Many orthopedic surgeons select this field because they are not dealing with life and death issues…because under most circumstances they won’t have to say, “I’m sorry, but we have done everything that we can.” That doesn’t mean, however, that they never have to deal with human expectations, disappointments—and sometimes worse.
Dr. John Bergfeld, a senior surgeon in the Department of Orthopaedic Surgery at Cleveland Clinic, says, “In one worst case scenario an orthopedist could well have to deliver the news that someone has a tumor. It is vital in those cases to not get ahead of yourself in communicating with the patient…always know exactly what it is that you are dealing with. You should not only have all of the information on that patient, but know the current data related to that person’s condition. Each tumor has its own outlook. You can’t really give the patient a definite scenario. Whatever you do, though, don’t walk in the exam room without being prepared to outline a treatment program for the person. This does many things, not the least of which is to give the person a sense of control and hope.”
In conveying this information, surgeons should be especially careful in their choice of words. “Many times the patient suspects that something bad is happening to them. The most frequent reaction I get is, ‘Are you sure?’ You can never be 100% sure, so you should encourage them to get other opinions. Their next question is usually, ‘What is the outlook if I go through all of this treatment?’ Certain tumors can be cured, while others cannot—you’ve got to be careful with the use of the word ‘cure.’ I once had a patient with a synovial sarcoma who was told by a medical oncologist, ‘You’ve survived three years and you are cured.’ I called the doctor and took issue with what he had told this person.”
Communicating such difficult information is a balancing act, says Dr. Bergfeld. “What the medical oncologist should have said was, ‘You have survived three years and that is better than the average patient in this situation.’ As you can imagine, he was terribly upset about this conflicting information. Unfortunately, a year and a half later he was dead. The bottom line is that you must tell them the truth while trying to be positive.
A good statement is usually, ‘We are going to go after this as aggressively as possible.
Most doctors aren’t so comfortable with these discussions, however, and can make the mistake of not allowing enough time to talk to the patient. Ideally, you should schedule the patient for the end of the day so that you can give them the attention they need.”
From a dawning feeling that something is wrong to the sudden realization that you’re waking up in an ER, patients will likely need comfort. Dr. Bergfeld: “In the event of a trauma, say, a motorcycle accident where someone’s leg is crushed, the person usually reacts along the lines of, ‘This can’t happen to me.’ Their world is turned upside down because they could be disabled for a couple of years and may have to find another line of work. Before that, however, they must undergo skin grafts and bone grafts. You can assist them emotionally, however, if you take a team approach and together outline a program to get them as healthy as possible. If appropriate, you may refer them to counseling and an entity that can provide them with workforce assistance.”
On the less dramatic, but still important, front, there are the injured athletes. “Most people I see with this injury never play basketball again.” You may be thinking this, but don’t say it. Dr. Bergfeld: “Let’s say you have a talented athlete who tears his ACL. Only after I have the entire picture do I sit down with the patient and say, ‘OK, we know what’s going on here.’ I focus on being positive but realistic. I will say, ‘We have good ways to fix this and there is a 90% chance that you can return to your sport.’ You do want them to realize, however, that there are 10% of people who don’t make it back to their sport.”
In many cases, either in adolescent sports or with those individuals who are on a professional level, treatment is a team event. “Get in the room with the athlete and his or her family member and outline everything, even what you will tell the public. I might say, ‘OK Jim, there are eight other people who want to know what’s going on with you. This is what I want to tell them.’ It may be the trainer, the coach, or the agent who wants to know. Or it could be the media. In the latter situation, I will tell the athlete, ‘Here is what I am going to tell the PR guy from the team and you and he can work out what you tell the newspapers.’ I will not talk directly with the media. It’s important that everyone is clear on this sort of thing. I recall an instance in which an orthopedist told a newspaper one thing and the athlete said another. The surgeon said, ‘That is the worst injury I have ever seen.’ The athlete was understandably shaken as he didn’t want people thinking that he would never play again.”
“If we slow down a little then we can act as doctors are supposed to act…with compassion. Some people need more reassurance than others. Tell patients that they should feel comfortable asking for more information. Have them go home and talk to their family members and let them know that they will probably have more questions later. Offer to talk to others such as parents who may be involved in and concerned about their situation. Yes, it’s hard to imagine having time for all of this, but we must make the time. If you have 15 patients scheduled between 8 and 11 and you know this patient is going to take an hour and make you run behind all day…and on top of that you’ve got surgery, it’s difficult. But no one said we’d have an easy job. If we’re lucky, what we have is a meaningful job.”
Tim Hosea, an orthopedic surgeon and partner with University Orthopedic Associates, LLC in New Brunswick and Princeton, New Jersey, also approaches difficult situations with caution. This sports medicine specialist says,
You should be careful to deliver the message at a level the patient can understand, without using esoteric medical terminology that may confuse the person. At the same time you don’t want to be patronizing or present an arrogant front—just maintain a calm, professional manner. And as my colleague noted, don’t deliver bad news until you are certain…otherwise the patient gets upset for no reason. If you suspect a problem, do a workup or refer the person if necessary.
Knowing that participating in sports represents a significant part of a young person’s life, Dr. Hosea always tries to stay positive. “Attempt to keep their thoughts focused on the half full part of the glass by engaging them in thoughts of the future. You can say for example, ‘Yes, you will miss the next game, but you should be ready to play in the next event.’ Get them involved in developing a treatment plan—that way they will be less likely to wallow in their current situation.”
And to give the patient and his family time to acclimate to the new situation, Dr. Hosea states, “Let’s say you do an initial evaluation on an athlete with a bad knee. It is good practice to give the person a range of possible diagnoses, saying, ‘We’re not sure yet. We may have to examine you under anesthesia.’ If you ask them to return in a week it gives the family and patient a chance to get used to the new scenario, process it, and understand the options.”
One thing you can’t do? Delegate. Dr. Hosea: “Even though it’s not fun to deliver bad news, it is never appropriate to duck the conversation. At no time should you leave this responsibility to your nurse or physicians assistant. You must sit down face to face with the person and take the time necessary to work through their concerns. In the end, this is what ‘doctoring’ is all about.”
