We share with you an insight into the idiosyncrasies of the people we love and cherish – what makes us so special and wondrous.
“If you operate on me, I’m sure I will get 100% better,” said Percy, a middle-aged, mid-sized, mild-mannered gentleman. He was single and lived with his mother, a status that is quite familiar and widely comfortable among Parsis. “My back is on fire,” he exclaimed animatedly, as he pulled out a cargo of blood tests and MRIs done every single year and religiously organized in colour coded folders.
“Your lab values are fine. The images look perfect. Your spine looks better than mine!” I said candidly after a detailed examination . “I’ve tried yoga , physiotherapy, medications, injections, acupressure and acupuncture, cupping , and even black magic,” he continued. I was curious to find out what the last one entailed but figured it would be best to move ahead; the voice in my seasoned brain whispered to me that this was going to be a long consultation.
“Anything else bothering you?” I asked, trying to get a more holistic perspective. Surgeons are often blamed for their single-pronged ‘you need surgery now’ approach, the kind where “When all you have is a hammer, everything looks like a nail.”
“My mouth is always dry. I’m extremely agitated and irritated all the time. I keep forgetting stuff. I’m perpetually tired and can’t multi-task . There is a constant feeling of doom. I keep burping and the ‘gas’ in my tummy never seems to subside; I’m not sure if it’s because I wear my pants right over my belly button. My eyebrows hurt a lot – not my head, my eyebrows; there is a difference. People think I’m crazy when I tell them this, but it happens mostly after sunset, and when it does, my nose itches. I’m constantly losing hair – I can’t be bald at this age!” My interest arose: Finally, we had a symptom in common that I thought concluded the description, but after a brief pause, he continued.
“There’s always something itching in my throat and I have to drink tons of water with a teaspoon of glycerol to clear it, but nothing seems to work. And if I cough to get rid of the itchiness, I go red in the face. I’m not sure if being constipated has anything to do with this constant feeling that something’s stuck in my throat.” I started sinking in my chair.
“I passed a stone in my urine recently. It was as painful as delivering a baby!” He placed the stone on my desk, neatly preserved in its original form in a plastic container. “Wow,” I said, my eyes widening to the circumference of the earth. I wanted to ask how he had retrieved it, but pretended to contain my intrigue and let him proceed. “The space between my ribs hurts and my knees are always crackling . I have this tingling sensation in my little toes all the time and my skin is so sensitive; it doesn’t tolerate temperatures above 32 and below 19 degrees. I’ve seen over 200 doctors and no one can help me,” he concluded, carefully placing the plastic container back in a zip lock. “Please operate on me,” he pleaded one more time.
I told him that I was a surgeon and that if there was one thing I was confident of, it was that he didn’t need surgery . I recommended guided physiotherapy, a change in medication, and a psychiatrist. I explained that a lot of his problems were psychosomatic and could be addressed by a detailed assessment and personalized therapy. This was a prognosis he had probably heard earlier, as evidenced by his melancholic exit.
A few weeks later, Percy sent me an email stating that another surgeon had finally understood his problems correctly, operated on him and that his back pain had disappeared. “How does one identify a patient who doesn’t need surgery but benefits from one?” I wondered to myself. This kind of placebo effect is often short-lived, but in this case, someone had delivered it: he had bolstered the patient’s confidence and provided a solution, leaving me perplexed about what had actually been done.
Thankfully, Percy’s case is not the norm. On some occasions, when I’ve told patients they didn’t need surgery and when they were eventually operated elsewhere, they returned solemnly stating that the surgery didn’t help.
In a slightly different context, I remember another lady who had severe back and leg pain; her MRI showed a grotesque compression in the lumbar spine. These symptoms disappeared remarkably after surgery, but 3 days later, just before discharge, she developed excruciating abdominal pain. Clinically, the abdomen was soft: the ultrasound and CT scan were clean and an endoscopy from both ends was clear. She insisted that something needed to be “removed from the stomach.” An experienced general surgeon, gastroenterologist , internist, gynecologist , and urologist conducted every test there was and gave varying combinations of medications, all of them confirming that there was no need for surgery. She was in immense pain for 2 weeks, and every time we told her we were giving her a pain injection (but gave her sterile water instead), she said her pain had temporarily vanished, only to return when the injection bottle hanging on the IV pole tethered to her arm was almost empty. Frustrated, they got discharged and were admitted to another hospital that removed her gall bladder the next day. Miraculously, her pain then evanesced forever.
There is more to disease pattern than we understand it. Patients don’t read medical textbooks. There is an alchemy to discerning the functional component of organic illness. Sometimes, patients invent symptoms to claim compensation or exaggerate them to prolong leave. Others genuinely believe that there is something wrong that can only be fixed by surgery, even when the surgeon feels otherwise. Can one ever justify performing an operation that is scientifically unwarranted, but which ends up completely curing the patient for some unforeseeable reason?
It takes a surgeon about 5 years to learn how to operate. But it takes us 10 years to learn when to and when not to operate and perhaps 15 years to adjudge on whom to and whom not to operate.
Here’s hoping that you never need surgery or even pretend to need one.
Stay safe. Stay sane. Yet, stay special.
The writer is a practicing Neurosurgeon at the prestigious Wockhardt Hospital, South Mumbai, India. He is also an Honorary Assistant Professor of Neurosurgery at the Grant Medical College and Sir J.J. Groups of Hospitals. He specializes in the treatment of diseases of the brain and spine and advocates an approach to neurosurgery that is both balanced and proactive.Read More