One of the most important skills that you will learn is when to NOT operate on someone. This very difficult lesson is often learned late in your training or practice. The earlier you can acquire this skill the better...

An example for you: 45 y/o female presents with moderate bunion and hammer toe pain. Her symptoms have been present for more than 5 years and she has made up her mind to have the surgery. On initial exam and radiograph review she is a perfect candidate for a metatarsal osteotomy and digital arthroplasty. HOWEVER, upon further review you note that she has a history of depression and is currently on medication, there is a history of multiple prior cosmetic surgical procedures, and she presents to your office wearing high heel boots. These are just SOME examples of reasons to look further before you decide to schedule someone for elective surgery. I am not saying that any one of these factors alone would be an exclusion, but when you put it all together there may be some concern.

If you have ANY doubt about whether you should undertake the risk of operating on a particular patient, I strongly suggest you NOT BOOK THE CASE. A wise choice would be to see the patient back again after additional conservative care (orthotics perhaps) and discuss options again. If you are concerned about someone being particularly 'vain', you should take additional steps such as physically drawing out the incision locations on their skin and asking them to bring in samples of shoes that they expect to wear post-operatively. You want to move very slowly with high-anxiety level patients. They will often be the very ones that push you for surgery, but you should move very carefully.

Finally, make sure that you ALWAYS LISTEN TO YOUR OFFICE STAFF. The nursing staff and office personnel can be a huge help in picking out patients who are poor surgical candidates. They have the advantage of seeing your patients outside of the actual visit time and the impressions that they get from pre and post visit settings can be quite insightful.

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John Steinberg, DPM
Editor - PRESENT