Medicine is complicated. This is one lesson I’ve learned over my past nine years of clinical podiatric practice.

Genius, right? I know! How smart am I?

Actually, it often amazes me how easy it is to fail to learn our lessons the first time. One of the activities I like to do with my residents is to review cases from the preceding week. The residents gather up the radiographs from the prior week, and we review them with a highly critical eye. If I can teach my residents to be ultra-critical of their own work (and not just the work of others), I will have successfully done my job as a teacher. As it turns out, we learn more from our errors than from our successes (as long as we are open to learning), and if I can use my mistakes and complications to make my trainees better, then they will be more successful physicians.

Recently, I had a patient that demonstrated to me an important lesson: always measure twice and cut once. This is a classic rule of thumb from carpentry that most podiatric foot and ankle surgeons know and break at their own peril. To be explicit, it’s pretty obvious that if you’re going to cut something, you should double-check your work before actually cutting. You’re more likely to be more precise and accurate with a reduced chance of making mistakes.

This has a straightforward application to surgery, but we can also apply it to intellectual endeavors. When I was a child, I was taught to check my math before turning it in. This universal lesson from childhood is one of the most important.

Back to my patient.

I’ve changed some of the circumstances to retain anonymity. This patient, let’s call him Jim, had a particular deformity that prevented him from walking for the past five years. When I saw him for an unrelated problem, I mentioned I might be able to help him walk again. We discussed a couple of broad surgical options (he had already tried several nonsurgical ones), and I sent him home to consider.

I’ll mention here that I almost never schedule elective surgery on the first visit. In this version of the measure twice cut once rule, I like to have my patients go home and consider the options we’ve discussed. It allows my patient the chance to get to know me better and vice versa. In some cases, it also affords me the chance to test my patient preoperatively. For example, if a pending surgical patient is unable to show up on time to a follow-up visit, then his past behavior indicates a high risk that he will be difficult postoperatively. I’m essentially looking for red flags. I’ve “measured” the patient twice before cutting once.

Now, when I first met Jim, I performed a physical examination and obtained a history, but I violated our all-important rule. I did not obtain radiographs before discussing my surgical plan (an important part of the measuring twice process). Jim and I went through the entire preoperative process including an H&P by both the primary care doctor and me, coordinating postoperative physical therapy, and scheduling preop labs.

During the third visit, I re-examined the patient under slightly different circumstances and found his deformity was rigid. The surgery I was planning could not be successful. He would need a much different, more invasive, longer procedure with a more challenging postoperative recovery. It was at this point that I ordered the radiographs to confirm my suspicion. Unfortunately, the radiographs did, in fact, demonstrate why this patient’s deformity was rigid, and he would in fact need a different set of procedures from what I had offered previously.

Knowing the patient was looking forward to the surgery and being able to walk again made our subsequent telephone conversation harder for both of us. I was disappointed in myself for not having more thoroughly evaluated the patient and ordering proper imaging studies, and I apologized to the patient for getting his hopes up – honesty is always the better policy. I explained that the planned procedure was doomed to fail, and that we should cancel the surgery and take a step back to reconsider our future path. Jim reluctantly agreed.

None of this makes me look like the experienced board certified foot and ankle surgeon that I am, but since my job (and my vow as a podiatrist) is to help and not harm my patients, it was my obligation to be honest both to myself and my patient and stop the train before it got too late. We will, in the near future, have another visit during which we further discuss the alterative surgery. If the patient decides against the procedure or having me as his doctor, then so be it.

Luckily for both of us I realized my error in time. I was going to cut before appropriately measuring twice. Taking a moment to stop, question your prior action, and seeing if it stands up to scrutiny will always hold you in good stead. All of us in the healthcare profession should listen carefully to the carpenters when they tell us to measure twice and cut once.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]