Stop-gap medicine
"DAD, I HURT my knee. The doctor recommended rest but I had him give me a brace so I can play."
"Doc, my rotator cuff is injured, but I have my violin solo in Symphony Hall tomorrow. Please give me a cortisone shot."
"We can pin your finger and let you play basketball today, or you can rest your finger and play in three weeks."
With the suturing and unsuturing of Curt Schilling's ankle, the dawn of "episodic medicine" has arrived. Episodic medicine is aggressive treatment for the now, and it inherently contradicts our "quality of life" policy.
Traditionally, surgery yielded long-term results. But surgeons today have options for short-term solutions that defer full treatment and allow the patient to return to activities immediately. Television has helped make surgery commonplace, but the "before and after" results, particularly in plastic surgery, have blinded us to consequences down the road.
Curt Schilling had episodic surgery with a new twist: It was for one event only. Admittedly, Schilling was at very low risk. The ankle suturing to prevent movement of the tendon, because it is short term, has a low risk of infection. The procedure was also designed to cause a low risk of tendon problems and was well thought out. But it has broader repercussions that have been lost amid the adulation afforded the Red Sox ace.
"Episodic medicine" by its very nature is medicine for the now and the now only. As doctors we were traditionally taught to improve life both quantitatively and qualitatively and impart to our patients the benefits of our actions for the "long term."
Granted, with terminal disease we work "for the now," but in general, we work to create a better long-term future for the patient. Long-term success often requires a short-term period of pain and immobility. But the current trend puts a priority on reducing pain and suffering to enable an immediate return to activity. Given society's expectations for instant gratification in this high-tech information age, it is no wonder that single-event medical treatment is following suit.
But there are consequences. What about the cost? Who pays for these procedures? What are the limits? Already, new technologies, new pharmaceuticals, and new procedures are stretching the medical dollar. Does everybody have the right to "episodic" care or do we ration it based on some yet to be determined set of standards? Since we are still in the embryonic stages of "episodic" medicine, protocols, and policy decisions can be implemented more easily now than later. The implications need to be monitored not just by doctors but also by coaches and parents.
The Curt Schilling treatment needs to be put in its proper perspective. Is episodic treatment like cosmetic surgery and deemed "nonessential"? If the baseball pitcher with a college scholarship can't afford the procedure that might allow him to pitch optimally after an injury, should we pay for it?
Young athletes need to know what is and is not appropriate to enable participation with, or after, an injury. Drugs, braces, surgical procedures, and injections can all be used with a low chance of complications -- yet a low chance is not a zero chance. Infections, further damage to the injured area, and adverse reactions to drugs are all potential side effects.
Another issue is the dynamic between the doctor and patient. The doctor, as always, has significant control over the outcome just in the manner of the discussion. "If you get an infection you could be out of commission for several months" is different from saying, "An infection is virtually unheard of in this operation."
The patient also may not be capable of making a rational decision in the context of the immediacy and the importance of the event in question. Even in amateur sports, orthopedists see inappropriate decisions based on upcoming events.
I don't know the answers. What I do know is that I, too, praised Schilling for his courage and fortitude. We need role models who give their all and sacrifice for the sake of the team. But beware the other side of the equation. The consequences in the future often far outweigh the immediate reward. Sometimes we need to accept these consequences. After all, there is always tomorrow.
Dr. Mark E. Haffenreffer is a surgeon with Needham Orthopedics & Sports Medicine.
