Safety in surgery and overall health: what is the responsibility of the patient?

I recently encountered a patient in her mid-40s with a Grade 2 spondylolisthesis at L4-5 and severe lumbar stenosis. She showed some mild weakness in her right foot, and failed extensive nonoperative treatment. Given the weakness and failure of conservative treatment, she wanted to discuss surgery as a possible option. Importantly, this patient was a Type 1 diabetic with poor glycemic control, and she smoked a pack of cigarettes a day. In light of those issues, we talked at length about the risks, benefits, and goals of surgery. We ultimately agreed to proceed with surgery provided that 1) we better control her diabetes, and 2) she stopped smoking cigarettes. I worked with her primary care provider, and the patient stopped smoking fairly quickly. The diabetes was a bit more challenging. It took some months, but she did get her glucose down to an acceptable level. At that point, we scheduled the surgery. But on the morning of surgery, her blood glucose level was more than 400 (amazingly, she was not comatose). Based on this, I cancelled her surgery in the preoperative area. We found that the patient had not kept up with her diabetes treatment for about a week before surgery. According to her primary care provider, this was not a first time occurrence. The primary care provider and I stressed the importance to the patient of maintaining her diabetes treatment. From this discussion, it was clear that she understood that I believed blood sugar control was critical to her safety. The patient obviously did not think it was quite so important, and she continued not complying with treatment. Somewhat frustrated at this point, I reminded her that I would not do the surgery unless she maintained her diabetes treatment. She promised to do better, and we scheduled her for surgery a few weeks later, provided she maintained reasonable blood sugar levels. But based on our discussion, I started to wonder if she had the same indifferent perspective on her smoking, so I ordered a urine cotinine test. The results came back sky high. When I confronted her with this, she shrugged her shoulders, and confessed that she was just kind of hoping I would not find out. In nonurgent and nonemergent situations, the surgeon-patient relationship is a partnership. Like any healthy partnership, there needs to be trust. Certainly as care providers, it is our duty to guide our patients through a thoughtful and shared decision-making process. However, there must be mutual trust to reach the goal of treatment. Despite our best efforts as physicians, at times we are unable to help patients. Sometimes, the disease burden is too great. Sometimes, we do not have the knowledge and skills to treat adequately. But sometimes we cannot help the patient, because of the patient’s own healthcare choices. We have all worked with patients who make lifestyle choices that are clearly detrimental to their health. Today, physicians and medical centers are increasingly scrutinized, graded, and penalized to ensure the best possible outcomes. It is poor form to blame a patient for a bad outcome, but even so, how much of the responsibility does the patient bear? How much of that responsibility should they bear? Clearly, lifestyle choices affect the health of patients and the safety of care of those patients. How much of this should the patient own? There is a lot that we as physicians can do. In my last column [2], I praised a program called Strong for Surgery. Strong for Surgery is a presurgical optimization program that assists patients in smoking cessation, nutrition optimization, and glycemic control before any elective surgery. The idea is that surgeons refrain from elective surgical intervention until the patient is as healthy as they can be. While there are barriers for these presurgical optimization programs from being universally applied, we can all agree that this would be a great step forward in reducing complications and enhancing patient safety with surgery. Strong for Surgery, and other programs like it, are great for improving the safety of surgery, but we should take a look at the larger picture. Why should it take a need for surgery to get a patient to become healthier? Maybe we need to push the starting point for patient optimization further upstream. No doubt, primary care physicians are constantly counseling patients on healthy lifestyle choices, but in the end, patients are free to make their own choices. For many patients, optimal health in itself is not enough of an incentive to change lifestyle. For example, despite all we know about smoking, 19% of the U.S. population smokes cigarettes [1]. We can no longer claim ignorance of the ill effects of smoking. In 2014, who in the United States does not know that smoking is bad for health? If all the patient counseling and education in the world is not effective in optimizing patient health, maybe patients can be encouraged from a different approach. Last year, 32.1% of the U.S. population enrolled in either Medicare or Medicaid [3]. What if the Center for Medicare & Medicaid Services (CMS) started placing more stringent requirements on patients? What if CMS required a baseline level of patient initiated health measures before paying for another tier of care? For example, what would happen if CMS announced that smokers would receive baseline care, but no elective care until they were documented to be nicotine free? No hip replacement, no knee replacement, no rotator cuff surgery, no carpal tunnel, nothing elective until they quit smoking? What would happen? The tobacco companies would most assuredly be enraged, but many people would very likely quit smoking to qualify for elective Medicare/Medicaid benefits. Almost 1/3 of the U.S. population would be healthier. Surgery and other treatments would be safer in this population. One might object and argue that such mandates impinge on personal freedoms. But taxpayer dollars fund CMS. If 1/3 of the population’s healthcare is covered by the American taxpayer, then it seems reasonable to have some ground rules for government health care. Just as medical centers and physicians are incentivized to optimize care and health, maybe it is time to incentivize patients similarly.