-20, but we saw, we look at these cases and we're
(04:18):
constantly discussing them.
And we said, you know what, we should do a department meeting and discuss these
challenging cases and the ethics and how we balance them, how we balance informed consent,
how do we have a discussion with patients, what are the barriers that we face,
and what are the ethics of this.
So we decided to have a department meeting and we discussed all these things
(04:38):
and we invited one of our medical ethicists, Dr.
Barron Lerner, who is an expert on the ethics of.
Medical care. And we sat at a round table and we had a really robust discussion
in person about a bunch of cases.
And we said, you know, we should really write about this because I think this
meeting, this department meeting was really beneficial for everyone that was here.
(05:03):
It generated a lot of discussion. It generated a lot of discussion after the department meeting.
And we thought we wanted to extend that benefit to the readers of a journal
that if the journal wanted to publish it. So that's really the reason we did that.
And we do have a history of publishing on medical ethics because we do have
a robust medical ethics department led by Art Kaplan, and he's a pretty well-known medical ethicist.
(05:28):
We've written a few papers before, especially when value-based care became prominent.
We wrote about the, we debated the ethics of value-based care.
So that's a long answer to a short question, but there's a lot of background there.
Well, I'm glad that you could bring this topic up and I'm glad that you wrote
this article just because there's just, you know, we spend so much time as surgeons
(05:49):
and I just, Scott and I just returned from the AOSSM meetings,
the summer sports medicine meeting, and there's just so much talk about surgery.
There's so much talk about surgical technique.
What surgery do we do? How do we do it? What are the outcomes from that surgery?
What are the pitfalls of that surgery?
But there's very little discussion at that meeting. It's not to impugn that
meeting. I like that meeting.
But the Academy meeting, the office meeting, the same kind of things,
(06:12):
that people are just talking about surgery and there's just not much discussion
on who are we actually operating on?
Who are we providing non-surgical care to?
What are the best, you know, the pearls and pitfalls that we can give people
better non-surgically?
It just seems like an area where we as orthopedic surgeons could really get
better and, you know, put our patients forward of our surgical volume and our surgical techniques.
(06:42):
And that's a great point because we are, and now that our pay as surgeons continues
to be decreased by congressional and regulatory decisions,
and I know that's in the news and all over social media now,
we are really pushed to do more procedures.
And it's more difficult to not
(07:04):
do them. We have to be able to support our practices and our institutions.
So a lot of our thinking is shifting because we need to be able to,
you know, keep up with the volume of patients.
And a lot of the time, we need to pause and consider the whole patient.
And some of our patients really aren't good candidates for surgical intervention.
(07:25):
And when are those patients better served by not having a surgery?
And that's a big decision we need to decide about.
Yeah. So you jump into that in the manuscript, which I was happy about that
from the very beginning when you talked about the medical, the legal,
the financial, and fiduciary environment that really surrounds this topic.
So before we even jump into that, just discuss a little bit about those kind
(07:48):
of backgrounds of the environment that we're all practicing in and how that
kind of sets the stage for starting to think about these things in a different way.
Well, absolutely. I mean, a lot of U.S. News and World Report just came out
this week, yet today, actually.
And, you know, we're number three in the nation, NYU, go NYU Langone.
But a lot of those metrics are, thank you, a lot of those metrics are based
(08:13):
on mortality and volume and all these things and hoops you need to jump through.
And I think sometimes we get blinded by these metrics that we have to meet.
And there's more than one set of metrics.
Medicare has a readmissions metric. I mean, there's lots of different things
that hospitals and surgeons are graded on with regard to what we call quality,
(08:33):
but what we really mean is compliance.
We want you to comply. We want to keep costs down. So we want you to comply
with what we think is quality.
And it's very, very difficult sometimes to navigate that.
So there's a lot of pressure. And also we have the legal environment.
In the US, we have the most aggressive legal system in the whole world.
(08:53):
And in some states like mine, it's extraordinarily aggressive.
There's almost no limit on what can happen to you as a physician,
even if you do everything you should do, you can still be sued and lose everything
depending upon the court you're in.
So there's a lot of things you have to consider as a doctor when you make these
decisions to operate on somebody.
Really not a topic at the sports medicine meeting. Just out a couple of high-profile
(09:17):
cases with multi-million dollar judgments against orthopedic surgeons for what
I perceive as some pretty straightforward decision-making in the operating room
that we make all the time.
And I hear those talks and I want to be educated on those, but it scares the
hell out of you to think about those. You know, this professional athlete comes
into my office, wants an ACL reconstruction, sweet, I can do this big,
(09:39):
you know, this big time athletes ACL reconstruction.
But what kind of, what kind of, you know, what does that open myself up to,
you know, how do I, how am I putting myself at risk versus I would get the same,
paid the same doing their ACL as I would yours or Scott's or any,
you know, anybody else's.
And it's just it's just a kind of an interesting time to be doing what we do in particular.
(10:02):
And hopefully, you know, the people at our societies and our in our academy
continue to work diligently to try to make that environment better.
We're pretty lucky here in Indiana, to be honest with you, that our malpractice
environment is is is much more much more physician friendly.
We have any kind of a suit that gets brought by a patient has to go to a medical
(10:23):
review panel of physicians for them to give a recommendation before it can get to the operating room.
That doesn't mean they can't bring the suit if they don't want to,
despite the fact that the physician panel says that it doesn't hold water.
But it gives us a layer of review if that were to happen.
And I understand the environment is not like that in other states. New
(10:46):
York is a frightening place for physicians and that's why we train everybody
and we retain almost nobody here because the environment here is absolutely
ridiculous in terms of you don't even need an expert in your same field to be
an expert witness against on the plaintiff's side.
The plaintiff's expert doesn't need to be board certified here.
(11:11):
And pretty much anybody can sue anybody. And there's unlimited liability.
There's no limit on anything. So you can lose everything. You can lose your
house. You can lose your kid's college tuition.
And it doesn't even mean that you did something wrong. It's just a bad outcome
can do that because your jury is a bunch of lay people.
(11:32):
And they don't understand medicine. They don't understand surgical decision-making.
And that's what the plaintiff's attorneys rely on, is that they don't understand
that you have a jury that you can manipulate to think that someone did something
wrong when we absolutely didn't, just because we are doctors and it's a different
world that we live in here.
So there's no way for you to have a fair trial as a physician in New York.
(11:56):
Long topic for another day, not exactly the subject of this paper,
but we could be talking about that one all day.
Yes. The one thing that I do recommend, though, is if you are a member of the
Academy, that one of the most beneficial things you could do is become a member
of the PAC, the Political Action Committee, because that does a lot of good work.
We have some fantastic people leading that. Wayne Johnson is now the PAC chair,
(12:18):
and Adam Brueggemann is the Council on Advocacy chair, and they're both really
dynamic hustlers. They hustle.
They make it work. They make it happen. They're amazing. amazing so you've got
a really good team working for us there so there it's worth an investment into
the pack if you haven't already joined.
Now, going back to the origin of this manuscript, you talked about a staff meeting,
(12:39):
and the three aspects that we were just talking about are pretty heavy topics.
We're talking medical, legal, and financial implications as it relates to the care of patients.
Now, when you said that really the impetus of this project was a staff meeting
that you had, what was that like in terms of who was there?
I know you said that it was a really robust discussion, but was it only orthopedic surgeons?
(13:01):
I know you said there were some ethical experts as well. But as far as other
members of the medical center or anything like that, can you go into a little
bit more detail about what that looked like?
And you don't have to get into that much detail about the exact conversations,
but just the overall tone and who was maybe involved with those decisions.
So we have a very large department.
(13:21):
We have almost about 250 orthopedic surgeons in our department.
That's very, very large.
And except for during covid when we
couldn't we have live in-person department
meetings and i don't know who else still does that
but we do and that room is packed like you there's standing room only for these
(13:43):
meetings and we we have some guest lecturers and they come in the door and they
just can't believe how many people are there you know they're taking pictures
you know to send to their chairman to say wait a minute look at this there's
actually like a you 250 people here.
And that also includes some of our physician extenders, our PAs,
nurse practitioners sometimes come to these meetings.
(14:05):
We do have affiliated faculty.
For instance, one of our vascular surgeons was there that day.
But the ethicists we invited specifically to come to the meeting.
Our residents are also at the meeting.
So it was a really good conversation because we spanned topics on a bunch of
different specialties.
(14:26):
And in the article, we, I mean, we changed a lot of the details about the patients
to protect their privacy.
The general idea of the case was the same. And we had a sports type case. We had a spine case.
We had a total joint case. We had a fracture case, a wrist fracture.
And all those patients came to an orthopedic surgeon one way or another and
(14:49):
had some, there was an ethical decision that was made when surgery was decided
on and outcomes were not so great in most of the cases.
And in one case, you know, you know, it was not so great, but the patient wanted
to have their other side done after that.
So you have to really understand that, you know, what's informed consent,
how do we talk to our patients?
So our department is kind of used to, or I mean, we're New Yorkers,
(15:13):
most of us, we are pretty vocal, we don't hide what we think.
So there was a lot of discussion and people speak up and say what they think.
So there were some people that thought that, you know, how could you possibly say this?
That's crazy. How can you deny patient surgery?
You're you're cherry picking. And then other people on the other side say, we need to do this more.
You're telling people you're going to help them and you're really not going
(15:36):
to help them that much and you're putting them at risk.
So there was a lot of debate and it was pretty passionate, actually.
So obviously that robust discussion
led to this paper and talked about the aspects of medical ethics.
And you really talked about the four aspects of beneficence,
non-maleficence, patient autonomy, and justice.
Before we get into the nitty gritty details here, can you just go briefly over
(15:58):
those four aspects and tell the listeners what you meant by those four?
Well, sure. I mean, these are pretty well established. So there's four basic
tenets of medical ethics or ethics.
And you just said what they are, the beneficence, non-malfeasance or non-maleficence,
patient autonomy, and then the question of justice.
(16:20):
And then we added our guiding principle that there's a primacy of patient interest,
meaning that you have to put the patient first when you make these decisions.
So basically, we'll go through them all.
So beneficence, and like it sounds, what we do should improve well-being for the patient.
(16:41):
And I can talk about a little bit of the controversies about what that means,
because well-being for us might not be the same thing as well-being for them, for the patient.
So we want to make patients better.
That's what we consider well-being. But patients think, okay,
what's going to make me happy? be? What's going to make me comfortable?
And they may not think about the bad things that can happen.
(17:04):
They think, oh, I want this carrot that you're dangling in front of me.
So beneficence may mean something to you that's different from what it means to the patient.
And then the second question, and that ties into the first one,
is a non-maleficence or non-malfeasance.
And that means don't hurt someone. Do no harm.
What you do should not cause harm.
(17:27):
But sometimes a patient would rather die than live with a painful condition.
So they think the harm is denying surgery, whereas you consider harm that they
might pass away or die because they're high risk for surgery.
So there's a lot of things that we have to consider when we think about what is harm.
(17:49):
And then the third thing is patient autonomy. So what that really means is not
that patients should to be able to do whatever they want, but that when they make decisions,
they should be allowed to make decisions without influence that's high pressure
to them, that they should be able to.
Make their own informed choices. Doesn't mean they're always going to get what they want.
(18:12):
As we all know, a lot of people don't make great choices, and that sometimes
lands them in a position of needing one of us, you know, especially trauma surgeons.
And then finally, the concept of justice.
And that goes back to the concept of the tragedy of the commons.
We have limited resources in our society, and that's become very,
very obvious in the past 15 years since we started and instituting value-based
(18:36):
care and trying to look at what things cost and the cost-benefit relationship
of anything that we do in medicine.
And the tragedy of the commons means that if there is a limited resource,
we need to protect that resource.
And you need to know that when people have access to a public resource,
(18:58):
you don't want them to have to deplete that resource. source.
And this goes back to, you see even in England in the NHS, if their region runs
out of money, they can't do any more surgery for that time period.
I mean, that's just how it is. This is your budget. If you run out of money,
you can't do anything else.
So it's very real. So if you're going to operate on a high-risk patient and
(19:20):
have a bad outcome and spend a lot more money, you can't treat 10 low-risk patients
with that same resource.
So these are real questions that We have to think about when we're doctors and
most of us just want to know, oh, do you need a knee replacement?
Oh, do you need a rotator cuff repair? Oh, you broke your wrist. Let's fix it.
Whereas, you know, we don't want to be thinking about all these questions all the time.
(19:41):
So it's very hard sometimes to think about all these processes when we're talking to our patients.
Yeah, I thought that was really interesting the way you laid that out in the
manuscript that we're referencing from the Orchid Forum and JVJS.
Go read it where you talked about the the the kind of intermingling of the high
and low risk patients and how taking care of high risk patients could potentially
(20:02):
deplete resources that could be used with low low risk patients and vice versa that you know the the.
It doesn't mean that the high-risk patients aren't prioritized.
It doesn't mean we shouldn't operate and work on trying to make better high-risk patients.
It just means we have to look at that in the context of the medical system as a whole.
(20:23):
And after reading about the experience in England, I'm glad that I don't have
to think about those kind of things as much as maybe other medical systems do
and that we're not dealing with quite as limited a resource.
But there's a couple things that you said that I think are specifically interesting
as we relate it to joint replacement, which you and I do. I'm just a knee specialist.
(20:47):
I do sports medicine and joint replacement, probably 70-30 adult reconstruction to sports medicine.
So I do a lot of total knees. And, you know, where I think about some of these
concepts is bilateral surgery and outpatient surgery.
When it comes to bilateral surgery, I've had several patients that have come
to me and say, well, you know, I came here because the other surgeon told me
(21:08):
I can't do both monies at the same time.
And I'm hoping you'll say that I can do them at the same time.
That's really the only reason I came here.
Wow. Interesting. Okay. Honesty. I like that. Very good.
You know what, Ronnie? Try being a woman surgeon because they think,
oh, the woman's going to be nice to me.
If every other doctor says no, she's going to say yes because she's a woman
and she's going to be nice.
(21:29):
So it's, you know, it's kind of a, it's a, it's definitely a real thing. Yeah.
That conversation is always interesting for me because when I ask friends that
say, yeah, I don't do bilaterals anymore. Really?
Why not? Well, you know, we only get paid half for the second one and it's a
longer operation and it kind of wears me out and, you know, people stay in the hospital longer.
(21:51):
So I have to round on them longer and, you know, blah, et cetera, et cetera.
And similar things with outpatient surgery. I had a friend recently,
he's like, hey, man, you do these as outpatients, you don't have to round on them anymore.
There's not as much a burden on your staff to come around and take care of things
in the hospital, et cetera, et cetera.
(22:12):
You can do them in the surgery center, and you're potentially an owner in the
surgery center, so that benefits the surgery center and you financially.
And in both of those, I get frustrated with those. Like there's a lot of,
a lot of things that are being thrown at me to benefit me.
Where do we talk about the part that benefits the patient? You know,
there's somebody that has two terrible knees and they have a low medical risk
profile and they say, I got three months off of work and I got to get back to
(22:35):
work. I don't have time to do two separate operations.
There's some specific situations where I think bilateral surgery is the best thing to do.
So to just summarily say, we don't do that because it doesn't benefit me.
Me, I think is just, I don't know if it violates these tenets of medical ethics
that we're talking about, but it seems to be in the face of the spirit of these
(22:58):
type of ethical considerations.
Oh, of course. I mean, and that really actually violates that whole fifth,
you know, tenet, the primacy of patient interest.
You know, if it's not, I mean, again, we know that double knee replacement is
a higher risk than a single knee replacement, you know, in general,
it's a bigger operation.
But if the patient is healthy and there's
(23:20):
a real benefit for them to do both at once and i
think you know severe deformity flexion contractures that are substantial because
it'll impede the healing of one to have you know a problem with the other you
know i have no problem doing that for the right patient but i do have some pretty
substantial parameters in terms of what i say to patients for that and the first
thing i say to them is well you're gonna feel like you got run run over by a train.
(23:43):
You know, you think that we are much better at this pain control after surgery,
but you know, this is a big hit.
I used to be a therapist in our office and I would say to all of those patients,
listen, a lot of my patients come back, say my knees are doing okay,
but I'm hungry, but I don't feel like eating. I'm tired, but I can't sleep.
My left knee hurts. So I roll over on my right side, but that hurts too.
(24:04):
And I can't stand up because I
got to use my leg and I want to push off on this one, but that one hurts.
So I push off this one, but that one hurts. it just takes a
lot out of people and you just got to say you know are you really up for that
kind of a commitment and figure out whether or not that
patient is one of those people that says good lord that sounds overwhelming
no way in hell i'm doing that versus are they one of the ones that say i couldn't
care less how bad it is i only want to do this one time well yeah and then you
(24:27):
also know those patients with the very high pain thresholds where their knees
look like you know bomb went off and they're taking tylenol um and you say all
right you're gonna you're gonna do do just fine.
I just recently, a few weeks ago, did a double knee replacement on a fitness instructor.
And she's like a maniac. She backed teats and spin classes two months later, pretty much.
(24:49):
And it's a, it's amazing. She's, she's doing very well.
So you just saw her in the office for her follow-up and now she's sending all
of her students, her spin students to me.
So now I have a lot of people who want to go back to doing that stuff.
But I tell people anyway, that after you do your knee replacement,
you're going to be mad at me for about two or three weeks.
(25:10):
I tell them you're going to be, you're going to be angry with me.
So this is just how it's going to go.
You're going to forgive me after about two or three weeks, and then you're you're going to be okay.
So, you know, so I totally agree with you with the double knee thing and that
people want to go around, they figure someone will say yes.
And that goes with other things like, and we're going to talk about this later,
you know, patients with BMI of 60.
And, you know, they say they'll just keep going somewhere else until someone says yes.
(25:36):
And I don't know if that's in their best interest. Well, you discussed obesity,
you just brought up obesity and joint replacement.
And that was really the next thing I had on my list to talk about.
And I think when we talk about these ethical considerations and patient selection,
patient screening, things like that.
You know, I think we do, I personally think we do a pretty poor job on this
(25:56):
as orthopedic surgeons about dealing with obesity.
When I hear people talk about this, a lot of times people are just awfully blunt.
Well, just don't operate on overweight people. Just don't do it.
I was at CCJR one year, it was a long time ago, and they showed a case of this
patient that had had horribly arthritic knee, significant varus deformity,
(26:19):
bone-on-bone arthritis, was like 50 years old, dialysis patient,
out-of-control diabetic, morbidly obese.
What do we do about that? And a guy that I really respect a lot and that I've
heard a lot of meetings said, I'd really have a discussion with that patient
on, we probably should not operate on him.
And the moderator, to his credit, really went after him. He's like,
(26:41):
hold on a second. He's like.
That's not a strategy and that's not a plan. Like, what are you going to do about this?
I just really try hard not to operate on it. Yeah, yeah. I know you won't operate.
Like he just kept, kept on it a little bit. And I thought that was really interesting
because like not operating is not a plan and telling somebody that they can't
have surgery because they're,
because they're overweight is not a, is not a strategy that really can, can help them that much.
(27:07):
So I try to talk to my patients about, listen, I want to be your advocate on,
on trying to get this surgery done.
I want to be a part of the solution, but we can't move forward for this reason.
And here are the complications that you're at risk for and why we can't move forward.
But here's some solutions that we're going to try to come up with.
And so I just want to hear your comments on that, on obesity and joint replacement
(27:29):
in particular, and how can we be better about this as orthopedic surgeons than we are now?
That's a really good question. And it's something that is controversial.
And as you just pointed out, you could just
put a whole bunch of of us on a podium and we'll just argue about that all
day long and i tell people those are
the taste great less filling arguments that we have that you're
just going to keep yelling at each other back and forth about but
(27:52):
you know obesity obviously is a big problem in
our country and and internationally in the whole world and the rate of obesity
continues to increase but that doesn't mean just obesity by itself shouldn't
be a reason not to operate on someone unless it's something that is going to impair the outcome.
(28:13):
And you know, it's going to. So in my practice, I have a soft.
Soft, not limit, but soft flag BMI of 45, where I say, Hey, you know,
let's try to get some weight off in a healthy way, get your muscles strong,
because you're going to have to recover from this operation.
But I won't say no. But BMI 50 or over, I say, Look, we got to get you down
(28:36):
a little bit. But before we do this operation, we've got to do it in a good way.
There's ways that we can do this now that didn't exist before.
And I'll help you and we'll get you plugged in.
We have a nurse navigator now that helps us with optimizing patients.
And she basically coordinates all of this stuff to help them get into bariatrics
or help them see the right person to get the weight under better control.
(28:59):
And it's been pretty successful. I mean, frankly, there are people who are overweight
and very unhealthy. And then there are people who are overweight and pretty healthy.
And you can do very well. You can help those people quite a bit by doing surgery
on them, especially if they have a really bad joint and you can fix it.
But people who are unhealthy and overweight, you have to address the problem.
What's underneath all of that? And one of my colleagues, Jim Slover,
(29:23):
wrote a lot about metabolic syndrome years ago, and now that's become even more of a hot topic.
Malnutrition, low albumin. So those are the things you can address.
Make them healthier so that they'll heal and they'll do very well.
You do have to maybe adjust how you do the operation. We just published on...
Tibial loosening with and without stems and finding a weight,
(29:44):
not just a BMI, but a weight that you have to consider adding a stem for some
cemented prosthesis, and that's 250 pounds.
So you have to think about doing that and adjusting your technique to make it
last longer so you don't have a complication.
And then things that you're saying otherwise, I mean, dialysis,
you can't change. That's not modifiable.
(30:05):
However, you can modify diabetes. diabetes and there
are a lot of medications that can improve diabetic control
a lot of people especially underserved populations
tend to have not a more disjointed care
so they're they're not seeing the same doctor every time they go to the doctor
they may not ever see yeah no pun intended but their care isn't isn't coordinated
(30:29):
as well because they may not see the same position they may see a position extender
and never see their doctor but their doctor just signs off on things.
So they might not get more aggressive treatment for uncontrolled diabetes or
other things that can be controlled.
So really getting those people plugged into the right specialist,
you know, having them see an endocrinologist.
(30:51):
And that can really change their life. I mean, I've had people come,
especially after COVID, when people just stopped going to the doctor,
you know, with their A1C at 13, 14.
And, you know, I try to keep getting under eight to
do elective surgery and then try to keep the
control or glucose control in the weeks prior
(31:11):
to and after surgery really tight so everything heals but you know some of these
folks have never they don't even know what an endocrinologist is and they haven't
don't they don't even correlate the fact that that high a1c may actually make
their pain worse and they don't understand that I'm like,
your blood is not delivering oxygen. It's delivering sugar.
(31:33):
There's no, your blood is molasses. It's not doing its job when it's like that.
So that kind of speaks to them and it can make them better.
And I've seen a lot of folks get much better and then it stays better.
We published on this, how we have prolonged improvement of A1C after joint replacements.
I kind of have a similar approach to you. I tell people if you're 40 and under, I think you're good.
(31:58):
If you're 50 and over, I don't think you're good. I think we're going to do something different.
When you're in between 40 and 50, that's where we have to think about where
are you trending? Where have you come from? Where have you gone?
And what's your medical risk profile look like? If I have somebody with a BMI
of 46 that says I'm as heavy as I've ever been, I can't really do much because
(32:19):
of my knee. but I haven't had any luck with losing weight.
That's the kind of person I really want to say, you know what,
let's get you a bariatric referral.
Let's talk to your primary care physician. Let's understand the implications
of your morbid obesity outside of your knee replacement or in addition to trying
to get your knee replaced.
Versus if I have somebody that said, my BMI used to be 61. I went and had bariatric surgery.
(32:43):
I got my BMI down to 38. Now it's back up to 44 and I've done everything I can.
And I've talked to my primary care doctor.
I have a nutrition specialist I meet with regularly, and I'm just really struggling to get it below 44.
You know what? In that case, good job for you for doing all you can to get where we have.
Let's roll and get this thing fixed, and hopefully it can help you.
A couple of things that I think are interesting from a research perspective, you brought up,
(33:06):
stems and surgical technique, but I also think the other things that are interesting
to look at in the literature is, yeah, there is a slight increase in infections.
Infections, there is a slight increase in overall complications.
But the idea that these patients can't do well and that they're not going to
get benefits from it is just not true.
I just know they improve so much. Their life improves tremendously.
(33:28):
They get a lot better in short order, you know, with exceptions, of course.
But I mean, for the most part, I think these patients do just as well.
They rehab just as well, et cetera.
And even though you have an increased risk of infection and complications.
I need to look this up again so I can give the authors credit,
but there was a VA study that showed, looking at people over a BMI of 40 who had surgery,
(33:53):
what were their outcomes like versus how many complications that they had,
so they could try to figure out a ratio of how many good outcomes would we have
avoided if we had denied these people over a BMI of 40 from surgery versus how many complications.
I thought it was Brian Ryan Springer wrote that. Yeah, and it was 14 to 1,
14 good outcomes that you would have avoided for every infection or complication
(34:16):
that you would have avoided.
So yeah, I realize that and I agree that there's an increased risk of complications,
but there's still patients that can do really well through there.
And you have to put it into context.
It's a relatively slight increase, but under the right circumstances,
I still think we can do better for these patients and get some good outcomes with them.
(34:38):
You're right on with that, and it's true. And that speaks to,
in the article that we just published.
The concept of the informed consent decision and how
do you talk to a patient about what's going to happen to
them and what you expect to happen to them and what their risk is not many we
you know we all say our speech and what your risks are but very very seldom
(34:59):
do we actually really personalize those risks yeah to say oh look you know if
i fix your knee you're probably going to get you're going to go from a 10 out
of 10 pain to probably maybe a 2 or 3 out of 10 pain,
but your risk of having a heart attack
is really high because you have your cholesterol
out of control and you know you're having angina and
(35:20):
all this stuff or whatever and so we need
to probably get that risk down because going from a 10 to a 3 may sound great
but if you have a heart attack and die who cares about the pain i want to do
a nice knee replacement for you so it looks good no more definitely exactly
so so really you know having a
a tailored conversation sometimes you don't need to be the one to do that.
(35:41):
You can have someone else on your team do that for the patient.
Like, we're going to have a risk discussion because, you know,
we've calculated your risk and here's what we have.
And that's, there's a lot of value to that. But, you know, risk calculators is a lot of fallibility.
We give, we wrote a, just an ICL chapter about that recently about how to calculate risk.
And there's a whole bunch of different ways to do it. But, you know,
(36:03):
having a conversation that one of the patients that we presented in this article
was a a younger person who had AVM of the femur and tibia.
And the surgeon, they had seen a bunch of different surgeons and nobody really
offered anything except for a sports surgeon who had had a little bit of a few
patients who had had an improvement with a certain arthroscopic technique and decompression.
(36:26):
And the patient was high risk. So how do you talk to that patient?
Like, okay, I've done this a few times and it's worked okay,
but there's really no evidence that it's going to to work.
Plus your risk is very high. So I don't know that the risk balances out with
the pros with, with the, with the benefits of it.
So being able to talk to patients that way and saying, look,
(36:47):
you know, the chance that we're going to make you better is not very high,
but the chance of something to go wrong with wrong is, is pretty high.
So yeah, the surgery exists, but.
Yeah, I found that fascinating as well. And that's something that I think really
gave a lot of depth to this article was when you talked about,
is there really true consent?
I think it was the first case you talked about. And one of the paragraphs ended
(37:08):
with, is there really true consent in this scenario?
And I really felt long and hard about that because it really is a perception.
You talk about a patient's risk profile, and they're perceiving their own consent
based on what they're being told.
So that kind of leads into my next question. you talked about palliative care.
And so I guess two questions. One relates to what you were talking about,
(37:31):
and you have these risk profiles, these risk calculators, which are great.
So my first question is, how does that conversation go?
I know you said you don't necessarily have to be the only one doing that.
You can have people in your office.
So are there go-to resources, whether you're trying to control diabetes or trying
to control obesity or smoking cessation or what have you.
So I guess we'll start there. Are there resources that you have found that are successful?
(37:55):
And just really talk in general about having those, let's be honest,
they're difficult conversations with patients when, like you said,
if their perception of success is whatever and you deem that you need to really
address some serious issues before surgery.
So I guess, how does that conversation go?
And are there any resources that you have found success with?
(38:17):
Well, yeah, yeah, that's a big question. But we, you know, at our institution,
we have a perioperative surgical home or perioperative surgical coordinator.
She's a nurse, and she helps with patients who need substantial optimization.
And we'll have a conversation and say, look, you know, you have a lot of these
factors that we can modify before surgery.
(38:39):
And I think we should do that if we can, because this is elective surgery.
It's not a burst appendix where you have to do surgery right now.
So why not make it safer for you if we can so i offer them to see that that
navigator and they help get them in with specialists and we do the best we can
and i see them again and then we see if we've gotten anywhere and then we can
book surgery but i think to the the question from the article.
(39:03):
There's high-risk patients that are elective patients, and we now have a team
of people who reviews these high-risk patients when they're cases,
and they're flagged by the perioperative team when they come through our—we
do everything on computer.
So, when it comes to the computer, oh, this person has all of these flags,
(39:23):
so that the committee looks at the patient and sees if they meet criteria to be very high risk.
And then we talk to the surgeon and say, look, have you tried X,
Y, and Z? I noticed you only saw them once in the office.
Maybe you can try some other things with this patient to see if they can't get
in a little bit healthier before the operation because we really don't want a bad outcome. on.
(39:44):
And most of the time when we review those things, the surgeon says, wow, you know what?
I wasn't even thinking about that. And that's a really good idea.
I'm going to let them know. And we're going to try and see him again in a couple
of months. We're going to get them a little bit better and healthier before surgery.
And then the other side of that is if you're in the office and you see someone
who's really, really high risk, but you know they might benefit from an operation,
(40:08):
you can say, look, I don't want to book surgery right now because your risk
seems is really high, but we do have a committee that reviews these more complex
surgeries and patients.
So what I'm going to do is I'm going to put your case in and we're going to
present it to this committee and then we'll see what they say.
So it helps the surgeon because the surgeon doesn't need to be face-to-face
(40:30):
with the patient saying no.
They can say, look, you know what? I have empathy for you. I understand that
you're in a bad situation and it hurts so much and you want me to fix this.
But there's a lot of risk here. And I think we need to unpack this before we proceed.
And we have a process here that we have to go through with patients that have
high risk. And we're going to go through that process.
(40:51):
So it takes the onus off the surgeon in that face-to-face encounter a little bit.
As with most things, I think these discussions are just all about communication.
And to boil it down even more than that, I think about this with the obesity
discussion a lot. Just don't be a jerk.
It's really as simple as that. Don't tell someone, well, you're too fat,
(41:13):
so I'm not operating on you. That doesn't help anybody.
All that's going to do is you're never going to see that patient again because
they're going to leave there thinking, Dr.
Benner's a jerk. They said this to me, and I can't believe that they said that.
And there's no chance they're ever coming back versus if you approach it as,
you know, I want to be part of the solution along with you. I understand this is difficult.
Like, you know, every, you know, there's millions of people in our country that
(41:35):
are struggling with this, but I'm not doing my job if I don't understand and
share with you the risks that we're, that we're up against.
And, you know, I don't want to
make it worse as much as you think it can't get worse. It can get worse.
And I would hate for us to do a surgery for us to have a complication and then
get done with it in the end and say, gosh, did I really need to do this,
you know, despite all these risk factors?
(41:57):
So, you know, I think this discussion and all these considerations are ones
that we all should be having on a daily basis.
And I'm sure this was really educational for you writing this to educate the rest of us.
So, you know, talk a little bit about that as we start to wrap up here.
How did writing this manuscript make you a better physician?
How did it make you better at what you do?
Well, you know, that's a very good question because when you write a paper like
(42:20):
this that explores ethical conundrums and informed consent and what do patients perceive as risk,
what resources do you have as a surgeon when you face these very complex problems,
it helps me become more aware of it.
And now when I speak to patients, especially higher risk patients in terms of
(42:43):
informed consent, I try to put it in layman's terms and say,
look, your chances of getting much Much better from this operation are seven and 10.
So seven people are going to do great. Three people, maybe not so great,
but your risk is nine out of 10.
So, you know, maybe we need to bring that risk down a little bit to make this
surgery worth it. So they understand that a little bit better.
(43:05):
The second thing is having other resources that you can say,
look, you know, let's try some other things. Let's see if we can get you to see some specialists.
Let's see if we can coordinate your care and get you better optimized.
One thing that we haven't talked about yet is I said we have that committee
outside of the hospital for patients who are not inpatients.
But we do have a team in the hospital for when patients have ethical.
(43:27):
There's an ethical challenge with a patient.
And if you aren't sure about what to do for someone, you can call on them.
And it is a team that's an escalation team that can review the care of the patient
and help you make a decision.
So if a family is demanding a surgery and you say, this is really too high risk,
that team can support you or tell you, no, you know what, you should proceed.
(43:51):
So you have another, you can phone a friend basically and have some help when
you make these very tough decisions.
As an outpatient or as an inpatient for the patients.
Last question. I think another important part of this, and this is going to
sound maybe a little less compassionate than what I've talked about before,
but I think as surgeons, we have to empower ourselves to say no.
(44:13):
There are just some patients that say, doctor, I just, I just,
we got to do this. Like, you don't understand how bad I'm hurting.
You don't understand how bad this is. Yeah, I do understand.
I've sympathized with you. I'm sorry that it's like this, but I just don't know
that I'm going to help you.
And there have been times that I, that I've just had to break it down and say,
listen, unfortunately, the answer, the answer is no, we're not,
we're, I'm not doing this operation.
(44:35):
We have to be able to buy into one another that we're on, that we're ready to
take this journey together. other.
And for the reasons that I've already articulated, I'm just not willing to do it.
So unfortunately, I'm sorry that we're not going to agree on this, but the answer is no.
And I think it really bothers me when I go to meetings and people say,
well, I kind of got talked into doing this case.
(44:56):
I was working on non-surgical treatment.
It weren't getting any better. And I finally just kind of gave in and did it.
And I think we need to give ourselves as orthopedic surgeons a space to say
no when we think it's appropriate.
Well, and that's this whole point of this is that it's okay to say,
look, either this is too high risk and I don't feel comfortable doing it.
And you're allowed to say that because as long as that patient is taken care of, that's the goal.
(45:24):
But feeling comfortable saying that declining surgery is difficult and it's hard,
but you should be allowed to do it if you feel that there's something that's
dangerous about it or that they're not going to benefit from it.
I have someone now that's, I've just been shaking my head. He's a guy with terrible knees.
(45:46):
I mean, it's terrible, but has cognitive problems.
Comes in two hours late, goes to the wrong place, goes to x-ray and leaves because
he doesn't remember he has to come down to the office afterwards.
And he lives by himself, has someone helping him, but that person isn't very helpful.
And he's terrible, terrible pathology in the knees. But, you know,
(46:07):
I can't justify doing surgery on someone that may not remember to take their
post-op VTE prophylaxis.
Even if I send him to a rehab place, he's going to go home eventually and then
not remember something.
I sent him to geriatrics to have them evaluate him.
They did cognitive testing. And, you know, geriatrics is a tremendous resource
(46:30):
for older patients, especially to go over people who have polypharmacy.
Everyone's piling medicine onto these old people and nobody takes any of them away.
So like, oh, yeah, this person's really confused because they're on 10 different
medicines when they should be on two.
So they help with that stuff. So but it's still not bad.
And I and the guy keeps calling and calling and want surgery.
(46:52):
But I don't you know, I feel so scared.
I'm afraid something terrible is going to happen.
Yeah. And that can happen. And if you have your gut says something is wrong,
you should listen to that gut, especially if you've been in practice a long
time. Absolutely. That means something is bad.
Yeah. For all our listeners out there, if you want to check this out,
it's the Orthopedic Forum on General Bone and Joint Surgery in press coming up soon.
(47:15):
Dr. Claudette Lejeune is the first author on this paper from NYU.
Thank you so much for joining us tonight. It's been a really interesting conversation.
I feel like I've really learned from this. I hope you and our listeners have
as well. And we really appreciate you coming on.
Thank you so much for having me. It's been an absolute pleasure and great talking to you.
Nice stuff. As we talked about before, we're all over social media.
We're on Twitter and Instagram at the SKC Podcast.
(47:38):
We have Facebook and YouTube pages for the Show Money Center Podcast.
You can email us comments or questions at the skcpodcast at gmail.com.
Check out our previous content. This is episode 42.
So we've got a lot of previous content you can check out. If you like what you
hear, give us a five-star review and share it for other people to see as well.
So thank you for joining us and we'll see you again next time on the Show Morning Center podcast.
(48:00):
Music.
Music.
(00:14):
And tonight's episode is going to be another interesting discussion,
a little bit of a different topic, as we're not necessarily discussing specifically
a surgical or physical therapy topic.
We're talking more about ethical considerations and things like that in orthopedics.
And we'll talk a little bit more about that topic here in a bit.
But I'm excited about our guests that we have tonight.
And I think it's going to be interesting content for all of you that are listening.
(00:36):
If you want to hit us on social media, we have Twitter and Instagram at the SKC Podcast. podcast.
We have a Facebook and YouTube channel as well for the Shelburne East Center podcast.
If you need to contact us, which we'd love to hear any questions you have,
you can send that to theskcpodcast at gmail.com.
If you want to catch any of our previous content, you can find us on any podcast
avenues at the Shelburne East Center podcast.
(00:58):
Leave us a five-star review if you like what you hear and check out our previous episodes.
And speaking of previous episodes, before we get started tonight,
just wanted to go over the recap for last week. We talked with Dr.
Catherine Harper from the D.C. area.
It was a great conversation. We talked about intraosseous medication delivery
for total knee replacements, and it was really a cool topic,
and it's one that I have not really had any experience with.
(01:20):
And learning from Dr. Harper was really fascinating in terms of what they're
looking at from a research perspective and what kind of outcomes they're getting with that.
So go back and check out last week's episode on intraosseous medication for total knees.
Tonight, we're discussing an article from the Journal of Bone and Joint Surgery,
another JPJS article from their orthopedic form section, where we talked about,
(01:40):
where we found ethical considerations of declining surgical intervention,
balancing patient wishes with fiduciary responsibility.
And the first author on that, Dr.
Claudette Lejeune is here tonight from NYU.
She is a joint replacement surgeon from NYU.
She's fellowship trained, actually we've learned now in talking before we started
(02:02):
here year that we did the same fellowship at Insull Scott Kelly.
She did residency at Mayo Clinic before that fellowship. She's now a professor
in the Department of Orthopedic Surgery at NYU Grossman School of Medicine.
She is also the Director of Quality and Safety in the Division of Adult Reconstruction,
and she is also the Quality and Safety System Chief for Orthopedic Surgery.
So, Dr. Lejeune, thank you for joining us tonight on the Shelburne Center Podcast,
(02:25):
and we're glad to have you here to discuss this topic.
Well, thank you so much for having me, Scott and Rodney, this is really an important
topic and it's very interesting to me.
So I really appreciate your giving me the opportunity to discuss it with you today.
Let's jump right in. How did you get interested in this topic?
How did you become a part of this, the generation of this manuscript?
And how did you become an expert on this to write for all of us to read about?
(02:47):
Well, you know, I'm sure a lot of us have been faced with these situations where
we have patients who are very, very high risk for surgery.
And we then perform surgery and then something really bad happens and then we
look back on it and we say, wow, okay, maybe we could have offered them something
else or maybe we could have declined or we could have done something else.
(03:10):
And now that it's oral boards time, a lot of our young surgeons are thinking
about those things right now.
So I think it's absolutely appropriate because indications are the most important thing we do.
We can be skilled surgeons. We can be technically amazing.
But if we don't select the correct patients to operate on in terms of risk benefits,
balancing the risks and the benefits of the operation, I think then that's how we fail.
(03:33):
And that's how we should train our young surgeons is to make sure they understand
when operating is the right move and when it's not the right move.
So the genesis of this paper came about because, as you said,
I'm the system chief of quality and safety for all of our sites,
and I see everything that goes wrong.
(03:56):
So when something goes wrong, I see it.
And Joe Bosco, who is our vice chair of clinical affairs and former president
of the academy, he and I discuss them frequently.
We discuss these cases and say, oh gosh, should they really have done this at this time?
Now, obviously hindsight is 20-20, but we saw, we look at these cases and we're
(04:18):
constantly discussing them.
And we said, you know what, we should do a department meeting and discuss these
challenging cases and the ethics and how we balance them, how we balance informed consent,
how do we have a discussion with patients, what are the barriers that we face,
and what are the ethics of this.
So we decided to have a department meeting and we discussed all these things
(04:38):
and we invited one of our medical ethicists, Dr.
Barron Lerner, who is an expert on the ethics of.
Medical care. And we sat at a round table and we had a really robust discussion
in person about a bunch of cases.
And we said, you know, we should really write about this because I think this
meeting, this department meeting was really beneficial for everyone that was here.
(05:03):
It generated a lot of discussion. It generated a lot of discussion after the department meeting.
And we thought we wanted to extend that benefit to the readers of a journal
that if the journal wanted to publish it. So that's really the reason we did that.
And we do have a history of publishing on medical ethics because we do have
a robust medical ethics department led by Art Kaplan, and he's a pretty well-known medical ethicist.
(05:28):
We've written a few papers before, especially when value-based care became prominent.
We wrote about the, we debated the ethics of value-based care.
So that's a long answer to a short question, but there's a lot of background there.
Well, I'm glad that you could bring this topic up and I'm glad that you wrote
this article just because there's just, you know, we spend so much time as surgeons
(05:49):
and I just, Scott and I just returned from the AOSSM meetings,
the summer sports medicine meeting, and there's just so much talk about surgery.
There's so much talk about surgical technique.
What surgery do we do? How do we do it? What are the outcomes from that surgery?
What are the pitfalls of that surgery?
But there's very little discussion at that meeting. It's not to impugn that
meeting. I like that meeting.
But the Academy meeting, the office meeting, the same kind of things,
(06:12):
that people are just talking about surgery and there's just not much discussion
on who are we actually operating on?
Who are we providing non-surgical care to?
What are the best, you know, the pearls and pitfalls that we can give people
better non-surgically?
It just seems like an area where we as orthopedic surgeons could really get
better and, you know, put our patients forward of our surgical volume and our surgical techniques.
(06:42):
And that's a great point because we are, and now that our pay as surgeons continues
to be decreased by congressional and regulatory decisions,
and I know that's in the news and all over social media now,
we are really pushed to do more procedures.
And it's more difficult to not
(07:04):
do them. We have to be able to support our practices and our institutions.
So a lot of our thinking is shifting because we need to be able to,
you know, keep up with the volume of patients.
And a lot of the time, we need to pause and consider the whole patient.
And some of our patients really aren't good candidates for surgical intervention.
(07:25):
And when are those patients better served by not having a surgery?
And that's a big decision we need to decide about.
Yeah. So you jump into that in the manuscript, which I was happy about that
from the very beginning when you talked about the medical, the legal,
the financial, and fiduciary environment that really surrounds this topic.
So before we even jump into that, just discuss a little bit about those kind
(07:48):
of backgrounds of the environment that we're all practicing in and how that
kind of sets the stage for starting to think about these things in a different way.
Well, absolutely. I mean, a lot of U.S. News and World Report just came out
this week, yet today, actually.
And, you know, we're number three in the nation, NYU, go NYU Langone.
But a lot of those metrics are, thank you, a lot of those metrics are based
(08:13):
on mortality and volume and all these things and hoops you need to jump through.
And I think sometimes we get blinded by these metrics that we have to meet.
And there's more than one set of metrics.
Medicare has a readmissions metric. I mean, there's lots of different things
that hospitals and surgeons are graded on with regard to what we call quality,
(08:33):
but what we really mean is compliance.
We want you to comply. We want to keep costs down. So we want you to comply
with what we think is quality.
And it's very, very difficult sometimes to navigate that.
So there's a lot of pressure. And also we have the legal environment.
In the US, we have the most aggressive legal system in the whole world.
(08:53):
And in some states like mine, it's extraordinarily aggressive.
There's almost no limit on what can happen to you as a physician,
even if you do everything you should do, you can still be sued and lose everything
depending upon the court you're in.
So there's a lot of things you have to consider as a doctor when you make these
decisions to operate on somebody.
Really not a topic at the sports medicine meeting. Just out a couple of high-profile
(09:17):
cases with multi-million dollar judgments against orthopedic surgeons for what
I perceive as some pretty straightforward decision-making in the operating room
that we make all the time.
And I hear those talks and I want to be educated on those, but it scares the
hell out of you to think about those. You know, this professional athlete comes
into my office, wants an ACL reconstruction, sweet, I can do this big,
(09:39):
you know, this big time athletes ACL reconstruction.
But what kind of, what kind of, you know, what does that open myself up to,
you know, how do I, how am I putting myself at risk versus I would get the same,
paid the same doing their ACL as I would yours or Scott's or any,
you know, anybody else's.
And it's just it's just a kind of an interesting time to be doing what we do in particular.
(10:02):
And hopefully, you know, the people at our societies and our in our academy
continue to work diligently to try to make that environment better.
We're pretty lucky here in Indiana, to be honest with you, that our malpractice
environment is is is much more much more physician friendly.
We have any kind of a suit that gets brought by a patient has to go to a medical
(10:23):
review panel of physicians for them to give a recommendation before it can get to the operating room.
That doesn't mean they can't bring the suit if they don't want to,
despite the fact that the physician panel says that it doesn't hold water.
But it gives us a layer of review if that were to happen.
And I understand the environment is not like that in other states. New
(10:46):
York is a frightening place for physicians and that's why we train everybody
and we retain almost nobody here because the environment here is absolutely
ridiculous in terms of you don't even need an expert in your same field to be
an expert witness against on the plaintiff's side.
The plaintiff's expert doesn't need to be board certified here.
(11:11):
And pretty much anybody can sue anybody. And there's unlimited liability.
There's no limit on anything. So you can lose everything. You can lose your
house. You can lose your kid's college tuition.
And it doesn't even mean that you did something wrong. It's just a bad outcome
can do that because your jury is a bunch of lay people.
(11:32):
And they don't understand medicine. They don't understand surgical decision-making.
And that's what the plaintiff's attorneys rely on, is that they don't understand
that you have a jury that you can manipulate to think that someone did something
wrong when we absolutely didn't, just because we are doctors and it's a different
world that we live in here.
So there's no way for you to have a fair trial as a physician in New York.
(11:56):
Long topic for another day, not exactly the subject of this paper,
but we could be talking about that one all day.
Yes. The one thing that I do recommend, though, is if you are a member of the
Academy, that one of the most beneficial things you could do is become a member
of the PAC, the Political Action Committee, because that does a lot of good work.
We have some fantastic people leading that. Wayne Johnson is now the PAC chair,
(12:18):
and Adam Brueggemann is the Council on Advocacy chair, and they're both really
dynamic hustlers. They hustle.
They make it work. They make it happen. They're amazing. amazing so you've got
a really good team working for us there so there it's worth an investment into
the pack if you haven't already joined.
Now, going back to the origin of this manuscript, you talked about a staff meeting,
(12:39):
and the three aspects that we were just talking about are pretty heavy topics.
We're talking medical, legal, and financial implications as it relates to the care of patients.
Now, when you said that really the impetus of this project was a staff meeting
that you had, what was that like in terms of who was there?
I know you said that it was a really robust discussion, but was it only orthopedic surgeons?
(13:01):
I know you said there were some ethical experts as well. But as far as other
members of the medical center or anything like that, can you go into a little
bit more detail about what that looked like?
And you don't have to get into that much detail about the exact conversations,
but just the overall tone and who was maybe involved with those decisions.
So we have a very large department.
(13:21):
We have almost about 250 orthopedic surgeons in our department.
That's very, very large.
And except for during covid when we
couldn't we have live in-person department
meetings and i don't know who else still does that
but we do and that room is packed like you there's standing room only for these
(13:43):
meetings and we we have some guest lecturers and they come in the door and they
just can't believe how many people are there you know they're taking pictures
you know to send to their chairman to say wait a minute look at this there's
actually like a you 250 people here.
And that also includes some of our physician extenders, our PAs,
nurse practitioners sometimes come to these meetings.
(14:05):
We do have affiliated faculty.
For instance, one of our vascular surgeons was there that day.
But the ethicists we invited specifically to come to the meeting.
Our residents are also at the meeting.
So it was a really good conversation because we spanned topics on a bunch of
different specialties.
(14:26):
And in the article, we, I mean, we changed a lot of the details about the patients
to protect their privacy.
The general idea of the case was the same. And we had a sports type case. We had a spine case.
We had a total joint case. We had a fracture case, a wrist fracture.
And all those patients came to an orthopedic surgeon one way or another and
(14:49):
had some, there was an ethical decision that was made when surgery was decided
on and outcomes were not so great in most of the cases.
And in one case, you know, you know, it was not so great, but the patient wanted
to have their other side done after that.
So you have to really understand that, you know, what's informed consent,
how do we talk to our patients?
So our department is kind of used to, or I mean, we're New Yorkers,
(15:13):
most of us, we are pretty vocal, we don't hide what we think.
So there was a lot of discussion and people speak up and say what they think.
So there were some people that thought that, you know, how could you possibly say this?
That's crazy. How can you deny patient surgery?
You're you're cherry picking. And then other people on the other side say, we need to do this more.
You're telling people you're going to help them and you're really not going
(15:36):
to help them that much and you're putting them at risk.
So there was a lot of debate and it was pretty passionate, actually.
So obviously that robust discussion
led to this paper and talked about the aspects of medical ethics.
And you really talked about the four aspects of beneficence,
non-maleficence, patient autonomy, and justice.
Before we get into the nitty gritty details here, can you just go briefly over
(15:58):
those four aspects and tell the listeners what you meant by those four?
Well, sure. I mean, these are pretty well established. So there's four basic
tenets of medical ethics or ethics.
And you just said what they are, the beneficence, non-malfeasance or non-maleficence,
patient autonomy, and then the question of justice.
(16:20):
And then we added our guiding principle that there's a primacy of patient interest,
meaning that you have to put the patient first when you make these decisions.
So basically, we'll go through them all.
So beneficence, and like it sounds, what we do should improve well-being for the patient.
(16:41):
And I can talk about a little bit of the controversies about what that means,
because well-being for us might not be the same thing as well-being for them, for the patient.
So we want to make patients better.
That's what we consider well-being. But patients think, okay,
what's going to make me happy? be? What's going to make me comfortable?
And they may not think about the bad things that can happen.
(17:04):
They think, oh, I want this carrot that you're dangling in front of me.
So beneficence may mean something to you that's different from what it means to the patient.
And then the second question, and that ties into the first one,
is a non-maleficence or non-malfeasance.
And that means don't hurt someone. Do no harm.
What you do should not cause harm.
(17:27):
But sometimes a patient would rather die than live with a painful condition.
So they think the harm is denying surgery, whereas you consider harm that they
might pass away or die because they're high risk for surgery.
So there's a lot of things that we have to consider when we think about what is harm.
(17:49):
And then the third thing is patient autonomy. So what that really means is not
that patients should to be able to do whatever they want, but that when they make decisions,
they should be allowed to make decisions without influence that's high pressure
to them, that they should be able to.
Make their own informed choices. Doesn't mean they're always going to get what they want.
(18:12):
As we all know, a lot of people don't make great choices, and that sometimes
lands them in a position of needing one of us, you know, especially trauma surgeons.
And then finally, the concept of justice.
And that goes back to the concept of the tragedy of the commons.
We have limited resources in our society, and that's become very,
very obvious in the past 15 years since we started and instituting value-based
(18:36):
care and trying to look at what things cost and the cost-benefit relationship
of anything that we do in medicine.
And the tragedy of the commons means that if there is a limited resource,
we need to protect that resource.
And you need to know that when people have access to a public resource,
(18:58):
you don't want them to have to deplete that resource. source.
And this goes back to, you see even in England in the NHS, if their region runs
out of money, they can't do any more surgery for that time period.
I mean, that's just how it is. This is your budget. If you run out of money,
you can't do anything else.
So it's very real. So if you're going to operate on a high-risk patient and
(19:20):
have a bad outcome and spend a lot more money, you can't treat 10 low-risk patients
with that same resource.
So these are real questions that We have to think about when we're doctors and
most of us just want to know, oh, do you need a knee replacement?
Oh, do you need a rotator cuff repair? Oh, you broke your wrist. Let's fix it.
Whereas, you know, we don't want to be thinking about all these questions all the time.
(19:41):
So it's very hard sometimes to think about all these processes when we're talking to our patients.
Yeah, I thought that was really interesting the way you laid that out in the
manuscript that we're referencing from the Orchid Forum and JVJS.
Go read it where you talked about the the the kind of intermingling of the high
and low risk patients and how taking care of high risk patients could potentially
(20:02):
deplete resources that could be used with low low risk patients and vice versa that you know the the.
It doesn't mean that the high-risk patients aren't prioritized.
It doesn't mean we shouldn't operate and work on trying to make better high-risk patients.
It just means we have to look at that in the context of the medical system as a whole.
(20:23):
And after reading about the experience in England, I'm glad that I don't have
to think about those kind of things as much as maybe other medical systems do
and that we're not dealing with quite as limited a resource.
But there's a couple things that you said that I think are specifically interesting
as we relate it to joint replacement, which you and I do. I'm just a knee specialist.
(20:47):
I do sports medicine and joint replacement, probably 70-30 adult reconstruction to sports medicine.
So I do a lot of total knees. And, you know, where I think about some of these
concepts is bilateral surgery and outpatient surgery.
When it comes to bilateral surgery, I've had several patients that have come
to me and say, well, you know, I came here because the other surgeon told me
(21:08):
I can't do both monies at the same time.
And I'm hoping you'll say that I can do them at the same time.
That's really the only reason I came here.
Wow. Interesting. Okay. Honesty. I like that. Very good.
You know what, Ronnie? Try being a woman surgeon because they think,
oh, the woman's going to be nice to me.
If every other doctor says no, she's going to say yes because she's a woman
and she's going to be nice.
(21:29):
So it's, you know, it's kind of a, it's a, it's definitely a real thing. Yeah.
That conversation is always interesting for me because when I ask friends that
say, yeah, I don't do bilaterals anymore. Really?
Why not? Well, you know, we only get paid half for the second one and it's a
longer operation and it kind of wears me out and, you know, people stay in the hospital longer.
(21:51):
So I have to round on them longer and, you know, blah, et cetera, et cetera.
And similar things with outpatient surgery. I had a friend recently,
he's like, hey, man, you do these as outpatients, you don't have to round on them anymore.
There's not as much a burden on your staff to come around and take care of things
in the hospital, et cetera, et cetera.
(22:12):
You can do them in the surgery center, and you're potentially an owner in the
surgery center, so that benefits the surgery center and you financially.
And in both of those, I get frustrated with those. Like there's a lot of,
a lot of things that are being thrown at me to benefit me.
Where do we talk about the part that benefits the patient? You know,
there's somebody that has two terrible knees and they have a low medical risk
profile and they say, I got three months off of work and I got to get back to
(22:35):
work. I don't have time to do two separate operations.
There's some specific situations where I think bilateral surgery is the best thing to do.
So to just summarily say, we don't do that because it doesn't benefit me.
Me, I think is just, I don't know if it violates these tenets of medical ethics
that we're talking about, but it seems to be in the face of the spirit of these
(22:58):
type of ethical considerations.
Oh, of course. I mean, and that really actually violates that whole fifth,
you know, tenet, the primacy of patient interest.
You know, if it's not, I mean, again, we know that double knee replacement is
a higher risk than a single knee replacement, you know, in general,
it's a bigger operation.
But if the patient is healthy and there's
(23:20):
a real benefit for them to do both at once and i
think you know severe deformity flexion contractures that are substantial because
it'll impede the healing of one to have you know a problem with the other you
know i have no problem doing that for the right patient but i do have some pretty
substantial parameters in terms of what i say to patients for that and the first
thing i say to them is well you're gonna feel like you got run run over by a train.
(23:43):
You know, you think that we are much better at this pain control after surgery,
but you know, this is a big hit.
I used to be a therapist in our office and I would say to all of those patients,
listen, a lot of my patients come back, say my knees are doing okay,
but I'm hungry, but I don't feel like eating. I'm tired, but I can't sleep.
My left knee hurts. So I roll over on my right side, but that hurts too.
(24:04):
And I can't stand up because I
got to use my leg and I want to push off on this one, but that one hurts.
So I push off this one, but that one hurts. it just takes a
lot out of people and you just got to say you know are you really up for that
kind of a commitment and figure out whether or not that
patient is one of those people that says good lord that sounds overwhelming
no way in hell i'm doing that versus are they one of the ones that say i couldn't
care less how bad it is i only want to do this one time well yeah and then you
(24:27):
also know those patients with the very high pain thresholds where their knees
look like you know bomb went off and they're taking tylenol um and you say all
right you're gonna you're gonna do do just fine.
I just recently, a few weeks ago, did a double knee replacement on a fitness instructor.
And she's like a maniac. She backed teats and spin classes two months later, pretty much.
(24:49):
And it's a, it's amazing. She's, she's doing very well.
So you just saw her in the office for her follow-up and now she's sending all
of her students, her spin students to me.
So now I have a lot of people who want to go back to doing that stuff.
But I tell people anyway, that after you do your knee replacement,
you're going to be mad at me for about two or three weeks.
(25:10):
I tell them you're going to be, you're going to be angry with me.
So this is just how it's going to go.
You're going to forgive me after about two or three weeks, and then you're you're going to be okay.
So, you know, so I totally agree with you with the double knee thing and that
people want to go around, they figure someone will say yes.
And that goes with other things like, and we're going to talk about this later,
you know, patients with BMI of 60.
And, you know, they say they'll just keep going somewhere else until someone says yes.
(25:36):
And I don't know if that's in their best interest. Well, you discussed obesity,
you just brought up obesity and joint replacement.
And that was really the next thing I had on my list to talk about.
And I think when we talk about these ethical considerations and patient selection,
patient screening, things like that.
You know, I think we do, I personally think we do a pretty poor job on this
(25:56):
as orthopedic surgeons about dealing with obesity.
When I hear people talk about this, a lot of times people are just awfully blunt.
Well, just don't operate on overweight people. Just don't do it.
I was at CCJR one year, it was a long time ago, and they showed a case of this
patient that had had horribly arthritic knee, significant varus deformity,
(26:19):
bone-on-bone arthritis, was like 50 years old, dialysis patient,
out-of-control diabetic, morbidly obese.
What do we do about that? And a guy that I really respect a lot and that I've
heard a lot of meetings said, I'd really have a discussion with that patient
on, we probably should not operate on him.
And the moderator, to his credit, really went after him. He's like,
(26:41):
hold on a second. He's like.
That's not a strategy and that's not a plan. Like, what are you going to do about this?
I just really try hard not to operate on it. Yeah, yeah. I know you won't operate.
Like he just kept, kept on it a little bit. And I thought that was really interesting
because like not operating is not a plan and telling somebody that they can't
have surgery because they're,
because they're overweight is not a, is not a strategy that really can, can help them that much.
(27:07):
So I try to talk to my patients about, listen, I want to be your advocate on,
on trying to get this surgery done.
I want to be a part of the solution, but we can't move forward for this reason.
And here are the complications that you're at risk for and why we can't move forward.
But here's some solutions that we're going to try to come up with.
And so I just want to hear your comments on that, on obesity and joint replacement
(27:29):
in particular, and how can we be better about this as orthopedic surgeons than we are now?
That's a really good question. And it's something that is controversial.
And as you just pointed out, you could just
put a whole bunch of of us on a podium and we'll just argue about that all
day long and i tell people those are
the taste great less filling arguments that we have that you're
just going to keep yelling at each other back and forth about but
(27:52):
you know obesity obviously is a big problem in
our country and and internationally in the whole world and the rate of obesity
continues to increase but that doesn't mean just obesity by itself shouldn't
be a reason not to operate on someone unless it's something that is going to impair the outcome.
(28:13):
And you know, it's going to. So in my practice, I have a soft.
Soft, not limit, but soft flag BMI of 45, where I say, Hey, you know,
let's try to get some weight off in a healthy way, get your muscles strong,
because you're going to have to recover from this operation.
But I won't say no. But BMI 50 or over, I say, Look, we got to get you down
(28:36):
a little bit. But before we do this operation, we've got to do it in a good way.
There's ways that we can do this now that didn't exist before.
And I'll help you and we'll get you plugged in.
We have a nurse navigator now that helps us with optimizing patients.
And she basically coordinates all of this stuff to help them get into bariatrics
or help them see the right person to get the weight under better control.
(28:59):
And it's been pretty successful. I mean, frankly, there are people who are overweight
and very unhealthy. And then there are people who are overweight and pretty healthy.
And you can do very well. You can help those people quite a bit by doing surgery
on them, especially if they have a really bad joint and you can fix it.
But people who are unhealthy and overweight, you have to address the problem.
What's underneath all of that? And one of my colleagues, Jim Slover,
(29:23):
wrote a lot about metabolic syndrome years ago, and now that's become even more of a hot topic.
Malnutrition, low albumin. So those are the things you can address.
Make them healthier so that they'll heal and they'll do very well.
You do have to maybe adjust how you do the operation. We just published on...
Tibial loosening with and without stems and finding a weight,
(29:44):
not just a BMI, but a weight that you have to consider adding a stem for some
cemented prosthesis, and that's 250 pounds.
So you have to think about doing that and adjusting your technique to make it
last longer so you don't have a complication.
And then things that you're saying otherwise, I mean, dialysis,
you can't change. That's not modifiable.
(30:05):
However, you can modify diabetes. diabetes and there
are a lot of medications that can improve diabetic control
a lot of people especially underserved populations
tend to have not a more disjointed care
so they're they're not seeing the same doctor every time they go to the doctor
they may not ever see yeah no pun intended but their care isn't isn't coordinated
(30:29):
as well because they may not see the same position they may see a position extender
and never see their doctor but their doctor just signs off on things.
So they might not get more aggressive treatment for uncontrolled diabetes or
other things that can be controlled.
So really getting those people plugged into the right specialist,
you know, having them see an endocrinologist.
(30:51):
And that can really change their life. I mean, I've had people come,
especially after COVID, when people just stopped going to the doctor,
you know, with their A1C at 13, 14.
And, you know, I try to keep getting under eight to
do elective surgery and then try to keep the
control or glucose control in the weeks prior
(31:11):
to and after surgery really tight so everything heals but you know some of these
folks have never they don't even know what an endocrinologist is and they haven't
don't they don't even correlate the fact that that high a1c may actually make
their pain worse and they don't understand that I'm like,
your blood is not delivering oxygen. It's delivering sugar.
(31:33):
There's no, your blood is molasses. It's not doing its job when it's like that.
So that kind of speaks to them and it can make them better.
And I've seen a lot of folks get much better and then it stays better.
We published on this, how we have prolonged improvement of A1C after joint replacements.
I kind of have a similar approach to you. I tell people if you're 40 and under, I think you're good.
(31:58):
If you're 50 and over, I don't think you're good. I think we're going to do something different.
When you're in between 40 and 50, that's where we have to think about where
are you trending? Where have you come from? Where have you gone?
And what's your medical risk profile look like? If I have somebody with a BMI
of 46 that says I'm as heavy as I've ever been, I can't really do much because
(32:19):
of my knee. but I haven't had any luck with losing weight.
That's the kind of person I really want to say, you know what,
let's get you a bariatric referral.
Let's talk to your primary care physician. Let's understand the implications
of your morbid obesity outside of your knee replacement or in addition to trying
to get your knee replaced.
Versus if I have somebody that said, my BMI used to be 61. I went and had bariatric surgery.
(32:43):
I got my BMI down to 38. Now it's back up to 44 and I've done everything I can.
And I've talked to my primary care doctor.
I have a nutrition specialist I meet with regularly, and I'm just really struggling to get it below 44.
You know what? In that case, good job for you for doing all you can to get where we have.
Let's roll and get this thing fixed, and hopefully it can help you.
A couple of things that I think are interesting from a research perspective, you brought up,
(33:06):
stems and surgical technique, but I also think the other things that are interesting
to look at in the literature is, yeah, there is a slight increase in infections.
Infections, there is a slight increase in overall complications.
But the idea that these patients can't do well and that they're not going to
get benefits from it is just not true.
I just know they improve so much. Their life improves tremendously.
(33:28):
They get a lot better in short order, you know, with exceptions, of course.
But I mean, for the most part, I think these patients do just as well.
They rehab just as well, et cetera.
And even though you have an increased risk of infection and complications.
I need to look this up again so I can give the authors credit,
but there was a VA study that showed, looking at people over a BMI of 40 who had surgery,
(33:53):
what were their outcomes like versus how many complications that they had,
so they could try to figure out a ratio of how many good outcomes would we have
avoided if we had denied these people over a BMI of 40 from surgery versus how many complications.
I thought it was Brian Ryan Springer wrote that. Yeah, and it was 14 to 1,
14 good outcomes that you would have avoided for every infection or complication
(34:16):
that you would have avoided.
So yeah, I realize that and I agree that there's an increased risk of complications,
but there's still patients that can do really well through there.
And you have to put it into context.
It's a relatively slight increase, but under the right circumstances,
I still think we can do better for these patients and get some good outcomes with them.
(34:38):
You're right on with that, and it's true. And that speaks to,
in the article that we just published.
The concept of the informed consent decision and how
do you talk to a patient about what's going to happen to
them and what you expect to happen to them and what their risk is not many we
you know we all say our speech and what your risks are but very very seldom
(34:59):
do we actually really personalize those risks yeah to say oh look you know if
i fix your knee you're probably going to get you're going to go from a 10 out
of 10 pain to probably maybe a 2 or 3 out of 10 pain,
but your risk of having a heart attack
is really high because you have your cholesterol
out of control and you know you're having angina and
(35:20):
all this stuff or whatever and so we need
to probably get that risk down because going from a 10 to a 3 may sound great
but if you have a heart attack and die who cares about the pain i want to do
a nice knee replacement for you so it looks good no more definitely exactly
so so really you know having a
a tailored conversation sometimes you don't need to be the one to do that.
(35:41):
You can have someone else on your team do that for the patient.
Like, we're going to have a risk discussion because, you know,
we've calculated your risk and here's what we have.
And that's, there's a lot of value to that. But, you know, risk calculators is a lot of fallibility.
We give, we wrote a, just an ICL chapter about that recently about how to calculate risk.
And there's a whole bunch of different ways to do it. But, you know,
(36:03):
having a conversation that one of the patients that we presented in this article
was a a younger person who had AVM of the femur and tibia.
And the surgeon, they had seen a bunch of different surgeons and nobody really
offered anything except for a sports surgeon who had had a little bit of a few
patients who had had an improvement with a certain arthroscopic technique and decompression.
(36:26):
And the patient was high risk. So how do you talk to that patient?
Like, okay, I've done this a few times and it's worked okay,
but there's really no evidence that it's going to to work.
Plus your risk is very high. So I don't know that the risk balances out with
the pros with, with the, with the benefits of it.
So being able to talk to patients that way and saying, look,
(36:47):
you know, the chance that we're going to make you better is not very high,
but the chance of something to go wrong with wrong is, is pretty high.
So yeah, the surgery exists, but.
Yeah, I found that fascinating as well. And that's something that I think really
gave a lot of depth to this article was when you talked about,
is there really true consent?
I think it was the first case you talked about. And one of the paragraphs ended
(37:08):
with, is there really true consent in this scenario?
And I really felt long and hard about that because it really is a perception.
You talk about a patient's risk profile, and they're perceiving their own consent
based on what they're being told.
So that kind of leads into my next question. you talked about palliative care.
And so I guess two questions. One relates to what you were talking about,
(37:31):
and you have these risk profiles, these risk calculators, which are great.
So my first question is, how does that conversation go?
I know you said you don't necessarily have to be the only one doing that.
You can have people in your office.
So are there go-to resources, whether you're trying to control diabetes or trying
to control obesity or smoking cessation or what have you.
So I guess we'll start there. Are there resources that you have found that are successful?
(37:55):
And just really talk in general about having those, let's be honest,
they're difficult conversations with patients when, like you said,
if their perception of success is whatever and you deem that you need to really
address some serious issues before surgery.
So I guess, how does that conversation go?
And are there any resources that you have found success with?
(38:17):
Well, yeah, yeah, that's a big question. But we, you know, at our institution,
we have a perioperative surgical home or perioperative surgical coordinator.
She's a nurse, and she helps with patients who need substantial optimization.
And we'll have a conversation and say, look, you know, you have a lot of these
factors that we can modify before surgery.
(38:39):
And I think we should do that if we can, because this is elective surgery.
It's not a burst appendix where you have to do surgery right now.
So why not make it safer for you if we can so i offer them to see that that
navigator and they help get them in with specialists and we do the best we can
and i see them again and then we see if we've gotten anywhere and then we can
book surgery but i think to the the question from the article.
(39:03):
There's high-risk patients that are elective patients, and we now have a team
of people who reviews these high-risk patients when they're cases,
and they're flagged by the perioperative team when they come through our—we
do everything on computer.
So, when it comes to the computer, oh, this person has all of these flags,
(39:23):
so that the committee looks at the patient and sees if they meet criteria to be very high risk.
And then we talk to the surgeon and say, look, have you tried X,
Y, and Z? I noticed you only saw them once in the office.
Maybe you can try some other things with this patient to see if they can't get
in a little bit healthier before the operation because we really don't want a bad outcome. on.
(39:44):
And most of the time when we review those things, the surgeon says, wow, you know what?
I wasn't even thinking about that. And that's a really good idea.
I'm going to let them know. And we're going to try and see him again in a couple
of months. We're going to get them a little bit better and healthier before surgery.
And then the other side of that is if you're in the office and you see someone
who's really, really high risk, but you know they might benefit from an operation,
(40:08):
you can say, look, I don't want to book surgery right now because your risk
seems is really high, but we do have a committee that reviews these more complex
surgeries and patients.
So what I'm going to do is I'm going to put your case in and we're going to
present it to this committee and then we'll see what they say.
So it helps the surgeon because the surgeon doesn't need to be face-to-face
(40:30):
with the patient saying no.
They can say, look, you know what? I have empathy for you. I understand that
you're in a bad situation and it hurts so much and you want me to fix this.
But there's a lot of risk here. And I think we need to unpack this before we proceed.
And we have a process here that we have to go through with patients that have
high risk. And we're going to go through that process.
(40:51):
So it takes the onus off the surgeon in that face-to-face encounter a little bit.
As with most things, I think these discussions are just all about communication.
And to boil it down even more than that, I think about this with the obesity
discussion a lot. Just don't be a jerk.
It's really as simple as that. Don't tell someone, well, you're too fat,
(41:13):
so I'm not operating on you. That doesn't help anybody.
All that's going to do is you're never going to see that patient again because
they're going to leave there thinking, Dr.
Benner's a jerk. They said this to me, and I can't believe that they said that.
And there's no chance they're ever coming back versus if you approach it as,
you know, I want to be part of the solution along with you. I understand this is difficult.
Like, you know, every, you know, there's millions of people in our country that
(41:35):
are struggling with this, but I'm not doing my job if I don't understand and
share with you the risks that we're, that we're up against.
And, you know, I don't want to
make it worse as much as you think it can't get worse. It can get worse.
And I would hate for us to do a surgery for us to have a complication and then
get done with it in the end and say, gosh, did I really need to do this,
you know, despite all these risk factors?
(41:57):
So, you know, I think this discussion and all these considerations are ones
that we all should be having on a daily basis.
And I'm sure this was really educational for you writing this to educate the rest of us.
So, you know, talk a little bit about that as we start to wrap up here.
How did writing this manuscript make you a better physician?
How did it make you better at what you do?
Well, you know, that's a very good question because when you write a paper like
(42:20):
this that explores ethical conundrums and informed consent and what do patients perceive as risk,
what resources do you have as a surgeon when you face these very complex problems,
it helps me become more aware of it.
And now when I speak to patients, especially higher risk patients in terms of
(42:43):
informed consent, I try to put it in layman's terms and say,
look, your chances of getting much Much better from this operation are seven and 10.
So seven people are going to do great. Three people, maybe not so great,
but your risk is nine out of 10.
So, you know, maybe we need to bring that risk down a little bit to make this
surgery worth it. So they understand that a little bit better.
(43:05):
The second thing is having other resources that you can say,
look, you know, let's try some other things. Let's see if we can get you to see some specialists.
Let's see if we can coordinate your care and get you better optimized.
One thing that we haven't talked about yet is I said we have that committee
outside of the hospital for patients who are not inpatients.
But we do have a team in the hospital for when patients have ethical.
(43:27):
There's an ethical challenge with a patient.
And if you aren't sure about what to do for someone, you can call on them.
And it is a team that's an escalation team that can review the care of the patient
and help you make a decision.
So if a family is demanding a surgery and you say, this is really too high risk,
that team can support you or tell you, no, you know what, you should proceed.
(43:51):
So you have another, you can phone a friend basically and have some help when
you make these very tough decisions.
As an outpatient or as an inpatient for the patients.
Last question. I think another important part of this, and this is going to
sound maybe a little less compassionate than what I've talked about before,
but I think as surgeons, we have to empower ourselves to say no.
(44:13):
There are just some patients that say, doctor, I just, I just,
we got to do this. Like, you don't understand how bad I'm hurting.
You don't understand how bad this is. Yeah, I do understand.
I've sympathized with you. I'm sorry that it's like this, but I just don't know
that I'm going to help you.
And there have been times that I, that I've just had to break it down and say,
listen, unfortunately, the answer, the answer is no, we're not,
we're, I'm not doing this operation.
(44:35):
We have to be able to buy into one another that we're on, that we're ready to
take this journey together. other.
And for the reasons that I've already articulated, I'm just not willing to do it.
So unfortunately, I'm sorry that we're not going to agree on this, but the answer is no.
And I think it really bothers me when I go to meetings and people say,
well, I kind of got talked into doing this case.
(44:56):
I was working on non-surgical treatment.
It weren't getting any better. And I finally just kind of gave in and did it.
And I think we need to give ourselves as orthopedic surgeons a space to say
no when we think it's appropriate.
Well, and that's this whole point of this is that it's okay to say,
look, either this is too high risk and I don't feel comfortable doing it.
And you're allowed to say that because as long as that patient is taken care of, that's the goal.
(45:24):
But feeling comfortable saying that declining surgery is difficult and it's hard,
but you should be allowed to do it if you feel that there's something that's
dangerous about it or that they're not going to benefit from it.
I have someone now that's, I've just been shaking my head. He's a guy with terrible knees.
(45:46):
I mean, it's terrible, but has cognitive problems.
Comes in two hours late, goes to the wrong place, goes to x-ray and leaves because
he doesn't remember he has to come down to the office afterwards.
And he lives by himself, has someone helping him, but that person isn't very helpful.
And he's terrible, terrible pathology in the knees. But, you know,
(46:07):
I can't justify doing surgery on someone that may not remember to take their
post-op VTE prophylaxis.
Even if I send him to a rehab place, he's going to go home eventually and then
not remember something.
I sent him to geriatrics to have them evaluate him.
They did cognitive testing. And, you know, geriatrics is a tremendous resource
(46:30):
for older patients, especially to go over people who have polypharmacy.
Everyone's piling medicine onto these old people and nobody takes any of them away.
So like, oh, yeah, this person's really confused because they're on 10 different
medicines when they should be on two.
So they help with that stuff. So but it's still not bad.
And I and the guy keeps calling and calling and want surgery.
(46:52):
But I don't you know, I feel so scared.
I'm afraid something terrible is going to happen.
Yeah. And that can happen. And if you have your gut says something is wrong,
you should listen to that gut, especially if you've been in practice a long
time. Absolutely. That means something is bad.
Yeah. For all our listeners out there, if you want to check this out,
it's the Orthopedic Forum on General Bone and Joint Surgery in press coming up soon.
(47:15):
Dr. Claudette Lejeune is the first author on this paper from NYU.
Thank you so much for joining us tonight. It's been a really interesting conversation.
I feel like I've really learned from this. I hope you and our listeners have
as well. And we really appreciate you coming on.
Thank you so much for having me. It's been an absolute pleasure and great talking to you.
Nice stuff. As we talked about before, we're all over social media.
We're on Twitter and Instagram at the SKC Podcast.
(47:38):
We have Facebook and YouTube pages for the Show Money Center Podcast.
You can email us comments or questions at the skcpodcast at gmail.com.
Check out our previous content. This is episode 42.
So we've got a lot of previous content you can check out. If you like what you
hear, give us a five-star review and share it for other people to see as well.
So thank you for joining us and we'll see you again next time on the Show Morning Center podcast.
(48:00):
Music.
Popular Podcasts
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.