When is Enough, Enough The Second Opinion: Over Treatment of Upper - PowerPoint PPT Presentation

10/3/2017 When is Enough, Enough The Second Opinion: Over Treatment of Upper Extremity When is it time to ask for help? Disorders Roger A. Daley M.D., Ph.D. Professor and Director Division Hand Upper Extremity and Microsurgery Department of Orthopaedic Surgery Medical College of Wisconsin Milwaukee, Wisconsin Introduction Disclaimer  When is recovery prolonged?  I perform IME’s  What happens when the patient isn’t recovering?  I perform Medical record review  Why does the patient have persistent  I have served as an expert witness symptoms?  How does the work ‐ up and treatment plan change when the initial treatment fails ?  When is it time to seek a second opinion?  How to approach providing a second opinion 1

10/3/2017 More Often Than Not!! Rarely  Physicians make the  Symptoms persist correct diagnosis  New symptoms  Treatment is successful develop  Patient recovery is  Recovery is prolonged predictable  Complications occur  Everyone is happy  No one is happy Case 1 Case 1  34 yo f massage therapist, vague forearm pain developed during work  EDX/EMG: compression of PIN at elbow  Exam: non focal/diffuse pain  Intra operative findings: severe compression  MRI: negative of nerve  Dx: lateral epicondylitis and wrist tendonitis  Post op: therapy and activity restrictions  Treatment: off work, wrist splint and therapy (30  2 nd IME at 6 months: persistent symptoms visits)  3 Rd IME at 16 months: slow but continued  Symptoms persist improvement  IME suggested Dx: Posterior Interosseous Nerve  90 therapy sessions Compression  Light duty work 2

10/3/2017 Normal Expected Recovery Case 1  Healing takes time  Expected recovery time?  Emphasize the time it takes to recover  What should be expected during recovery  Proper diagnosis?  Risk factors and variables that may delay and  Is continued therapy beneficial? impact outcome  Are further diagnostic tests indicated?  provide a realistic prediction of the results of  What factors are delaying recovery? treatment  Educate patient to expect recovery milestones  Not a simple answer Reasonable Recovery Time? Recovery guidelines  Fractures ‐ heal in 3 wks to 6 mos or longer  Define : return to work, MMI,  Tendons – min 6 wks with rehab to follow end of healing  Diagnosis dependent  Ligaments – min 6 wks plus therapy  Severity of condition treated  Nerve regeneration – 1 mm per day  Co ‐ morbid factors affecting recovery  3 ‐ 6 months for tenderness to resolve following Carpal Tunnel Release !  Patient and physicians expectations  Epicondylitis may take over 9 mos to get better, treated conservatively for at least that  Patient motivation long 3

10/3/2017 Prolonged Recovery What Happens When the Patient Isn’t Recovering?  Not meeting the expected  Financial impact milestones to recovery:  Personal  resolution of symptoms  employer  return to normal activities (work)  society  Prior experience with similar  Psychosocial issues cases  Family ‐ ”breadwinner”  Our responsibility as health ‐ “disabled mentality” care providers ‐ to determine  Job stress/ job satisfaction reason why  Doctor / Patient relationship  May need to set expectations is challenged  Quickly identify delays Why does the patient have persistent Persistent Symptoms or New Complaints symptoms?  1 st determine that there is not What went Wrong ? another reason to explain symptoms  Recurrent Problem  Treatment specific  Persistent problem  Incomplete surgery  Patient specific  Wrong surgery (wrong Dx )  New complaints  New diagnosis  Complication of original treatment 4

10/3/2017 Patient Specific Causes Co ‐ morbid conditions  Co ‐ morbid conditions  Diabetes & other chronic disease  Unrecognized Dx  Obesity  Chronic disease  Smoking  Age & body condition  Psychiatric conditions  Patient directed care  Behavior  Factitious disorder  Conversion disorder  Malingering Patient Directed Care Behavioral Causes  Alternative treatments  Internet driven  Holistic medicine  Factitious disorder  Massage therapy  Acupuncture  Conversion Disorder  Chiropractic care  Malingering 5

10/3/2017 Factitious disorder Conversion Disorder  A psychiatric condition –  Intentionally fake or create a disease  Non ‐ intentional  Inflict injury to create illness  Believes condition is real  Munchausen Syndrome  Possibly due to an overload of emotional stress  Munchausen Syndrome by Proxy  Doesn’t stand up to extensive scrutiny  Aim is to obtain sympathy, nurturance, & attention (notion of being ill)  Common diagnosis  Often undergo unnecessary surgery  Pseudoseizures  No motivation for secondary gain  Limb paralysis  Somatic Symptom and Related Disorder  Vision or hearing loss Malingering Considerations  Often difficult to differentiate real medical  Intentional fake or create illness for secondary gain problems from factitious disorders or  workers comp malingering  drug seeking behavior  Potential tell tail signs of malingering:  Intentional abuse of the Medical System (Fraud)  Previous dx of Antisocial personality disorder  exaggerating symptoms  Early involvement of lawyers in a medical issue  Dis ‐ incentive to recover  Poor compliance with treatment  Antisocial personality disorder  Inconsistencies in presenting symptoms 6

10/3/2017 Complications that Delay Recovery Health Care Provider ‐ Specific Causes for Delay in Recovery  Infection  Unaware of early signs of delay in recovery  Failed hardware  Not listening to patient  Injury to adjacent  Lacks expertise that would allow provider to structures recognize problems  Re ‐ injury during recovery  Ego ‐ arrogance –  Incomplete surgery  Fail to admit that medical error occurred  Wrong surgery  Providers failure to admit that he/she lacks expertise to treat problem How Does the Work ‐ up and Treatment Plan Response to a Delay in Recovery Change When the Initial Treatment Fails?  Re ‐ think diagnostic work ‐ up &  Identify that recovery isn’t progressing as treatment to date expected  Repeat thorough exam  React with a multi ‐ directional approach  Consider other contributing  Review records, tests, reexamine patient and factors rethink diagnosis  Obtain studies when appropriate “Think outside the Box”  Encourage patient to actively participate in their own recovery (therapy at home)  Look for rare or atypical  Discuss case with colleagues or seek a second findings opinion  Retesting 7

10/3/2017 Conditions Seen When is it Time to Seek a 2nd Opinion? for 2 nd Opinion  Patient initiated  Atypical presentation of  Not happy with status of compressive neuropathy recovery  Lost confidence in treating  Thoracic outlet syndrome physician  Prox. Median N. Comp  Complex wrist disorder  Physician initiated  Loss of confidence in own  Scaphoid nonunion ability to solve problem  Kienbock’s disease  Seek confirmation about care  Persistent pain & loss of use  Lack of specialty training Conditions Often Seen for a 2 nd Opinion Management of Patients with Failed Surgery or Those Seeking a 2 nd Opinion  Highly specialized problem  More challenging than primary  Vascular (Raynaud’s Disease) procedure  Ulnar hammer syndrome  Must rule out non surgical causes  Complex wrist disorder  Often a significant pain  Infection/ complication component  Failed surgery  Dealing with scar  Dissatisfied patient  Frequently require a salvage or  Not hearing what he wants to reconstructive procedure hear (malingerer)  Realistic expectation of results 8

10/3/2017 Persistent Symptoms or New Complaints Management of Patients with Failed Surgery  1 st determine that there is  If you determine that more not another reason to surgery is indicated proceed explain symptoms with care.  Don’t convince yourself that you can solve the  Recurrent Problem problem  Persistent problem  Have strong objective  Incomplete surgery evidence before proceeding  Wrong surgery (missed Dx )  Don’t be surprised if the patient doesn’t get better  New complaints  Don’t follow a mistake with another mistake  New diagnosis  Complication of original treatment Case 2 Case 2  48 yo F obese with diabetes, reports a gradual onset of non focal wrist pain from typing, no  Immobilized 8 wks then therapy 2X/wk reported injury. On job 18 months  MRI repeated at 4 months for persistent  Exam showed diffuse wrist pain, MRI should symptoms ‐ Scar at peripheral repair site and early osteoarthritis, small volar wrist ganglion, defect in volar capsule (ganglion site), early no TFCC tear OA  Surgery for wrist arthroscopy and open  Light duty work , therapy 2x/wk ganglionectomy, early OA appreciated, ulnar  Seen at 7 months for persistent wrist pain a attachment of TFCC thought to be loose! 3 rd MRI was performed with no new findings Percutaneous repair and open ganglionectomy 9