Sunday, March 30, 2008

Making decisions for surgical treatment

I have always been curious about the process by which patients make decisions about their care.  I remember being in fellowship training in Hand & Microsurgery at the Massachusetts General Hospital.  I supervised 2 chief residents in plastic surgery, 2 junior residents in plastic surgery, and whichever general surgery residents were rotating on the Plastic Surgery Service that particular month.  One of the most frequently performed procedures we did on call was replantation of amputated fingers.  As a matter of course, most of these cases were done late into the night.  Sometimes I felt that we were the only replantation center for the whole city of Boston considering the volume of work we did.

Obviously, most patients WANTED everything done to save the amputated part.  But we (the community of replantation surgeons) knew from more than 2 decades of accumulated experience that just because a finger COULD be replanted, did not mean it SHOULD be replanted.  In other words, a single digit amputation through zone II (from the mid palm past the middle knuckle of the finger - where the 2 flexor tendons run through a delicate sheath where scarring can significantly effect function) may survive, but may be more of a functional hindrance than a help.  But who wants to walk around with a stump for a finger?  But if you are a manual laborer who supports their family, and return to work will be significantly prolonged with replantation and rehabilitation of a single amputated finger, and functionally one could perform their job capably without the finger replanted - what is the right choice?  In these cases, recommendations by the surgeon play a major role in the decisions ultimately made by patients.  Maybe there is a "better" choice to be made based on the available information.

Women who are diagnosed with breast cancer face several initial choices for surgical treatment - breast conservation versus mastectomy.  These treatments have been shown to lead to equivalent survival rates.  What influences what choices are made?  Shouldn't patient preference be a major part of the decision making process because of the equivalent survival rates?  I will describe some interesting findings about decision making in early stage breast cancer in my next post, but I wanted to try a reader poll about the subject.  I am sure there is nothing too scientific about the poll I have posted on the sidebar, but I am interested more in the readers' commentary than the answers per se.


Just One of Many said...

I've been thinking about how to answer this post and keep it succinct, because the decision making process was long and difficult. Once made, however, I was calm and never looked back. Unfortunately, I know more than one breast cancer survivor, so I had the benefit of first hand experiences. I also had a lot of feedback from my primary care doctor, my gynecologist, a genetic counselor and some nurses. Lastly, and probably most influential, was my second surgical consultation and my consultation with you. I matched all my newfound information to a list of priorities I had made which was based largely on the ages of my children. I will say that most of the feedback I received (both professional and laypersons) weighed in on the side of mastectomy.

Anonymous said...

It would take a novel to respond to this answer. The emotions, confusion, & tumult that you are thrust into makes this decision extremely difficult. With that said, the short answer is complete trust & blinding intuitive feeling & connection you have with the team that is treating you. The best advice I received from someone was, when you come to a decision, do not look backwards, it’s the right decision. I can only say that at my consultation with you, I found you extremely caring, informative & calm. Your staff was top notch & on the ball. It was comforting. You took the time to answer my numerous questions & passed me the box of tissues when I went into meltdown. I think that once a connection is made with a Doctor, the decision making becomes easier. I have zero regrets. I love my new breasts; in fact they look nicer than my original ones! I feel like a woman again & totally love never having to wear a bra.

Anonymous said...

i have to say that my decision didnt take much thought.With everything moving along so quickly, i didn't even have the time to truly think it out. and honestly, that worked out better for me. with the options before me, i knew that bilateral mastectomy was the right choice. i have no regrets. even with the constant discomfort of my tissue expanders, i wouldn't have done it any other way. i give credit to both my surgeons and the amazing nurses at Good Sam breast health center. like anonymous said, it is pretty much based on intuition and trust. i didn't go with the first general surgeon i consulted with. i just didnt feel comfortable with him, period. it wasn't anything he said or didn't say, it was just what i felt. Dr. Harris was the one and only plastic surgeon i saw. after our first meeting, i didn't feel the need to consult with anyone else. i knew he was the right surgeon for me.