How Doctors Think (21 page)

An additional problem is that many procedures have multiple outcomes and it is not sufficient to examine just one of them. For example, a coronary artery bypass may change the life expectancy of a 60-year-old man with triple vessel disease, but it will also change his joy of life for several weeks after the operation, the degree and severity of chest pain, his ability to walk and make love, his relationship with his son, the physical appearance of his chest and his pocketbook. Pain, disability, anxiety, family relations, and any number of other outcomes are all important consequences of a procedure that deserve consideration, but the list is too long for practical experiments and many of the items on it are invisible or not measurable at all.

Does acknowledging uncertainty undermine a patient's sense of hope and confidence in his physician and the proposed therapy? Paradoxically, taking uncertainty into account can enhance a physician's therapeutic effectiveness, because it demonstrates his honesty, his willingness to be more engaged with his patients, his commitment to the reality of the situation rather than resorting to evasion, half-truth, and even lies. And it makes it easier for the doctor to change course if the first strategy fails, to keep trying. Uncertainty sometimes is essential for success.

Chapter 7

Surgery and Satisfaction

T
HE HUMAN HAND
contains twenty-seven bones and scores of ligaments, muscles, and tendons. Working in concert, these parts give us the ability to thread a needle, bow a cello, deliver a left hook, operate a jackhammer, and caress a lover. Dr. Terry Light of Loyola University is a hand surgeon. When I spoke with him in the autumn of 2005, he had just finished his tenure as president of the American Society for Surgery of the Hand and was about to assume the presidency of the American Orthopedic Association. But at the time, these honors paled next to the fact that Dr. Light had once served as the hand surgeon for the Chicago White Sox. I had no doubt on which side Light stood in the eternal debate about whether a team's pitching or hitting is more important—pitching, of course.

Baseball occupied only part of our conversation, because I took the opportunity to present a complex diagnostic dilemma to Dr. Light, the case of a patient with debilitating pain and swelling in his right hand, the hand he used to write, turn his door key, and perform the innumerable tasks that mark each of our days. Over the course of three years, the patient had consulted six hand surgeons and got four different opinions about what was wrong and what to do about it. I was that patient.

The trouble with my hand can be traced to my never learning to type. My fifth-grade teacher told my parents that I was not college material, and advised that I be tracked to a vocational school to learn a trade. Truth be told, I was not a model child, too eager to engage in mischief, paying little attention in class, looking at the clock and counting the minutes until recess. A psychologist today might fix the label of ADHD to me, but at the time my family concluded that mine was a classic case of
shpilkes,
a Yiddish word meaning, roughly, "ants in your pants." My parents would later reject the teacher's advice, but in fifth grade I spent afternoons in metal shop instead of typing class; there was no expectation that I would ever need to use a typewriter.

Ten years ago, I bought my first laptop and banged clumsily at the keyboard for many hours at a time. I soon developed a roaring case of tendinitis in my wrists. I rested, returned to the computer, and suffered repeated bouts of pain. After a year, I gave up and went back to writing by hand. But I was left with a persistent ache in my right wrist—annoying, but not severe enough to require medical attention. Then, one day in the pool, a swimmer in the neighboring lane happened to fling his arm in a downward arc at the same moment my right arm moved up. He delivered a blow to my right wrist.

I iced the bruised wrist, and after a week the pain went back to its usual dull ache. Some months later at the hospital, an elderly woman was making her way toward the elevator. I was already inside and saw the doors begin to close; reflexively, I extended my right hand, but it was too late for the electric eye to respond. The elevator briefly closed on my wrist. Ice again treated the trauma.

Dr. Light listened closely, not interrupting. I told him I was coming to the key event that caused me to consult the first surgeon. A few weeks after the elevator incident, I struggled to open the lid of a bottle of fruit juice. After much forceful twisting I succeeded, but in a flash, excruciating pain erupted in my right wrist. The hand became hot, beet red, and swollen. I couldn't move it. I took some naproxen, an anti-inflammatory drug, and applied ice. After a few days the swelling subsided. But each time I tried to write more than a few sentences, I developed sharp pain in my wrist below my thumb. I went for x-rays, which revealed cysts, essentially fluid-filled holes, within the scaphoid and lunate, two small bones on the thumb side of the wrist.

The first hand surgeon I consulted I will call Dr. A. In his early forties, A was known in the Boston medical community as the doctor for many professional athletes injured during play. His waiting room was jam-packed. Nearly two hours after my scheduled appointment, his nurse finally ushered me in to an examining room. Five rooms were already occupied by other patients, some with casts, other with pins, still others in slings. Dr. A entered some thirty minutes later, asking me where I worked and what kind of medicine I practiced—a "name, rank, and serial number" bedside manner. As he listened to my story, he jotted a few notes. Dr. A examined my hand, and I winced when he pressed over the bones beneath the thumb. "Let's get some x-rays," he said.

I said that I'd already had x-rays in my own hospital, but he insisted that I repeat them in his clinic. An hour later, he returned. The x-rays were as before. Dr. A told me that many people have cysts in their bones and show no symptoms. Other people have bone cysts and have symptoms from them. Some people have a hereditary disposition to cysts, while others develop cysts that are degenerative, the result of trauma or the wear and tear of work, sports, and daily living. Dr. A suggested that I be splinted for a month, and we would see what happened.

At the end of four weeks, I was back in his clinic, waiting another two hours to be examined. I had used the splint diligently, but when I took it off to shower, I had pain in my wrist. Dr. A briefly examined my hand and then told me to see how my wrist felt when I used it out of the splint over the coming weeks. The appointment ended in minutes.

I gradually started doing things with my right hand. It was painful to hold even light objects, like a mug of coffee, but I persisted. And then one day, while writing a few sentences with a narrow pen, I felt my hand begin to heat up. Within minutes it was swollen and red. I could not bend the wrist, and the smallest shift from a fixed neutral position was excruciating. It was like the episode with the juice bottle.

I called Dr. A's office. His secretary instructed me to come in the next day. Dr. A looked at the hot, swollen hand and shook his head. "Let's get an MRI scan," he said.

I asked what he thought was wrong.

"I really don't know."

In a strange way, I was reassured. Some doctors do not readily admit ignorance.

The next week, Dr. A reviewed the results of the MRI scan with me. The scan was formatted digitally on his computer screen so he could enlarge it and zoom in on various parts. He led me through a tour of my hand. It was fascinating to visualize the connecting bones, ligaments, muscles, and tendons. The MRI showed the cysts in the scaphoid and lunate bones. Against the white background of bone, the cysts resembled craters on the moon. There was considerable swelling, with the rope-like tendons suspended in a sea of fluid. Dr. A still had no diagnosis, and suggested that I be splinted again.

Later, when I reviewed my history with Dr. Terry Light, he agreed with Dr. A's approach. "Better to say you're not sure and take the time to figure it out. Often we don't know what accounts for symptoms of pain in the hand, given that almost everyone has a hole in a bone if you look hard enough."

The splint gave me temporary relief. But over the next few months, with the most minor activity my hand would become swollen, red, and painful. I saw Dr. A at least four times over the course of the year. At each visit I pressed him to try to figure out what was wrong. He wondered whether the hot, swollen wrist might represent some underlying systemic disease, like lupus or rheumatoid arthritis, and whether the history of tendinitis from the computer and the trauma in the swimming pool and the elevator were red herrings. But all of my blood tests for systemic diseases that cause arthritis were negative. A steroid injection into the wrist was no help.

At each follow-up visit, I pressed Dr. A for answers. He would just shrug. Then, a year after I first consulted him, he said, "I think you have developed a hyperreactive synovium." The synovium, the lining of the joints around the wrist and hand, Dr. A explained, had become too sensitive to endure even minor stresses. It overreacted by becoming inflamed. He suggested a surgical procedure to strip away all of it. I asked whether the synovium was essential for the joint to function properly, whether there might be scarring after the procedure. Dr. A allowed that the synovium was necessary, but eventually a new lining would grow back—and yes, there could be residual scar tissue.

I am not a specialist in diseases of the bones and joints, and I'd never heard of a "hyperreactive synovium." Neither had Dr. Light: he said that the diagnosis "didn't register. It doesn't really mean anything to me."

Dr. A had come to the end of his thinking. But instead of returning to the honesty of "I really don't know," he invented something to respond to my plaintive questioning and suggested an operation that could be damaging. It was time to seek another opinion.

I went to a neighboring state to see Dr. B. He was prompt, had a focused, deliberate approach, examined me carefully, and agreed that "hyperreactive synovium" was not a real clinical condition. He said he was determined to find out what was wrong and fix it. Dr. B studied in detail every unusual shadow and shape on my x-rays and MRI scan. In addition to the cysts in the scaphoid and lunate bones, he noted a tiny cyst in another bone, on the pinkie side of the wrist. The tendon that runs toward the pinkie also seemed to have slipped slightly out of position. Dr. B thought there was a hairline fracture in the scaphoid bone, not simply a cyst. He said that I needed three surgeries. The first would pin the fracture, the second would involve draining the three cysts and filling each with bone grafts taken from my hip, and the third would reposition the displaced tendon. "The wrist works like a set of gears," he said. "When one or more of the components is out of alignment or malfunctioning, then you can get stuck all across the hand." My straining to shift the stuck gears caused the swelling and pain.

I asked Dr. B how long the recovery period would be from three sequential operations. "Eighteen to twenty-four months," he said.

Dr. Terry Light said, of course, that to comment properly on Dr. B's opinion, he would have had to examine me and view the MRI; but the idea of three surgeries to address every finding on the scan—this gave Light pause. "That's the problem with MRI. It can show us way too much."

I was increasingly frustrated and desperate for a solution, but leery of the idea of undergoing three operations. My wife, Pam, also a physician, said she was worried that my judgment might be impaired by the long siege of pain and debility, so she came along to my next appointment.

I had to pull strings to see Dr. C, one of the most renowned hand surgeons in the United States. He was the kind of doctor whose name routinely comes to the lips of other physicians and who is listed every year in his city's magazine under "The Best Doctors in..."His waiting room was packed, like Dr. A's, but instead of the artwork that typically adorned physicians' offices—photographs of sailboats or paintings of meadows—the walls of Dr. C's clinic were filled with plaques. Hardly a space was left uncovered. I read a few of the plaques; each attested to Dr. C's fame. One was from the International Conference on Abnormalities of the Thumb, held in Rio de Janeiro. Another was on the Repair of the Rheumatoid Finger, held in Saint Moritz, Switzerland (during the height of ski season). Framed conference programs were mounted next to the plaques, and Dr. C was a prominently featured speaker on each.

I was greeted first by a resident in orthopedic surgery. In his mid-twenties, with a boyish smile and Brooks Brothers attire, the resident took my history and looked at my x-rays and MRI as he prepared to present my case to Dr. C.

Dr. C entered the room. He nodded hello to Pam and me. Standing before me, he took my right hand in his and began to examine it while simultaneously listening to the resident recite my clinical history. "Where are the x-rays?" he asked. The resident handed them to him, and without a word Dr. C darted from the room with the resident in tow. He moved so quickly he could have been on roller skates. Not more than five minutes later, Dr. C returned. "We need to do an arthroscopy," he said. This meant inserting an instrument like a flexible telescope into my wrist in order to see the actual bones and ligaments. "I'll have the resident schedule it." Dr. C turned to leave.

"I realize you are in a rush...,"I ventured.

"Rush? Why do you think I'm in a rush?" Dr. C shot back.

"Well, I wonder if you could tell me what you expect to find with the arthroscopy."

"I'll figure it out when I get in there," he said, and left the room.

The resident sat down and took out the sheet of paper that I was to sign to authorize the arthroscopy.

Pam had been quiet, communicating through glances with me. As I read the paper, she began to question the resident, politely but pointedly. She wanted to know how long the procedure took, what the likelihood of each complication was—not just a list of possible complications—and how long it took to recover. Pam tells her patients that no intervention in medicine is completely innocuous or without risk. The resident answered her in a tense voice, unaccustomed to being the primary interlocutor in place of Dr. C. The procedure would take about twenty minutes, not counting the preparation with anesthesia that involved numbing the nerves to the arm; pain and swelling were the main complications, infection being rare; a full recovery would take about two to three weeks.