My hopes were to be that rare individual who went through life never having to see the sharp end of a Bard-Parker scalpel. That fantasy is about to come to an abrupt end.
Raoul S. Concepcion, MD, FACS
For close to 62 years, I have managed to stay healthy enough to keep clear of being on the receiving end in the operating theater. My hopes were to be that rare individual who went through life never having to see the sharp end of a Bard-Parker scalpel. That fantasy is about to come to an abrupt end, as I am scheduled to undergo a total hip replacement to eliminate this unrelenting pain that has plagued me now for 5 weeks, despite many temporizing maneuvers. Through it all, I have gained some valuable insights I thought worth sharing.
In both medical school and my first 2 years of general surgical practice pre-urology, I never had an orthopedic rotation. I knew the musculoskeletal system and the anatomy, had learned enough to talk competently with the ortho residents when evaluating patients during my emergency department rotations, but had never learned, per se, how patients present with early-stage disease. Now looking through the retrospectoscope with 20/20 vision, I more than likely had been having very early symptoms of osteoarthritis over the past 2 years but never comprehended it. Because I was not experiencing pain, I attributed the “tightness” in my hip to not stretching my hip flexors. Had I recognized that some of these early symptoms were true indications of progressive disease, been more proactive, and not waited for pain to determine when to finally seek treatment, I might have staved off for a few more years the destruction of my joint, although I certainly would have averted these 5 weeks of misery and inactivity. This is exactly the sin we commit when evaluating our patients with advanced prostate cancer. We disregard or minimize minor symptoms, attributing them to “other” causes and wait for patient-reported pain to signal the time for action. The result is often a critical delay in the diagnosis of metastatic disease and possibly the loss of that window for certain treatments to be efficacious.
In preparation for my procedure, I became a patient and a consumer for the first time. Once I'd made the decision to move forward and proceed with surgery, imagine my dismay when forced to give the exact same information to 3 distinct factions that would be integral to my case: the surgeon, the anesthesiologist, and the hospital. Yes, I was able to provide the information over the phone or in a centralized setting. But despite the billions of dollars spent in the conversion to a digital healthcare record over the past couple of decades, I found the process of repeatedly exchanging information highly frustrating. How much have we truly advanced if it seems that even basic information is not shared or transportable? Perhaps I expect too much.
But along this journey from diagnosis to treatment decision making, a couple of things happened that validated what many of us have advocated in the management of our patients with cancer.
Like many of us in the field, and given the quasi-acute onset of my symptoms, I was able to bypass the normal process for consultation. I called an orthopedic colleague to work me in for an immediate office visit, an evaluation, and a working diagnosis. After unsuccessful attempts to eradicate my pain, the recommendation was for hip arthroplasty via an anterior approach. Being the consummate consumer, I sought a second opinion from another colleague in a different practice, who concurred. To my satisfaction, both encouraged me to see a third provider—another colleague. This was a former student and a partner in yet a third, distinct practice who had performed a much higher volume of anterior replacements than anyone in the city.
Getting Ready for Treatment
After consultation and, dare I say, “shared decision making,” I accepted the fait accompli of needing a bionic hip. I was then routed into a joint replacement “center of excellence.” In my opinion, this moniker is thrown around quite loosely, and practices and hospitals slap it on just about anything in a ploy to attract patients. However, from the moment I initiated the process, the care provided truly was comprehensive, dedicated to an optimal outcome, and a model for all of us to follow. I was assigned a nurse navigator, who coordinated my imaging and lab work and scheduled my operating room (OR) time and subsequent physical therapy appointments. In addition, she arranged meetings with physical therapy, occupational therapy, anesthesia, their dedicated hospitalist, and my surgeon’s physician assistant, who provided the bulk of the education, both what to do and expect pre- and post op. But perhaps more important, they have a 10-room OR that is dedicated to joint replacements with dedicated anesthesia staff, as well as a post-op floor. Dear to my heart, they asked me to participate in their health economics and outcomes research study, which is tracking all their patients and looking at multiple parameters. This all took place in a window of 4 hours, 7 days prior to surgery!
I am hoping the denouement will fulfill my expectations for a quick return to normal activity. But seeing this process now firsthand, it appears that once again, we as urologists can learn from our colleagues in other specialties how to advance and optimize care. Clearly, the volume of patients we manage could benefit from this model of efficiency, which could be realized if we allow physicians and partners to manage what they are passionate about. We should not be afraid to defer to those with expertise or to make patient-centered outcomes and protocols the centerpiece of how we deliver care.