Portal de Periódicos da CAPES

What’s Important: Empathy in Patient Care

2020; Wolters Kluwer; Volume: 103; Issue: 2 Linguagem: Inglês

10.2106/jbjs.20.00820

1535-1386

Thomas K. Fehring,

Clinical Reasoning and Diagnostic Skills

My orthopaedic problems began when I was a junior in high school playing football. During the last preseason scrimmage, I was covering a punt. I ran down the field, broke to make a tackle, but twisted my knee and felt something "pop." My knee was immediately unstable. I was seen by our team physician, a primary care doctor, who recommended 6 weeks in a cast for treatment of an acute anterior cruciate ligament (ACL) tear. I then went back to playing football with some difficulty. I definitely could feel a difference in my agility. Fortunately, I recovered enough to be recruited to play Division I football in college. I arrived at college for summer workouts. At that time, in the 1970s, 3 practices a day were commonplace. I must have been dozing during orientation because I did not realize that you could turn in your pants after every practice to get a clean pair. After about a week of practicing in 90°F to 100°F (32.2°C to 37.8°C) temperatures without turning in my pants, I developed multiple furuncles about my knee. I spiked a fever of 103°F (39.4°C), and my knee became very swollen and painful. Because this happened on a weekend night, the training room was not open. Instead, I went to the infirmary, where a general practitioner told me, "Son, looks like you've got an infection in that knee. I'm going to give you some IV [intravenous] antibiotics and keep you in the infirmary for the weekend." When my fever broke Monday morning, the doctor slapped me on my back and sent me back to practice. My knee was never the same after that. I had repeated effusions during my freshman season. In retrospect, I had septic arthritis that was not treated surgically. My orthopaedic problems continued. During a scrimmage a week before the first game of my sophomore year, I incurred a midshaft "both-bone" forearm fracture that required open reduction and internal fixation (ORIF). My season was over. During a postseason pick-up game of basketball, I injured my "good" knee. The operating surgeon performed both an open medial meniscectomy and an open lateral meniscectomy, theorizing that removing the normal lateral meniscus would prevent a tear later that would force me to miss another season. I went back to football my junior season but was injured once again in the final game. My previously infected knee locked up, requiring surgery for a torn medial meniscus. I underwent an open medial meniscectomy and an open lateral meniscectomy on that knee. However, this time when the doctor met with me postoperatively, he told me that I had the knee of a 70-year-old man and that I needed to quit playing football. Of course, that went in one ear and out the other. In retrospect, he basically told me that the infection I had incurred when I was a freshman had destroyed my articular cartilage. During medical school, I injured my knee yet again during a pick-up basketball game. Radiographically it appeared that I had an osteochondral fragment in my now degenerative knee. I underwent an arthrotomy, the fragment was removed, and an open microfracture was performed. For almost 40 years following this surgical experience, I had a recurring knee problem. Working and playing on a severely degenerative knee became part of life, not unlike the way many individuals put up with their own orthopaedic maladies. It was not until later in my life as an orthopaedic surgeon that I began to fully appreciate what patients with complex orthopaedic issues have to go through. It has been enlightening. In 2018, walking back and forth on the concourse at the American Academy of Orthopaedic Surgeons (AAOS) meeting in New Orleans, my knee became terribly painful and swollen. After returning home, I had an aspiration and an injection as this had worked for me in the past. However, this time the swelling persisted, and my knee did not return to its steady state. Radiographically, my knee had deteriorated, and there was a proximal tibial cyst that appeared to be close to the articular surface. As I had long feared, I might have had a recurrent infection in my knee. The aspiration showed that I had 75,000 white blood cells/mm3 in the synovial fluid, and the culture showed a Streptococcus species. As a revision total joint physician with a special interest in infection, I understand the irony that I was now staring down the barrel of a 2-stage procedure to get well. In March 2018, I had my knee debrided, and an articulating spacer was placed by one of my associates, Bill Griffin, MD. From this experience, I learned a great deal about the physical and psychological aspects of being a patient who required multiple procedures to get well. For instance, the difficulties and logistics of receiving home IV antibiotics and using a PICC (peripherally inserted central catheter) line were frankly never on my radar as a treating physician. In addition, for the first 3 weeks, I was treated with IV vancomycin. This drug really did not bother me much. However, my infectious disease doctor transitioned me to ceftriaxone, which made me feel terribly ill. I lost my appetite and shed 12 lb (5.4 kg) over 4 weeks. In discussing this with my doctor, he was incredulous and said, "Didn't you know that all these antibiotics are like chemotherapy for cancer?" That gave me a new appreciation for the patients I treat for periprosthetic joint infection (PJI). After 6 weeks of IV antibiotics, a 2-week drug holiday, and a clean aspiration, I was finally ready for reimplantation. I am now 2 years out, riding my bike, playing golf, and having less pain now than I did between the ages of 20 and 65 years. Another ironic part of my saga is that I am the principal investigator in a national 1-stage versus 2-stage PJI study, and I ended up having a 2-stage procedure right in the middle of it. I had a discussion with one of my patients recently about the difficulties of going through a 2-stage procedure. We commiserated about the fact that after the first stage, you have to undergo another painful surgery in short order. I was admittedly depressed after the first stage and anxious to get on with my life. This same patient challenged me and said "Well, when a patient has a heart attack and ends up in the hospital, people who have been through it before help other patients cope. You need to have something like that for patients who are having these 2-stage procedures." So I went to work on this, helping to create the site healingjoints.org, which educates patients and their caregivers on what to expect when going through PJI and related procedures. We also have ambassadors who coach patients through these procedures. We have had a good initial response to this. As I recovered, I also reflected on the need for a center that could provide multidisciplinary care for the unique needs of patients with a PJI as well as to develop research protocols to help obtain the best outcomes. Fortunately, I work with a group of orthopaedic surgeons, plastic surgeons, and infectious disease consultants with vast clinical and research experience concerning PJIs. Therefore, formalizing this concept into the OrthoCarolina Periprosthetic Joint Infection Center was just an extension of the commitment that we have made to help physicians and their patients within our region. We hope that this center may become a model for other regional centers across the U.S. to provide multidisciplinary care and research collaboration. What else have I learned along the way? I know what it is like to be disappointed and how to come back from adversity. I know that you have to put your faith in your doctor to do the best he or she can, and that a good result is not guaranteed. I know that part of recovery is incumbent on the patient to perform the rehabilitation. But what I have learned the most from my personal experience is empathy. I now have the ability to look patients in the eye and say, "I know it is awful. I have been through it myself, and I understand the pain, the sleep deprivation, the isolation, and the doubt that you have about your recovery." I try to be empathetic to all patients who come in. They are in that room not just to be treated for a specific problem, but for us to try to understand how that problem is affecting their lives. To be honest, I probably was not as good about that as I should have been throughout my career as I moved from room to room during a busy clinic day. My hair is gray and I am entering the winter of my career. I wish I had expressed more empathy toward all of my patients. While it is certainly an impractical prerequisite for a surgeon to go through an actual procedure to fully understand what it is like to be a patient, it would make us all better physicians. Short of that, each time we push open that clinic door, we should try to put ourselves in our patients' shoes. If we do so, we will be much more effective.