Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [31]
We spoke with Lisa some four months later. “I have pain in my foot all the time,” she said. “It has thrown off my gait. So now I also have pain in my hip.” It was difficult to stand while teaching; all her household chores had to be delegated to her husband and daughter: shopping, laundry, standing in line in the post office to mail a package. Lisa Norton was frustrated, bitter, and consumed with regret.
Carl Simpson was also a distance runner. As a tall, lanky youth with a fierce, competitive spirit, he grew up scaling the hills of coal country in western Pennsylvania. Then, as a businessman who traveled in the United States and overseas, he never failed to make time for an intense morning run. Simpson, like many athletes, wore down his knees. And like Lisa Norton, he had a bad outcome from surgery. Yet he has no regrets.
Carl was in his early forties when he first developed pain in his left knee. He had been sprinting up steep hills to maintain his conditioning, determined to sustain his times despite the onset of middle age. But after several months, he couldn’t ignore the discomfort; the pain worsened, flaring when he ran not only on hills, but also on flat terrain. Carl saw an orthopedic surgeon who told him that the cartilage in the knee was frayed. The surgeon did an arthroscopic procedure in which he threaded a thin fiber-optic device under the kneecap to visualize the joint and remove the torn pieces of cartilage.
“I had an excellent result,” Carl told us. “And within a few weeks, I was back running hills.”
Eight years and many miles later, Carl again developed pain, this time in his right knee. Every time he straightened his leg, he heard a crunching sound. “I could not even get out of the car without sharp pain,” Carl recalled. “And at three in the morning, I had to ask myself, Do I really want to get up to pee?”
He returned to the orthopedic surgeon who had done the previous operation on his other knee and described his intense pain. “I’m ready for surgery again,” Carl said.
The doctor studied an X-ray of Carl’s knee on his computer screen. “You know, there was much more good cartilage in the other knee when I operated,” the doctor explained. “This knee is very degenerated. There are places where it’s bone on bone. So arthroscopic surgery may not help.” The doctor turned the screen toward Carl and showed him the X-ray images. He could see the stark scalloped edges of the bones nearly touching. The findings in Simpson’s knee are typical of aging, where the wear and tear on the joints erode the cartilage until the surfaces of the bones are exposed.
“First, we should try a conservative approach,” the orthopedist advised Carl. “It doesn’t work for everyone, but it may work for you. I’ll write you a prescription for physical therapy, and you may get some relief by taking an anti-inflammatory medication.” The surgeon continued, “If it doesn’t work, we’ll talk again about surgery.”
The orthopedist wanted to assess Carl’s level of pain and limitation, what some doctors would call Carl’s “misery index.” The term originated in economics, where it refers to the sum of the unemployment rate and inflation rate, a measure of a nation’s financial ill health. In medicine it is used to mean how much pain and limitation a person is experiencing from a condition. Different people have different thresholds of pain; some can tolerate discomfort without it significantly altering the quality of their lives, while others are made miserable by it. Carl Simpson was suffering considerably, and his misery index would be scored as high.
George Loewenstein of Carnegie Mellon University, who has done extensive studies in decision making, distinguishes between “hot” and “cold” emotional states. For example, if we go grocery shopping when we’re very hungry, a “hot” emotional state, we tend to buy much more than we need. Similarly, when we’re in pain, anxious, angry, or frustrated, we are “hot” and prone to make choices that we imagine will quickly improve our condition. In such a hot state,