Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

Underestimation

Oh, the joys of home ownership. After moving into our new home about 5 months ago and making some changes to the inside of the house, my wife and I decided it was time attack the outside. We have a small backyard paved with rocks, and we wanted to put down some grass so the kids could run around and play.

Enter the shovels!

While slowly destroying my back with each shovel-full of rocks, I reached a point where, eerily, I had a "Close Encounters of the Third Kind" moment. After pulling away a plastic sheet under the pebbles, my rock clearing job began to look strikingly like a surgery I had done just two days prior. Look at the images below and marvel at the amazing coincidence of life. I’ll admit that my patient’s surgery may have been floating around in my subconscious, but I did not intentionally reproduce the appearance of his donor site.

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As weird as these similarities between my home trials and my recent surgery were, there existed another deeper connection. You see, just as my wife and I underestimated the job at home (we anticipated one quick afternoon of shoveling — oh were we wrong!), so also did my patient underestimate the significance of his surgery.

My patient was a thirty something year-old male who had previously sustained a gunshot injury to his lateral heel with a resultant ulceration. After local wound care for several weeks, it was now time to finish the job with a split thickness skin graft.

As I walked in to the surgical holding bay to see my patient preoperatively, the nurse made an interesting comment.

"I talked your patient out of going to school tonight," she said. My patient attends night school to get his Associate’s degree.

The patient then asked me, "Do you think it would be OK if I went to school tonight?"

I had to stop for a second to think about my response. It wasn’t that I was uncertain whether or not he should go to school after just undergoing surgery. It was pretty clear — even obvious — that he shouldn’t. My first thought was, "This guy’s nuts if he wants to go somewhere immediately after surgery." My second thought, then, was, "How do I impart the gravity of his situation to him effectively?"

I had failed to ascertain the level of judgment of my patient

Now, granted the nurse should not have advised the patient — that was my responsibility. However, her comment demonstrated to me a pivotal mistake I had made during the several office visits I’d had prior to this patient’s surgery. I had failed to ascertain the level of judgment of my patient. Clearly, he anticipated "minor" surgery that would have him back to regular activities immediately. He misapprehended the seriousness of surgery and had a much different expectation of his postoperative course than I did.

We had a detailed discussion about exactly what I expected, and (hopefully) I adequately imparted the gravity of his surgery.

Similarly, about a month ago I had a surgical patient that expected to be back at work full time within three weeks of undergoing a reasonably significant ankle surgery. Demonstrating just how common these misperceptions are, she told me about a friend of hers who underwent "bunion surgery" (not sure what kind – likely a head procedure) and went back to work two weeks after her procedure. The telling comment was that her friend wished she had "taken three weeks off." Even after the likely pain, swelling, and functional issues so soon after a bunionectomy, my patient’s friend still thought that one extra week would have made all the difference.

Clearly our patients’ expectations may commonly differ from ours. This is the base reason, I believe, for patient noncompliance. They simply have different – and much higher - expectations. From my own mistakes, I’ve learned a couple of lessons to minimize the risks of differing expectations leading to unintended noncompliance:

Don’t do elective surgery after the first visit. Emergencies are understandable. Sometimes you just don’t have the luxury of getting to know your patients. But when it comes to elective surgery, there’s no rush. Make certain you know your patient as much as possible before cutting them open.
Look for the red flags. Look for judgment problems. This is best predicted by how well they listen to you during their nonsurgical care. If, for example, a patient preoperatively continually removes her fracture boot despite your instructions not to, she’s likely to do the same postoperatively.
Communicate. If you desire to know your patient’s views on their upcoming surgery, simply ask them. Ask focused questions to test their thought process. For example, I could have asked, "How long do you think it will take after your surgery to become active?" Or "how do you think this surgery will affect you?" Any variation of questions will be helpful – as long as you ask them!
Educate. It’s OK to trust your patients, but make certain you’ve given them the tools to comply with your instructions. Don’t leave anything up to chance or interpretation. Give patients written postoperative instructions with all the important information they need.
Trust but verify. Some patients have questionable motives, but the vast majority of patients honestly want to heal and move on with their lives. They’re not deliberately trying to mess up your surgical result. Trust your patients, as long as they don’t breach your confidence, but confirm this behavior with the other tools mentioned above.

Unfortunately for my poor aching back, my wife and I underestimated the amount of work necessary to clear our backyard. Maybe the universe was trying to send me a message about expectations. Just like my patient, I wanted to be finished with my backyard project in as short a time as possible. However, like any large project, whether a garden renovation or surgery, we must put in the time for success and be realistic about the amount of energy necessary for completion. Consider this the next time you preop your patients.