To cut or not to cut - That is the question

We live in a consumer society.

We want everything. And we want it now.

This attitude can become really dangerous when it is applied to your medical care.

Nothing is more alluring than the idea of an "immediate fix".

In and out and done!

Isn't that what we all want?

The pressure is on. You hear it everywhere:

"Call now and get 50% off."
"Only until the end of the month."
"While supplies last."
"This offer expires in one week."
"Offer available for the first 50 customers."
"Decide today."

And on, and on it goes.

High expectations from surgery

By now we got adjusted to this kind of expectation.

We don’t wait, we do, we buy, we get.

Surgery may sometimes seems like the easy and fast solution to a problem (of course, I am NOT talking about life-saving emergency surgery here but rather elective procedures). 

On the one hand, we don’t want to live in pain. On the other, we don’t want to have the hassle of months of physical therapy, changing our diets and taking medications.

Surgery - oh how alluring it is!

On TV medicine is so dramatic. They rush into the operating room and they might even have a cardiac arrest on the table – but of course they come back from it and soon WALK out of the hospital. So, we might start to believe that this was really how it worked.

Any elderly individual undergoing major surgery, especially orthopedic surgery, will require many weeks of post-operative rehabilitation. There you will have to do a lot of physical therapy – and you will likely be in a lot of pain. You will still need to take medications to alleviate the symptoms and you should still change your life-style and diet to prevent future problems. So, now the only difference is that you also had a surgery.

Don’t forget: ANY procedure has its risks.

There is no such thing as a risk-free surgery. What many forget to consider is the following, though: yes, you will likely survive the surgery but you are far from “out of the woods” at that time!

There are many complications that can follow surgery: wound healing problems, serious or minor infections, confusion and delirium, blood clots, stroke, decline of functional status, pain and many more.

I think it is time we faced the reality: there is no such thing as a quick fix.

There are ways to prevent complications of surgery.

One is to very carefully consider the indication of this procedure. 

• Ask your doctor what to expect during and after the surgery:
• How much will you actually benefit from it?
• What does that mean for your everyday life?
• How likely will you suffer post-operative complications?
• How long is the expected rehabilitative phase?
• Will your problem recur after some time?
• How long is that time frame?
• If you were your physician’s mother or father: would they recommend that surgery to you?

And if you are not sure or feel pressured, maybe you should take your time making this decision.

Think about what is important to you.

Consider getting a second opinion.

Speak to people that are important to you and may guide you in this process.

Of course, there are other ways to prevent complications. There is more and more literature and attention to that topic – especially in regards to the elderly surgical patients. 

Surgeons in the OR

A large expert panel has evaluated this topic and has recently (October 2012) come up with guidelines of pre-operative assessment in the elderly. There are no less than 13 (!!!) points that the physicians should address before any surgery in the elderly. I will start a small series talking about these 13 keypoints on this blog – so stay tuned.

Of course, I speak as an internist. My first thought rarely is “surgery”. There are very beneficial procedures available and great surgeons out there. But remember, just because your surgeon is great and the procedure is sophisticated – it doesn’t mean it is for you.

I wish you well in this maze. There is a lot of confusion and it is not an easy decision to make. I just want you to consider to take your time (when you have the luxury of time) and really think it through.

Check out this great article about this topic on the amazing seniorplanet blog.

I wish you wisdom.

Be well,

Dr. B

Why is level of functioning important to a doctor?

We all understand intuitively how somebody is doing when we see through their eyes how they experience the world.

Dancing Janet! Tango

Janet

Imagine Janet. Janet is a lean, tall woman who is full of energy. Janet wakes up at 6:30AM to do an hour of Yoga, she eats fruits and yoghurt for breakfast. Then she is out the door and to the community center. She loves to volunteer and provide meaningful support to her community. In the afternoon she gets together with her friends for a coffee and they chitchat and lough. Tonight Janet takes a class in ballroom dancing.

Angela

Now let’s meet Angela. Angela has an aide who comes at 7AM and gets her washed and out of bed. The aide helps her with breakfast and then sits her in front of the TV. Angela sometimes thinks that it would be nice to go to the Park or meet her friends but she couldn’t really ask her aide to help her with that… at least she doesn’t dare to. The hours don’t seem to pass by, there is one game show after the other, one talk show after another… well, you know how irritating TV can be. And then tonight Angela goes back to bed with the help of her aide.

Who is doing better, health wise? How old is Janet? How old is Angela?

This is pretty obvious: Janet seems in great health. She is independent, energetic and very active. Angela on the other hand is probably seriously ill. Angela needs help with the some of the most basic activities of her daily life and might even be depressed.

What you might not expect is their ages: Janet is 92 years old! Angela is only 63, she could be Janet’s daughter.

And that is why we don’t look at a number when we treat a patient. Numbers play a role but not the biggest. We want to see the whole person. And that is when we evaluate their functional status. How dependent is someone in his or her “activities of daily living” (=ADL)? These are some ADLs: transferring out of bed, dressing, washing, toileting, feeding. And then there are the more advanced activities: instrumental ADLs (iADLs) such as managing the household, the medications, finances, and transportation. When we know which of these are done independently and which require assistance (and how much) then we have a much better understanding of the person as a whole and of this person’s needs.

Believe it or not: someone’s functional status may sometimes be one of the most important factors to be considered by the physicians when estimating whether a patient is a candidate for a procedure, a surgery, or even chemotherapy. Functional status really matters and helps to keep the big picture “vivid”.

Can you do something to improve functional status?

This really depends on the underlying cause of your impairment. A person with dementia will over time become worse and worse without much hope of significant improvement. Somebody healthy who broke a hip may benefit from rehabilitation and may recover a very high level of functioning.

 

Staying active is key. You may do this on your own (even taking regular brisk walks 30 min. three times a week is already great!) or you may require the help of a physical therapist – this depends on your situation and you should ask your doctor.

There are several great physical therapist and physical therapy clinics out there. I like to work with Fox Rehab (check out their blog: http://blog.foxrehab.org ). They are a “mobile” outpatient clinic and come to your house for 50 min one-on-one intense physical, occupational, speech and cognitive therapy. And what I like best: they have extensive experience with the older patient generation – which the geriatrician in me loves!

I hope this helped.

Have a great day and stay active,

Dr. B