Surgery Just for the Heck of It

Last week I was going over the list of inpatients on our service with two of my attendings when we came to a diabetic male who was admitted with fever and chills. The patient had an ulceration on the bottom of his foot resulting from something called Charcot Foot. Diabetics often develop what is called peripheral neuropathy...bascially, the peripheral nerves become damaged, and the patients develop numbness in their hands and feet. This not only affects the nerves that are responsible for our touch sensation, but the nerves that are part of something called the sympathetic nervous system as well. This results in the break down of bones in the foot with multiple fractures and dislocation of the joints. The patient often develops something called a roker bottom foot, or a bony protuberance on the bottom of their foot. Over time the skin overlying this area breaks down and becomes ulcerated...and so, this was the case for this patient. A very complicated (but high paying) foot surgery is a charcot reconstruction, or the surgical attempt at putting the foot back together again. Let me add here that this surgery does not have a great success rate. As soon as my attending saw that there was a patient on our list (without even seeing the patient in person), he wanted me to talk to the patient and book him for a charcot reconstruction with an external fixator. This is basically a big metal frame that goes on the outside of the foot and has pins going into the bones of the foot. This would be a 4-5 hour surgery with a long recovery time. The other option, which would be less costly (pay less), and have a much quicker recovery time for the patient would be to simply cut away the bony protuberance on the bottom of the foot and close up the ulcer. The attending who wanted to do the charcot reconstruction made an attempt at guilting me into booking the case by saying "I thought you guys wanted to do surgery! This is a surgical program, so if you want to do interesting surgical cases, book this patient!" He wanted to put a patient through a complicated (and unnecessary) procedure to make a quick buck and brag about the recontruction he did. Sure, in the right hands, and under the right circumstances, this procedure would have its place...but this was not it! The patient was lucky that there was more then one attending involved, and the other attending intervened preventing the surgery from going forward. It is sad when medicine becomes more about money and experience rather than the care of patients.