When It's Hard to Please Everybody: Etiquette Serving Ethics When You Disagree With a Colleague

Abstract

You are a Pain Medicine physician who is asked to see a patient with low back and leg pain in consultation. The orthopedic surgeon requesting the consultation refers a large number of cases to you. He would like you to do two “nerve root blocks,” which will give him confirmation of the “pain generators” and allow him to proceed with a “decompression laminectomy” and most likely a multiple level “posterior fusion,” because of concern about future spinal stability. The patient, a 36-year-old electrician who does not like his present job, has a 5-year history of increasing low back pain, recently exacerbated (according to the patient) by sudden leg pain when carrying a toolbox at work. Although the patient volunteers a whole array of pain complaints, findings from your clinical examination are essentially normal. MRI shows several degenerative disks, which are also bulging at L3-L4 and L4-L5. After trying many medications, the patient is presently not taking any of them (“they don't work” or “I can't tolerate them”). He has spent most of the last two months at home lying down, is on workman's compensation, and is anxious to have surgery as soon as possible “to get rid of the pain.” When you try to tell him that, given your assessment, other treatments may be of benefit to him, he leaves your office in a very agitated state and goes back to the orthopedic surgeon to complain. The surgeon calls to tell you that the patient does not understand “what is going on.” The surgeon is also surprised that the nerve root blocks have not been done, disagrees with you, and is planning to go ahead with surgery. ### Negotiating Uncertainty: “Let's talk …” In his book The Lost Art of Healing , Bernard Lown quotes William Osler's observation that medicine is the “science of uncertainty, and …