|
An important part of any medical practice is follow-up. How do you know if whatever treatment you applied was effective? For most of us, short-term follow-up is not a problem. A patient comes in with gouty arthropathy, and you treat them with indomethacin. What's the next step before discharging them from your office? Setting up a follow-up appointment, of course. The question I have for you is this: Do you follow-up one year, two years…ten years after the initial event? My guess's your answer is no. Many podiatrists will refer that patient back to either the primary care doctor or rheumatologist for chronic treatment with medications such as allopurinol; but after the acute event, many of us lose that patient.
The same is true for so many of our treatments. How long do you follow your bunionectomies? I think we can all guess the answer.
Follow-up is important for several reasons such as:
| • |
Determining treatment safety |
| • |
Monitoring patients for success or failure of treatment |
| • |
Watching for side-effects and adverse reactions |
 Most important for our overall system of medical and surgical care, though, is the long-term effectiveness of our treatments. Unfortunately, the only method we currently employ is the medical literature. Only from published accounts of 2, 5, or 10-year follow-ups do we know if our treatments are successful in the long term.
Here's an example. Trnka, et al, retrospectively reviewed the minimum 10 year outcomes of closing base wedge osteotomies in 42 of their patients (60 feet). They found that, despite successfully closing the intermetatarsal angle and correcting the tibial sesamoid position, their patients had a significantly high number of complications (dorsal malalignment, shortening, and metatarsalgia).1
Without even looking at the details of the study, one can quickly see problems. First, this is a very small number of patients over a minimum 10 year period. Additionally, we can't know if their patients are generalizable to our own populations. However, if we take their results at face value, we can use this study to demonstrate the problem with short-term follow-up. Let's say, hypothetically, that one does a base wedge osteotomy and follows the patient for one year. Initially, they do great. They are happy with the cosmetic appearance and have less first metatarsophalangeal joint pain than they did before the procedure. Then two years goes by, and they start noticing plantar 2nd metatarsophalangeal joint pain. Perhaps I had shortened the metatarsal excessively or allowed the metatarsal to dorsiflex. In the short-term, this wasn't a problem, but the complication took more than my one year of follow-up to develop. For any number of circumstances, they may go to another doctor for the complaint (How many patients of other doctors do you see? If you're like me, then you see a good number). In the meantime, I continue to think my procedure is successful. This is a sampling bias that leads us to incorrectly conclude the success of our procedures.
I'll admit that I'm no different from anyone else. The longest term follow-up I have with any series of patients is at my current job at Western University, where I have been working for about five years. My two previous jobs were each a little over two years, so those patients were at best short-term follow-ups. Clearly this has the potential to inappropriately bias my thoughts. For example, when I do distal metatarsal osteotomies for bunions, the patients are out of my practice with a maximum of six month follow-up, with instructions to return if their orthotics need replacement or they have other problems.
The patient population that receives my best long-term follow-up are the diabetics. As do many podiatrists, I see some routine foot care which stays active within my practice for years. Add to this those patients with diabetic foot complications, such as various foot amputations. These patients, after stabilization and placement into appropriate prescription shoes, are seen by me every three months in perpetuity. I still see one of my first patients from my Southern California practice five years out after doing limb salvage surgery.
 This problem doesn’t just exist in medical practice. It’s endemic in residency training. I’m sure all of you physicians out there remember your training. How much follow-up did you receive during the many procedures you performed? Very few, I’ll wager.
In fact, a recent study looking at general surgery resident training found this very same thing. Daly and colleagues looked at 228 surgical procedures performed with resident participation over a one-year period. A total of ZERO PERCENT of postoperative patient care involved the resident to any significant degree.2 And they were only looking at short-term follow-up! Patients were seen for an average of only 24 days after surgery.
There are a couple problems with the answer to this question. First of all, if our residents spend time following up on all their surgical cases, they would never have time to actually do the surgical procedures. Second, the longest term direct follow-up a podiatric resident could possibly have would be three years. That's still not the follow-up time period that would be truly beneficial to practice and our patients.
So, how can we deal with this problem of diminutive follow-up? Here are a few suggestions for both the resident and active practitioner.
| • |
Residents should make an active individual effort to find out how their various surgical patients did over their training. This is possible with certain attendings that are willing to communicate the various follow-up issues that occur. |
| • |
Add these types of discussions into the didactic component of residency training. Many residencies have a surgical case review in which the cases of the week are discussed in detail. Add to this discussion some cases with longer-term follow-up. How did the patient do after that flat foot reconstruction? Did that problem fixation turn into a postoperative nonunion? Assign a resident to find out how their cases actually turned out. |
| • |
We should always push for higher quality research that includes long-term results. A well designed, prospective study that tracks patients over a 10-year period is difficult to do, granted, but not impossible. This type of study may allow better generalization of the results to our own patient populations. |
| • |
For those of you in practice, consider creating your own registry of patient follow-up for your more commonly treated conditions. This takes a bit of time at first to create, but electronic medical records are making this much easier. If you want to know what your postoperative bunionectomy dehiscence rate is, you could use ICD-9 (soon to be ICD-10) codes comparing all bunions with dehiscence codes. Simple descriptive statistics would, at the very least, provide basic information to help with clinical practice. |
| • |
Make it a standard in your practice to follow your treated patients at specific time points at the completion of successful initial treatment. After that bunionectomy, schedule follow-up appointments at six month intervals for a couple of times and then ask to see the patient yearly. Not only is this a great way to follow-up on long-term results, it's a good practice management method to retain patients. Granted, not all of your patients will follow-up, and some of your patients with poor results will likely go to someone else, creating a bias, but this is a much better follow-up plan than doing nothing. |
 My final suggestion is for the various podiatric professional organizations such as ACFAS and APMA and the other specialty groups. Consider creating the same registry mentioned above on a national scale. A concerted effort from various parts of the country with many podiatrists would allow for very large patient numbers and potentially very long-term follow-up. The power is in the numbers. The next time you discuss "what works well in my hands", recall that unless you do the long-term follow-up, you don't truly know if that favorite treatment actually did work well in your hands.
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References
- Trnka H, Mühlbauer M, Zembsch, A et al. Basal Closing Wedge Osteotomy for Correction of Hallux Valgus and Metatarsus Primus Varus: 10- to 22-Year Follow-up. Foot and Ankle International. March 1999; 20(3):171-177.
- Daly S, Klairmont M, Rinewalt D, et al. Continuity of care in general surgery resident education. The American Journal of Surgery. 2015. In Press
Get a steady stream of all the NEW PRESENT Podiatry
eLearning by becoming our Facebook Fan.
Effective eLearning and a Colleague Network await you. |
 |
This ezine was made possible through the support of our sponsors: |
|
