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^{Chapter III. Finding a Surgeon}

Having made the decision to get a new hip, you are faced with the next and most important decision: who will perform the surgery and in which facility? In some cases, Medicare or private health insurance plans will limit your freedom of choice. Nevertheless, it is important to take advantage of as much flexibility as is available to you. The skill and experience of the surgeon has an important bearing on the favorable outcome of the surgery. Furthermore, a relaxed, comfortable, caring environment for the stressful time of surgery is of obvious benefit to the patient. In this chapter, I discuss the healthcare system and doctors, after which I describe my personal experiences in choosing a surgeon.

The healthcare system

In the United States, healthcare options for most people relate to which type of medical insurance an individual has. For this reason, my experiences involving choice of physicians and facilities are likely to be different from others with a different type of insurance. In this pursuit, as in most others, money talks. If you are wealthy, you have absolute freedom of choice. You can either self-insure or buy an expensive, total indemnity, fee-for-service insurance policy that allows you to choose whichever practitioners and hospitals you want. Most of us, however, do not have that complete freedom. At some point, the insurance company, the Government, or the healthcare industry’s subjugation to these entities will get in the way. If you are of qualifying age, you are eligible for government funded Medicare, which has certain limits and restrictions. Low-income families are eligible for Medicaid, which has other limits. Most people working for medium to large employers have a company sponsored health insurance plan, which is usually a PPO or HMO plan. PPO plans allow freedom to choose any doctor or hospital, but the insurance company bases the amount paid on a schedule of fees negotiated with “preferred providers.” If you choose someone other than a preferred provider, you will pay much more out of pocket. Still, you have freedom of choice to the extent that your wallet will allow. With an HMO plan, the insurance company generally chooses the doctors and healthcare facilities for you. You have only limited choices. This is not good.

However, if you are fortunate enough to be employed where an open enrollment in a variety of different insurance plans are offered, you can probably switch plans at one specific time each year. This could allow you to choose a plan that enables you to use a specific provider that was not “in network” on your existing health insurance. You should consult your company benefits administrator to see whether this is a possibility for you.

This capitalistic medical care system, much the same as in the more socialistic schemes in England and Canada, has created a bifurcated market. A surgeon with excellent credentials is likely to be commanding fees at the top end of the scale, which would make it unlikely that you would find him or her on the approved list for the lower paying insurance plans. At the bottom end, you are likely to find the less experienced surgeons. The grass is not greener on the other side of the fence. Adam Smith was right; Karl Marx was wrong. You get what you pay for. Actually, for the masses in the U.K., for example, socialized medicine’s bulk approach is replete with long waiting lists for total hip replacement surgery. I have heard that because of the disparity between supply and demand, people who are deemed unworthy of the surgery, for example the grossly obese, are completely denied a place on the waiting list. So much for the humanitarian side of medicine! The dismal science of economics has a firm grip on the health care industry.

I shall issue my disclaimer once again. If this was a well-researched book—which it may be someday if there is enough interest in fleshing it out—I would present information about HMOs, PPOs, Medicare, Medicaid, etc., and offer differing perspectives corresponding to the vagaries of the various plans. In its present form, however, the book is a compendium of my personal experiences and observations. Some of the concepts may be applicable to patients in all health insurance situations, but others might apply only to those with insurance coverage similar to mine. I will avoid further editorializing about the way the bottom-line orientation of the health insurance and healthcare industries has transformed hospitals and many doctors over the past thirty years or so. I do not think any of us are happy with it; therefore, perhaps it is time for some grass-roots activism in this area.

Doctors

Unless you are a member of an HMO, you will need to choose a doctor for any specialized medical procedures that cannot be performed by your family doctor, internist, or GP (now collectively referred to in 21^st century insurance-speak as your PCP or Primary Care Physician). A highly trained orthopedic surgeon must perform total hip arthroplasty. In a perfect world, education and training of doctors would be consistent. Unfortunately, it is not. Furthermore, the surgeons you may be able to choose among will have a wide range of levels of experience in this procedure. Without any significant medical training, you are going to have to determine if this man or woman gets to cut you open saw, and drill your bones, and put you back together. How can you possibly accomplish this task?

The first thing you must do is lose your awe of doctors. They save lives and they work hard, but they are not miracle workers. Some might be geniuses, but the majority possess above-average intelligence. They are highly trained in their craft, but they are not God. This bluntness is necessary if we are to get anywhere here. Too many people will let a doctor sell them the Brooklyn Bridge just because “a doctor told me to do it, so it must be good for me.” Now, I am not suggesting that there are doctors who would deliberately suggest treatments that would harm a patient. What I am saying is that there is a tremendous range of skills and interpersonal sensitivities (a.k.a. bedside manner) among physicians. You obviously want a doctor who has the necessary technical skills. In this connection, you would hope that a medical degree, licensure, board certification, many years of experience, and continuing education requirements would guarantee a competent collection of such skills. That is, however, only half the battle. Importantly, no amount of testing or continuing education will correct a poor attitude toward patients. The doctor in whom you place your trust must be the complete package: technically competent yet highly communicative and, above all, humane. You and only you can be the judge.

Older generations of patients had been taught to place blind trust in the godlike powers of doctors. “If you do what the doctor says, everything will be alright.” The old school of thought did not provide for differences in competence among doctors. Am I suggesting that there are doctors who are incompetent and should not be practicing? Yes, this is certainly true in any profession. However, aside from the few who are completely incompetent, some doctors are better than others at what they do. We must reject the notions of the past if we are to obtain the best care for ourselves. It is reasonable to be at least as careful about selecting a doctor as one would be in selecting a house painter. Yet, too many of us still feel that a doctor is a doctor.

Beyond the basic credentials, you will want a surgeon who specializes in hip and knee replacement, one who has performed the surgery many times, and with regularity. You do not want a generalist who does the occasional hip replacement. Nor do you want a new surgeon who has not yet performed several dozen hip replacements. Sure, they have to gain their experience somewhere, but they do not have to obtain it while operating on you! This is a complex operation; you have one chance to get it right. If a second surgery, known as a revision, is necessary, it is much more difficult than the first. The experience level of the surgeon is the easiest thing to check, so do yourself a great favor and check it.

Getting back to the bedside manner, I do not deal well with arrogant doctors. They might be highly skilled otherwise, but if there is no way to cut through the smokescreen of arrogance, I can neither judge their competence nor communicate my needs effectively. A doctor of this personality type will tell me what he or she will do to me without allowing discussion or questions. He or she will not give details. Some of them will toss you a pamphlet about the surgery in question—usually published by a drug company or orthopedic appliance manufacturer—written in such generalized, eighth grade level baby talk that it inspires far more questions than it answers. By the time you get serious about evaluating doctors for performing a complex procedure such as a hip replacement, you should have done sufficient reading on the subject to render such pamphlets superfluous. You do not want or need the baby talk generalizations. You want interaction with the doctor and clarification of the fine points—the specifics of your case. You want answers to the medical and practical questions that have entered your mind as your study of the subject has progressed.

Assuming that you have found a doctor who is sincere, interested, and communicative, you must convince this rare individual that you have done a significant amount of background work on your own and you wish to discuss the finer points and concerns that have entered your mind. You will know that you have a good one if there is no hesitation to talk at an adult-to-adult level about your concerns. He or she will appreciate the work you have done on your own, which will allow more time for discussing specifics. You can be an informed consumer even if you do not want to invest time in studying hard-core medicine. If you do not understand something, the doctor should feel obligated to explain it thoroughly. It is a two-way street. Be full of questions. They are expected.

If a doctor insists on giving you baby talk or pontificating to you, even after you have expressed a preference to discuss your health on an adult level, find another doctor. You are eventually going to be subjecting yourself to considerable bodily trauma. For your own peace of mind, which is essential to a successful outcome, you need to place complete faith and trust in your surgeon. If you go into surgery feeling hostility toward a doctor who does not give you credit for your intelligence, you will be reducing your chances of a good result.

Similarly, if you encounter a surgeon who offers an opinion that does not seem to make sense or that bothers you in some way, seek additional opinions. Ah, the dreaded second opinion! Many patients fear seeking another opinion because it might offend the doctor. You would not hesitate to interview three contractors with different ideas about how to remodel your bathroom, and you would not worry about offending any of them by telling them that you would like to see what the others have to say. Why should remodeling your hip work any differently? The more opinions you obtain, the better versed you are and the better able you are to converge on a decision.

Take as much time as necessary to discuss the subject to your satisfaction with your surgeon at whatever level is most comfortable to you. The surgeon should adjust his or her level of communication to yours. On the other hand, do recognize that an orthopedic surgeon is a busy person. Do not burden him or her with extraneous small talk or gossip. Keep the conversation centered on the specific medical situation that brought you. Concise answers and a good, warm feeling about the professional you have chosen will reward your focus.

I have found many good, communicative doctors during my lifetime. For example, my relationship with my family doctor (PCP, if you must) has lasted over 20 years. On the other hand, I have had encounters with doctors with whom one appointment was too many. (You will read about one of them in the forthcoming pages.) Fortunately, there have not been many in that category. It is my hope that it is possible for you to choose your doctor. I know that for some of you your choices will be limited by the type of insurance arrangement you have, but for those who have the freedom to choose, I hope you can find the best possible surgeon to conduct your journey through hip surgery—one in whom you can place your complete faith and trust.

Choosing a surgeon: personal experiences

My quest for a surgeon began back in 1995, even before I had reached the point of no return for my hip. While I did not yet know whether the replacement surgery would be the ultimate solution, I thought I was being highly organized in preparing for all possible outcomes. I had done an on-line search on Medline using the keywords “total hip arthroplasty.” The search yielded many abstracts, which I began narrowing down. When I came across a paper written by a surgeon in my city, I ordered the full text.

Dr. B: the elder statesman

The paper was written by Dr. B, a prominent “hip man” in town, describing a technique in which the artificial joint was machined by a numerically controlled apparatus while the patient was on the operating table. A CT scan or MRI would provide the exact dimensions necessary for each particular patient. This appealed to my scientific curiosity, so I made an appointment with the good doctor to hear more about it and to have him evaluate my hip. Well, it turned out that the “while you wait” manufacturing process was not completely effective, either economically or medically. It was no longer in use. Dr. B looked at my X-rays, telling me that my bone structure was good and that a standard, off-the-shelf prosthesis would work fine. Upon hearing that I had previously discussed the hip with Dr. S, Dr B asked me what he had to say. I told him he had said, “You’ll know when it is time.” Dr. B reiterated that notion. I asked him what scheduling surgery with him would entail. He then broke the news to me that he would be retiring from surgery at year-end. I teasingly accused him of deciding to retire on the spot after looking at my hip. He somewhat accepted the bait, offering that orthopedic surgery is a lot of hard work and it is a young man’s game. His young associates would be doing the surgery while he would be doing consulting. That was the last I saw of Dr. B.

I liked Dr. B. He was confident and secure; thus, he did not talk down to me as a patient. Obviously, bedside manner and straight talk are important to me. Some of my consultations, however, did not go similarly well. The next doctor I interviewed would turn me off completely.

Dr. O: go away, kid!

In the years after seeing Dr. B, I tore up whatever cartilage remained in my left hip. Fifteen months of grueling, cross-continental commuting and one large construction project later, I was anxious to resume the search for a surgeon. I was in pain day and night, and I was absolutely convinced that surgery was the only solution. The subsequent initial consultation with an orthopedic surgeon recommended to me by several different people, however, was to be a demoralizing setback. Please read on. I have included this failed doctor-patient relationship hoping that you can avoid a similar debacle.

Call this surgeon Dr. O. I made an appointment with him for an evaluation. After spending the usual time in the waiting room filling out forms and so forth, I waited and waited and was finally ushered to an examining room, where I waited some more. Eventually, Dr. O came in, asked me a few perfunctory questions, and did some leg manipulation to test my range of motion. He also looked at the soles of my shoes to discern their wear pattern. Knowing that I had recently suffered some painful back spasms, he asked me how I was able to tell whether the pain was coming from my back or my hip. I told him that I had had many years of experience with both back spasms and hip pain, and that I could differentiate the pain between the two. I do not know whether he believed me or not.

He sent me back to X-ray. I had no doubt that upon seeing the films, the good doctor would conclude that total hip replacement surgery was indicated. The joint degeneration was such that it was already bone-on-bone when Dr. B did his X-rays—and that was prior to the coast-to-coast commuting grind. There was almost no cartilage left. That, plus the pain and lifestyle degeneration (which, by the way, Dr. O never even discussed) should have been enough to not only qualify me for surgery but also make it an urgent situation. The X-ray technician “posed” me for several shots, developed them, checked them, and told me I could go back to the examining room.

I got dressed and I was walking down the hall when Dr. O motioned me over to the X-ray viewer. He pointed out the problem, osteophytes that looked like the topography of the Himalayas, and told me that I had a lot of degeneration. He measured parts of the X-ray, noting that because of the cartilage loss, my left leg was about 10 mm shorter than the right. Then he told me that he would not recommend surgery because I was only 53 years old. What did he just say? He would recommend only conservative measures until I was 60, and then we would revisit the situation. I could not believe it! I told him that I had been in pain for at least seven years and had had quite enough of NSAIDS and other conservative measures, which were becoming increasingly ineffectual. However, he was unrelenting. Conservative measures. “Here, have you tried Voltaren? I’ll give you a prescription. And I’ll give you a 6 mm heel cushion for that shorter leg.” He advised that I should lose all my excess weight because it increases risk factors for surgery. I was well versed about the increased risk factors, and I was willing to accept them. Apparently, he was not. He continued the soliloquy by telling me that the first replacement joint might last 10-15 years, probably less, and the second surgery is more difficult. For that reason, he would not want to have to do the second [revision] surgery. I eventually told him not to be concerned about that—there was absolutely no chance that he would be doing it.

Dr. O told me he left me some pamphlets about arthritis and hip surgery on the chair in my examining room, which I should take with me on my way out. These were very cursory pamphlets about arthritis and hip surgery, comic book stuff, which further insulted my intelligence. If I had not made it clear that my reading on the subject had transcended baby books a long time ago, then Dr. O simply was not listening. As a parting shot, he told me, “…lose all that excess weight. I know it’s like Catch-22 to get some serious exercise when you have only one good leg, but there are ways. OK, so you know where we are if you need us.” I do not have a problem with doctors or well-meaning friends or family telling me that I need to lose weight. I know I am overweight to the extent that my health is compromised. However, here I felt that I was getting an ultimatum: “get down to your ideal weight for your height or I will not operate on you.” To add insult to injury, he wanted me to wait seven years. I left this encounter with great bitterness.

I am reasonably certain that Dr. O did not want to operate on me because of the additional risks associated with my being overweight. Whether this was merely a personal preference to operate only under ideal circumstances or a strong desire to avoid malpractice suits, he chose the “safe” way out. This seems to fit with the rest of his one-sided attitude. Of course, it is a free society and total hip arthroplasty is elective surgery. A surgeon is entitled to decide for himself whether to operate on any given patient for whatever reason he or she chooses. There are indeed doctors these days who will treat only healthy patients. However, I believe that it is essential for a surgeon to be open, honest, and communicative about such issues. We might agree to disagree, but the doctor must at least be forthcoming enough to tell me exactly why he or she does not wish to take on the case.

I had no intention of enduring excruciating pain and debilitation for seven more years. Had Dr. O’s diatribe cowed me, as it would some patients, I might have accepted his word as gospel, suffering considerably more pain and possibly damaging my stomach, liver, or kidneys, after the trial and failure of additional conservative measures.

Sayonara, Dr. O, big help that you were!

Dr. G: the search ends successfully

After the Dr. O experience, I was somewhat disconcerted. My friends and my family doctor (Dr. M) were sympathetic and supportive, consoling me with the fact that there are many more orthopedic surgeons in the world, and others will have different attitudes about performing the surgery on me. Nevertheless, it took time to restore my faith in the medical community in general and orthopedic surgeons in particular. In spite of the assurances of my confidantes, was I going to run into the same attitude everywhere I went? Would I have to suffer that awful, debilitating pain for the rest of my life? I buried my head in the sand for a while, thinking about just what I would do.

An inspiration came to me to check out the medical center at the University of Florida. I thought that it would be interesting to investigate what a large university medical center could do. I felt that they might be closer to the leading edge in research. Hospitals in Orlando, the area in which I live, had struck me as being short-staffed bastions of unfriendly people. I suppose hospitals are in that condition everywhere, but here the two big hospital entities were having a well-publicized bidding war for nurses, which seemed ludicrous. The net result could not possibly improve care levels for the patients. Therefore, I was ready and willing to consider alternatives outside the area. Accuse me of thinking that the grass was always greener on the other side of the fence, but Shands Hospital at the University of Florida had a good reputation, so why not see what was going on there. Gainesville, the location of the University of Florida, was only a two-hour drive from Orlando. The people there are a little less hurried—you can still do some pretty good fishing around that part of the state. I had a plan!

Of course, the hospital is only part of the equation. I would still have to find a surgeon who was compatible with me, one who could inspire me to place my faith and trust in him or her.

In October 2000, I obtained a referral to Dr. G, who has an excellent reputation as a hip man. He does only knee and hip replacements. He had been chief of staff there at Shands Hospital, and at the time I saw him, was chief of the orthopedic service. I was looking forward to meeting him, hoping that this would not be another wild goose chase. I drove up to Gainesville, anxious to resume my quest.

I arrived on time for my appointment at the Orthopedic Clinic. Most of the paperwork issues had been handled on the phone beforehand, so we could get right down to business. This efficiency pleasantly surprised me. Upon arrival, I was sent immediately to X-ray, where the usual films were taken, quickly developed, and given to me in a large envelope to take back to the clinic. Shortly after handing them to the receptionist, a nurse called my name, mispronouncing it as usual.

The nurse led me back to an examining room and told me to have a seat. Shortly thereafter, another nurse stopped by to review some things with me and to ask if I had brought the photograph of me, as instructed. I whipped out a nice, 5” x 7” glamour shot for the files. Eight months later, this photograph would enable Dr. G to impress me by commenting that I was then sporting a completely different haircut than I had when he last saw me.

Then I waited. And waited. And waited. The examining room door was open, so I amused myself by watching other patients in various stages of joint impairment or recovery. Listening to the inevitable hospital humor that nurses and doctors employ to reduce tension further amused me. I had essentially committed the day to this visit, so I had no reason to be impatient. I would go with the flow. Actually, I had not been waiting more than about 45 minutes when Dr. G walked in with my X-rays.

After the usual amenities, the soft-spoken Dr. G summed up my situation. “Your left hip is shot and your right one is a couple of years behind it.” Soft-spoken though he might have been, he had gotten directly to the point. He then proceeded to explain exactly what was happening with the hip joint, using the X-rays. The amazing thing was that without any beating around the bush, Dr. G was able to choose an appropriately high level for communications. Knowing that I had an engineering background, he explained the forces involved in the hip joint, both as nature intended it and as it had degenerated in my case, using vectors and the terminology of physics. This was an impressive move. Surely, he would have taken a completely different tack for an artist or a CPA. Tailoring the presentation to meet the needs of the audience is standard in most industrial settings, but I have heretofore never observed it pulled off with this degree of finesse in doctor to patient presentations. Either you get the standard baby talk or you are pontificated to, but how often do you meet a doctor who takes the time and effort—and has the talent—to discuss a proposed medical procedure in the lingua franca of your industry or profession? Not very often! Here, I had a consummate pitchman and his record of accomplishment stood behind his sales pitch.

Dr. G apprised me that there were three reasons to have the surgery: abatement of pain, reduction of potential further damage, and resumption of a more normal lifestyle. He felt that in my case, all three were important, but that the lifestyle changes were the most significant. Obviously, I needed exercise, too, and the hip was increasingly getting in the way of that. He believed that I had a high tolerance threshold for pain, and I could probably accommodate more pain that I was then experiencing. (Speaking for myself, I had my doubts about just how much more pain I could handle). The lifestyle changes were really impeding my ability to enjoy life. Dr. G was able to tell me exactly how I was withdrawing from various activities without my having told him anything. He said that it would be not a matter of if I would be having the surgery, but when. Moreover, he noted, it needed to be soon because of the risk of further dislocation of the joint or damage to the bone structure, which he demonstrated to me with the X-ray.

Obviously, I did not need much convincing as to the need for surgery, as it was a preconceived notion before I even sat down in the examining room. Nevertheless, as further icing on the cake, Dr. G showed me how the outward and upward rotation of the femoral head was creating unusual stresses on the pelvic bone, causing pockets of something akin to ulceration that would eventually weaken it. If the pelvic bone were to fracture because it was compromised in this manner, or if it otherwise required reinforcement, it would require a much more difficult operation. This was the reason that there was some urgency as to when the surgery was scheduled.

Dr. G offered one further, superfluous notion to his sales pitch. He could give me an injection of a local anesthetic in that left hip joint that would eliminate my pain for an hour or so. I would be quickly convinced. No need.

I had heard all that I needed to hear. Although Dr. G spent more time with me and answered further questions from me, I had made up my mind. I would schedule the surgery here and this was my surgeon.

One of the more important questions involved my being fat and having risk factors that were perhaps more significant than the average case. Recall that I thought that the main reason Dr. O did not want to operate on me was the presence of those increased risk factors, not because of the nonsensical and arbitrary notion about needing to continue conservative treatment until I became 60. I felt that Dr. O did not handle that in a very forthright manner. On the other hand, Dr. G told me that my size makes surgery more difficult for both the surgeon and the patient, but that he had operated on people bigger than I am. He advised me that if I decided to go ahead with surgery, I should commit myself to “sweat” for an hour a day between then and the date of surgery, choosing a method that would be appropriate to not being able to use my left hip. Swimming or water aerobics would work. This would get me into better shape for both the surgery and the rehabilitation.

I left Gainesville that day feeling good about the surgery. I finally met a no-nonsense surgeon with a can-do attitude and a great record of accomplishment. After giving it a couple of weeks thought, talking with friends, preening my schedule, and doing a little more research, I would call the clinic to schedule the surgery. I had one significant business commitment on my calendar that I wished to provide for before I could schedule any downtime for myself. This project was scheduled for completion on March 31, 2001. Knowing the players involved, I allowed one extra month of slop-over time, which would take me to the end of April. Then, I decided that I would like to commit a month to myself for relaxation, socialization, and preparation for the surgery. This brought me up to June 2001. That would be the earliest I could schedule the surgery. Therefore, I did. June 7, 2001 was the date.

An Unplanned Encounter with Dr. S

Recall that my first orthopedic evaluation relating to the hip problem was performed by Dr. S way back at the time of my earliest realization that something was wrong. I had eliminated Dr. S from consideration as the surgeon who would replace my hip for a couple of reasons. He had not acted very interested in discussing the surgery option with me back at that time, a time when I could have used more information. More importantly, he is a general orthopedic surgeon, doing a lot of arthroscopy and office treatments, whereas I wanted a specialist who does only hip and knee replacements.

In early 2001, my old heel spur had flared up on me, necessitating a visit to Dr. S to get an X-ray and be apprised of treatment options. During the examination, I told Dr. S that I would be having the total hip replacement in Gainesville, and it would be performed by Dr. G. He looked surprised and somewhat hurt, telling me that there was still time to change my mind. I told him that the issue was decided. Dr. S gave me a shot of cortisone for the heel pain and, while doing so, continued to proselytize me about using his services for the hip replacement. I continued to state that my decision was made and there was no going back. He finally gave up and joked that he would send me a postcard every week reminding me that he does that surgery, too.

Obviously, doctors have to market their services somehow, so I don’t have a problem with Dr S trying to get me to change my mind. However, this experience is illustrative of something you might encounter in your travails while choosing a surgeon. The decision should be yours (subject, of course, to the restrictions imposed upon you by your health insurance), and you must stick to your guns. It is your hip, not the doctor’s, and you must consider it first and foremost. If you hurt somebody’s feelings, that’s life.

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