How do you decide on a course of treatment?
July 22, 2017 2:57 PM   Subscribe

walk me through your thought process when making medical decisions? Tell me about the factors you consider and how you prioritize them; how you make sure you receive complete and thorough advice from doctors; how you set and manage your expectations and goals. I have a broken collarbone that needs decidin' about, and I have no idea how to decide what to do!

I've been lucky enough so far to never have had to make a real medical decision, and I feel like my critical thinking here is pretty shallow. Specific background (though my question can definitely be answered more generally): my collarbone had a badly displaced (just under 2cm) break; given that I'm relatively young (in my early 30s) my orthopedic surgeon suggested being conservative at the start and waiting and seeing if it started to heal on its own. After five weeks in a sling it shows minimal-to-no signs of healing and after this last X-ray with no progress he said it was up to me what we do next. I don't know how to decide confidently!

Pros to surgery: displacement and length corrected before fixing. Strong right away and can get back to activity/work relatively sooner. Recovery time has fixed expectations.

Cons to surgery: bigass scar (and I'm a terrible scar-er), will probably see/feel the plate and want it removed eventually, all the inherent risks that go with any surgery.

Pros to continuing to let it heal on its own: no surgery (can't overstate that one, I'm terrified of surgery). Have made lots of new friends by being in a sling, ha.

Cons to leaving it alone: even if it does eventually heal there will be significant shortening and asymmetry, the doctor doesn't think it will have long-term impact on shoulder function but I have doubts. Serious pain and inconvenience for an indefinite amount of time. Out of full work duties for same.

In a perfect world I could talk through all this with my doctor, and I have, but briefly and I'm not convinced either way. Assume that I'm normally very active and function is important to me; I didn't THINK I was particularly vain until I realized how much I hated both the idea of being noticeably asymmetrical AND the idea of a huge scar :( Costs should be covered whichever course (yay workman's comp). What other big factors am I not considering? What's your rubric for thinking through decisions like this? Thank you!
posted by peachfuzz to Health & Fitness (14 answers total) 6 users marked this as a favorite
 
If I were scared of surgery, I think I'd want to know more about the procedure and my options. Quick googling suggests that it's at least possible for you to have clavicle surgery under local anaesthesia, so that might help. I'd want to talk to someone who actually conducts such surgeries, if at all possible, and ask for more guidance. Hopefully the surgeon you've consulted will be open to discussing this stuff.

I'd investigate non-surgical interventions. Are there other well-supported (or less well-supported but low risk) options your surgeon hasn't indicated yet?

I'd also want to know what my chances of ending up needing surgery, in the end, are. It seems like your doctor isn't too worried about the risk of impairment, but it seems possible that aesthetic dissatisfaction might push you to have surgery, in the end. That would be perfectly reasonable, and you shouldn't discount the importance of your own feelings. I'd also weigh up my feelings about scars v asymmetry. Personally I'd much rather have a scar than a change to my body shape; I think I'd feel less like it made me the object of public judgement. I have a lot of non-facial scars, and they don't affect my life in any noticeable way, apart from occasionally having to tell people what they are. But my priorities may not be yours.

In terms of fear and anxiety, I think that I'd weigh up the fear of a booked surgery against the anxiety of any uncertainty in not opting for it now. I guess this means that if you're really certain that you're not ever going to have surgery if you decide not to now, then that's an argument for the "no surgery" position, while any level of doubt about your decision makes "no surgery" a less appealing choice.

Ultimately I'd make my decision based upon the overall prognosis. In your case, it seems like you're primarily weighing up a likely improved prognosis against the risks of surgery and, probably more importantly, your fear of surgery. Maybe finding out more about the physical risks would help you work out your level of fear about this specific surgery, which would aid decision making.

As indicated above, I think it's going to be better for you if you make a decision and stick to it until your condition changes or you get different medical advice. It seems like the worst thing you could do is let indecision gnaw away at you.

Whatever you choose, the very best of luck!
posted by howfar at 3:34 PM on July 22, 2017


One thing I didn't exactly see in your post is how your decision (surgery or not) will effect your ability to do things you enjoy. Do you use the shoulder on the side with the break for any sports, etc.?
posted by schroedingersgirl at 3:57 PM on July 22, 2017 [1 favorite]


YES! This was an important one and I can't believe i haven't been able to articulate it until now, I knew asking this question was a good idea. The break is on my dominant side and it will absolutely affect me negatively in both daily life and in enjoyment-of-life activities if range of motion or strength are impeded on that side. I can already see and feel how turned-in and collapsed the shoulder is and my shoulder blade wings out dramatically, the doctor says the resulting weakness and leverage problems are "likely" just because I'm not using it much right now but I just feel really nervous that it will be permanent.
posted by peachfuzz at 4:08 PM on July 22, 2017


This is by no means an expert opinion, but I've been dealing with the side effects of a previously, seemingly minor, broken foot bone for 5 years. The imbalances, pain, and weakness have thrown off my whole body. I was terrified of surgery at the time, and now almost every day, I wish I'd done it. Little injuries have a way of getting bigger over time.
posted by mostlymartha at 4:31 PM on July 22, 2017 [6 favorites]


I prioritize prognosis over anxiety, then identify what can be done to ameliorate anxiety. I am also terrified of anesthesia, so I always get some versed prior to going under. This smooths things out considerably.
posted by xyzzy at 5:04 PM on July 22, 2017 [2 favorites]


One thing I think it's important to commit to in advance, if you possibly can, is that you're not going to regret your choice, whatever it is. You have limited information and can't see into the future. The best you can do is make a thoughtful, well-reasoned decision that respects your emotions without giving them disproportionate weight. After that, the rest is on God/the universe/fate/chance (take your pick). Agree with yourself not to look back, even if things don't turn out for the best.
posted by praemunire at 5:49 PM on July 22, 2017 [2 favorites]


This is anecdata, but my sister in law regrets not having the surgery when given this choice in her mid-30s. It's been 20 years, but she gradually developed a bunch of range-of-motion issues, aches, etc. and she's noticeably assymetrical. Of course there's no way to know whether the surgery would have given her a better long term result, but things may change over decades. I hope you have a good outcome, whatever decision you make.
posted by carmicha at 5:50 PM on July 22, 2017


Please solicit second (and third...) professional medical opinions. A different orthopedist/ortho surgeon could offer some input to clarify matters in your mind.
posted by Iris Gambol at 6:15 PM on July 22, 2017 [3 favorites]


Hm. Anecdote: I had a medical decision to make. It was going to be expensive, not guaranteed to work, and the results either way would greatly affect me and my lifestyle for the rest of my life. Because it was elective (100% out-of-pocket) I was free to go to any doctor I chose.

Here's what I did: I interviewed pretty much every specialist in town about the particulars of my case (you should have seen the file of medical history and test results I carried around!). Some of the specialists would say to me "well, I could do A or I could do B or I could do C, it's up to you. "

The doctor I chose said to me "I could A or B or C, but A and B (the conservative and overall the cheaper options - IF they worked) are unlikely to work given your medical history, and are going to cost you time and money. I already have enough money, I don't need to waste yours. I suggest we go straight to C because it is least likely to waste your time and is the most likely to get you the results you want."

The takeaway? I chose him because each of these doctors is supposedly an expert in their field, and I was really unhappy with the idea of someone I was paying tens of thousands of dollars for their expert opinion to make their advice to me "well it's up to you".

If I were in your position I'd get a second and third opinion, and I'd ask lots of questions about the pros and cons of their recommendations. Don't forget to ask what the next step will be if their recommendation doesn't work.

As for finding doctors, one friend of mine always makes an appointment with whoever is the head of that specialty at the local hospital. Another friend calls every doctor, dentist, physical therapist, body worker, etc that she knows in town and asks for recommendations.
posted by vignettist at 6:24 PM on July 22, 2017 [9 favorites]


All surgery has risks, but as far as I know (IANAD, TINMA), this is a fairly superficial surgery whose risks are relatively low. It won't involve interfering with many, if any, muscles, let alone other organs. My own inclination would be to prioritize activity and function, and to treat the scar as a reminder of the fact that our bodies bear their histories (and a scar is a better reminder than loss of function). I do like the idea of getting a second opinion, though. If you're athletic, perhaps ask for a referral to a sports medicine specialist who has experience with clavicle fractures.
posted by brianogilvie at 8:01 PM on July 22, 2017 [2 favorites]


It sounds to me like the main overriding factors here are (a) not doing this will result in significant long lasting or possibly permanent negative effects (b) you have a really strong fear reaction to the idea of surgery.

Sounds like your mind is doing a bang-up job of trying to protect you from risky things, by using fear to push you really hard to avoid this. But if you have kind of already decided that the surgery would be the better option long-term, then maybe it's time to find a way to get your mind to shut up about that and let you get on with it.

Maybe you have a therapist that could help or you can get your hands on some anti anxiety meds? or just schedule this thing as soon as possible to minimise the time you have to spend feeling terrified about it. "the only thing to fear is fear itself" and all that.
posted by emilyw at 1:05 AM on July 23, 2017 [1 favorite]


I broke my collarbone in the same manner, did not have surgery because it was not an option for stupid reasons, regret it. This surgery is actually a no-brainer: having it will improve your long-term quality of life.

Scars, plates, whatever. These are part of being lucky enough to age.
posted by DarlingBri at 3:09 AM on July 23, 2017 [1 favorite]


Two thoughts:

1. Big incisions do not necessarily create big scars. A surgical incision forms scar very differently from any injuries you've had in the past that lead you to think that you scar badly. Ask close friends or family members to show you any surgical scars they might have; I have a few on my own body that are less than a decade old and hard to see without bright, direct light (I've even had physicians say "I thought you said you had surgery here" while pointing to my body because they can't find the scar).

2. A few years back I had to make the decision between having one surgery and having three surgeries, with the latter option associated ultimately with a better quality of life. I also had a lot of anxiety around surgery and although I wanted the better outcome from having the extra surgeries, I had a lot of trouble choosing it because of my fear of surgery and anxiety about the guilt I would feel if something went wrong. I went to a therapist for a few weeks just to talk it out. I found it really, really helpful.
posted by telegraph at 4:10 AM on July 23, 2017


Quick final update: I digested the advice in this thread, sought second opinions, and did opt for surgery in the end. The surgeon I ended up going with discovered that the broken distal piece was rotated quite a lot - the bones were "healing" with a more perpendicular than straight union. It wasn't apparent on the plane the X-rays are taken along but explains the ongoing tenderness (Bc bra straps pressing directly on a broken bone end, hello) and dramatic shortening. Surgery took longer than expected bc of that and I feel pretty rough now, but already I feel tensions in the rest of my torso relaxing because the mechanics have been corrected.

Thanks for the advice, it really helped me process and keep my head about me.
posted by peachfuzz at 2:42 PM on October 28, 2017 [3 favorites]


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