Hendry, a neurosurgeon in his first year of private practice, entered the exam room to see Ms. Davis. She explained that she had been experiencing...

Dr. Hendry, a neurosurgeon in his first year of private practice, entered the exam room to see Ms. Davis. She explained that she had been experiencing back pain and paraesthesia in her right leg. Her symptoms had begun one month before, after she had bent down to pick up her grandson. While examining her, Dr. Hendry noticed that Ms. Davis's right leg was slightly weaker than her left and that she had a right foot drop. After reviewing the MRI, Dr. Hendry saw that Ms. Davis had a ruptured L5-S1 disk and mild degenerative changes. He explained the MRI results to her, and said that she could either have surgery now or wait longer to see if her symptoms would resolve on their own. "I thought I might need surgery," she said. "Is that what you recommend?" she asked. As the newest member of a three-surgeon practice, Dr. Hendry had the fewest patients and had performed the fewest surgeries. At the group's monthly meeting the week before, one of the partners assured him that it was normal for young surgeons to take a few months to build their practices. But Dr. Hendry also noticed subtle suggestions that his was moving slower than most. There was a joking reminder that, as surgeons, they were paid for doing surgery and that office visits alone would not "pay the rent." Ms. Davis was the first patient on his schedule for the following week. Dr. Hendry felt confident that he could remove the extruded disk material and that Ms. Davis, who was 58 years old and in good health, would have a favourable outcome. She seemed to have come to his office expecting that she would need—and he would recommend—surgery, and she had medical insurance that would pay a substantial part of the bill. Dr. Hendry also knew that, as he explained to Ms. Davis, some patients recover without surgery. The disk fragment can be resorbed by the body, relieving the pressure on the nerve. He also knew that it was impossible to predict if or when the symptoms might resolve, and, as he told Ms. Davis, the longer they were allowed to persist, the greater the chance of doing lasting damage to the nerve. As Dr. Hendry considered the case, he remembered his partner's joking that office visits would not cover the group's expenses. Dr. Hendry knew that—from a clinical point of view—it was one of those 50/50 calls in which the patient, having been given the necessary information, should make the decision, based on her own pain and reduced function.