Synchronizing Expectations
Medicine is fraught with perils for both the physician and patient. Whether it’s failure of treatment, dissatisfaction with service, or an unexpected complication, the treatment of patients and their diseases is a highly complex pursuit. Among all of these variables, the one that seems to create the greatest headache for physicians is when there is a discrepancy of expectations. Very few things seem to get us into more trouble with our patients. What’s wrong with us having different expectations from our patients? And how can we synchronize our patients’ expectations with our own, for better outcomes and more patient satisfaction?
What’s the Big Deal?
So what? What’s so significant about a surgeon and his or her patient having diverging expectations? If we were dealing with machines, this might not matter so much. However, we’re dealing with live human beings who have complex psychologies and often an agenda of their own. I’ll provide two quick examples about what happens when there is an expectation mis-match. First, I had a patient some time ago with hallux valgus on which I performed a Lapidus arthrodesis. The surgery went well with a good result (in my determination), but 8 weeks postoperatively, the patient was unhappy with a slight loss of dorsiflexion strength (I had lengthened her EHL tendon). Her toe purchase was fine, the hallux was rectus, and she had a normalized range of motion while weightbearing. Unfortunately, her expectations were that she would immediately be back on her feet, fully functioning, with full healing within a couple of months.
How Could I Have Met the Patient's Expectations?
The big mistake I made with this patient was not taking enough time to fully understand her expectations. When I schedule elective surgeries, I always have two visits with my patients. During the first one, we decide it is time for surgery. I schedule the 2nd as the official preoperative visit (including the consent process). I very rarely schedule elective procedures on the first visit. Unfortunately for me, during these two visits, I never said the following to my patient: “What exactly are your expectations for your surgery?” This patient and I needed to have a much deeper conversation about what was running through her mind. Now, in my defense, I always tell my patients they are going to have a long recovery after foot surgery with potentially six months to one year of swelling and likely, occasional pain. Of course, I always discuss the possible complications of surgery, and these issues were all verbalized to the patient with ample time to answer questions. With a patient who was preoperatively anxious about any surgery, I needed to spend more time to LOWER her expectations. This, I think, is the key to success.
A Second Example
Example number two involves one of my partners. Just a few days prior to publication of this issue, I assisted my partner with a revisional ankle fusion on a patient who’d been taken care of by anotherphysician who had performed a tibiotalocalcaneal fusion with an intramedullary nail. Unfortunately, the ankle collapsed into valgus, despite the nail, with subsequent pain and disability for the patient. The case was challenging but went well and with a good result.
How My Partner Met Expectations
Prior to surgery, my partner met with the patient more than once. During all occasions, my partner phrased the expectations conversation as his hoping to make his patient completely pain free with a perfectly functioning foot, but expected the patient would have a little less pain and a straighter foot. During the entire conversation, he was clear that his expectations for success were realistically low. And more importantly, he allowed the patient to express his own expectations for the surgery. As it turns out, just before the procedure, the patient demonstrated his own lower expectations when he said, “Doc, just do the best you can. Anything will be better than this.”
Education and Perception
It all boils down to education and perception. The patient must be adequately educated in exactly what the expectations of the doctor are, while understanding no surgery will make a person perfect again. Nothing beats nature. Additionally, doctors must educate themselves on what their patients are thinking, not just what they’re saying. It takes time to truly understand what patients want, and physicians must understand this in order to best educate their patients.
It also comes down to perception. The patient must appropriately perceive the situation in order to have clear expectations. This is likely the reason why panmetatarsal head resection procedures in rheumatoid arthritis patients are typically so successful. The patients have such a high level of pain preoperatively (their perception) that any procedure that eliminates the pain will be welcome. Alternatively, think about doing this procedure for a typical 60 year-old patient with severe bunion and hammertoe deformities. You’re less likely to have the same positive result. With people, perception is reality. Understand your patients' perception, meet their expectations and you'll maximize your success.
Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum.
Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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