September 22, 2011

Medicine Is Anything But Perfect

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Fourth-year Weill Cornell Medical student Ximena Levander emphasizes the importance of balancing risk and benefit in medical care.

Jan. 3, 2009, is a day that will live on in infamy — at least in my own personal medical record. That’s the day I hit a patch of ice and landed in a heap of intertwined poles and skis, and I’m unable to verbalize the degree of pain I felt in language appropriate for print.

Despite being a second year medical student at the time and having learned about the “classic” presentation of injuries, I was convinced nothing serious had happened. I kept telling myself I would be fine, and denial is powerful medicine.

During the next couple of days, I hobbled around using borrowed crutches until I saw my primary care physician, who quickly referred me to an orthopedic surgeon. Unfortunately, the MRI sealed my left knee’s fate: complete ACL rupture, second degree MCL sprain and possible medial meniscus tear. This was pretty close to the “unhappy triad,” the medical term used to describe a torn ACL, MCL and medial meniscus, three of the main structures that provide stability (ACL and MCL) and cushioning (medial meniscus) to the knee joint. It is called unhappy for good reason.

My orthopedist referred me to physical therapy to strengthen my knee prior to surgery. My injury, and the swelling that followed, had shocked all the nearby muscles. I would need those to be as strong as possible since the surgery itself would cause them further damage.

By the time I was ready to head to the operating room a month later, I could take a few careful and deliberate steps without crutches. As I walked down the surgery hallway, I was terrified. But I was determined to get my knee ready for the 2009-2010 winter sports season.

Now, I’m not telling you about my injury to scare you two months before ski season starts. I wanted to let you know about what I learned during my recovery: Medicine and surgery are not perfect. This may seem obvious, but when an unexpected complication occurs it can be a tough pill to swallow. And what it comes down to is managing expectations and understanding the risks versus the benefits of any medical decision.

Before my surgery, I was convinced my knee would be as good as new — after a few months of physical therapy, of course. In the same way you replace a broken tire without even noticing a difference the next time you drive, my torn ACL would be replaced with a ligament made out of my own tissue. I would be ready to hit the slopes of Mt. Snow in no time. My knee, on the other hand, had a very different plan.

During a routine follow-up my orthopedist felt the replacement ligament was looser than he would’ve liked. Then a little over a year after my surgery, I started having pain, more so than usual. A repeat MRI showed the ligament had torn again. I couldn’t believe it. I had done everything I was supposed to and still my surgery had failed. My orthopedist could see my shock and disappointment. He looked me in the eyes and said, “Of the over 1,000 ACL surgeries I’ve done, you are one of only two that I’ve wanted to redo.”

A 0.2 percent failure rate, or 99.8 percent success rate, is incredible in the field of medicine — unless you’re in that 0.2 percent minority requiring further intervention.

The possible need for a second surgery is something I had never discussed with my surgeon and was certainly something I never thought would happen to me. I later found a study from The Journal of Bone and Joint Surgery where researchers found that up to 6.5 percent of ACL surgeries required a second operation, on either knee, within one year. That number seemed high enough to suggest that perhaps this was something I should have realized was a possibility before agreeing to the first operation. Perhaps then I would have been better prepared when I went through the whole process again.

This conversation, between patient and physician, discussing the short-term and long-term risks and benefits and all possible complications, is something that the medical profession as a whole needs to work on improving. I’ve seen innumerable patients caught off-guard when the surgeon rushes in to wheel them back into the operating room because something went wrong after the first surgery. When you watch pharmaceutical advertisements and they run-off the laundry list of possible side effects and adverse reactions, you have to ask yourself, “What would I do if one of those happened to me?” and “Are the benefits worth the very real and possible risks?”

An article recently published in the Journal of the National Cancer Institute outlined the difficulties physicians face in helping patients make tough decisions about their medical care and the importance of effectively communicating risks versus benefits, specifically in the field of oncology. However, physicians from all specialties need to have this type of conversation with their patients. They need to use plain, non-medical language, explain with pictures and graphics, and lay out risks along the timeline in which they usually appear.

However, it is not just up to physicians. Patients and their families need to take initiative ask, “What are the risks? What are the benefits?” with every intervention, be it surgical or medical. I think that too often we are afraid to think about the risks, but this fear is much worse when the side effects come and we are not prepared. Everything in life has some degree of risk, whether you choose to drive your car to work instead of ride your bike or eat a slice of pizza versus a soup and salad. In order to live life we have to embrace risk, and the same goes for wanting increasing advances in medicine. We have to be prepared to discuss the benefits and the risks of new medical breakthroughs.

It has been nearly 32 months since my initial injury (31 months since my first surgery and 10 months since my second surgery). My knee is nowhere near perfect and I have come to the realization it never will be. Getting to this level of acceptance took me a long time. My knee still gives out every once and a while, usually when I least expect it. At first this scared me but now it serves as a not-so-gentle reminder that it is time for more squats, lunges and straight leg raises. My physical therapy is something I can control.

Ximena Levander is in her final year of medical school at Weill Cornell Medical College. She may be reached at xal2001@med.cornell.edu. What’s Up, Doc? appears alternate Fridays this semester.

Original Author: Ximena Levander