second opinions

Monday, October 15, 2012

What should we learn from Derek Jeter and his decision to visit with North Carolina surgeon, Dr. Robert Anderson, the specialist in foot and ankle injuries? 

The Yankee’s Jeter fractured his ankle after landing awkwardly while fielding a ground ball and had to be carried from the field. X-rays were positive for the broken bone but these were soon followed by CT and MRI scans to confirm the extent of injury. Now the treatment plans are being finalized to give Mr. Jeter the best opportunity to return to the field of play.

The lessons:

It is reasonable to seek second opinions when dealing with a potential operation. There are always different ways of doing things in medicine and there is often no “right” way. While elite athletes have the funds to go almost anywhere in the world for that second opinion, most people have quality alternatives nearby. The hardest part of the second opinion process is asking the doctor for a referral before agreeing to an operation. Most patients fear insulting or upsetting their doctor, while in fact, most docs appreciate patients who get involved with their care and are happy to make those arrangements. A patient who is comfortable and satisfied before the first incision makes for a happier post op patient. Be wary of the physician who takes umbrage.

Most injuries do not need an emergency intervention or operation. Treatment plans are often discussed for a future arranged date. Options for care vary based on the type of injury, the patient’s underlying health and the functional goal. Mr. Jeter wants to maximize his chances of playing baseball at Yankee Stadium. A 70 year old might want only to walk comfortably in the woods. There is also the patient’s commitment to post op rehabilitation. The result of surgery is only as good as the patient’s work after the operation to return range of motion and power. An elite athlete will spend hours a day in physical therapy, while a person with less time and resources might spend hours a month.

The rise in medical tourism is a reminder that there are places less expensive than the United States for surgery. The physicians are often US trained and the hospitals may be certified by federal agencies like The Joint Commission. However, it will be the patient’s responsibility to arrange follow up on their home turf, whether the operation was done in Charlotte, potentially like Mr. Jeter’s, or in Bangalore, India. Aside from the routine wound checks for infection, there needs to be plans for physical therapy and rehabilitation arranged before the surgery occurs. This would be no different than having the operation done locally, but the transition of care from surgeon to therapist is less seamless as the distance between the two grows. It’s important to have a home doctor willing and able to deal with post-op issues should they arise.

Athletes tend to get more imaging than they really need. It may be overkill to get plain x-rays, CTs and MRIs on one ankle injury as was the case with Mr. Jeter. When a pro gets injured, they are treated more like a prized racehorse than a human patient. Physical examination is often all that is needed to make an informed diagnosis and imaging may not be necessary. Patients and family members take lessons from the pros and often demand some sort of test to “prove” the clinical diagnosis. It’s hard for physicians to decline; it takes more effort to say “no” and explain their thinking to an upset patient than it does to click on a computer screen and order a test.

Mr. Jeter seeks another opinion with a specialist in North Carolina in hopes of finding the magic that will allow him to continue his baseball career, even at age 38. Dr. Anderson may have special skills and experience, but it is likely that there are equally gifted surgeons closer to home. Athletes will run through walls for coaches that they trust and having faith and trust in one’s doctor may be half the battle in doing well after an operation. While the grass may seem greener the farther one gets from home, the doctor’s skills and surgery outcomes might best be found just around the corner.

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