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Matching Expectations
Matching Expectations
Let’s talk about patient expectations. There is what seems to be a well-kept secret that foot surgery recovery is quick and easy. At least, this is what many patients appear to think. For example, when I tell a patient before a bunionectomy that they will be out of shoes for a period of time (obviously this varies based on the procedure), they are often surprised. Same thing with patients who have neuropathic foot ulcers. I’m often surprised, myself, at the high expectation patients have of the speed and ease of their foot surgery recovery.
Let’s look at a specific example. I once saw a patient who underwent a staged forefoot reconstruction that required two trips to the operating room and eight weeks of K-wires in all the lesser toes. During each of the follow-up appointments, the patient complained of both the presence of the K-wires and the need to be non-weightbearing. At the end of the recovery, just after removal of the pins, the patient was clamoring to return to shoes. The patient did not seem to understand the extent of the surgery that had been performed or the need for a prolonged recovery despite detailed preoperative discussions.
Similarly, I commonly deal with diabetic patients with wounds who never seem to understand just how serious their disease is. Of course, they’re ignorant of the potential decrease in life expectancy marked by the presence of a neuropathic ulcer, or that it is a marker of malignant diabetes. They additionally have little understanding of just how slow the human body heals under the best of circumstances. The second their ulcer is healed; they are ready to return to work/activity/shoes and are shocked when I tell them they can’t return to work yet.
Clearly, many patients’ expectations do not match their physician’s. Why does this happen and what can we as their providers do to help?
Mismatched Expectations
It is easy to explain mismatched expectations. It’s a combination of accidental and willful ignorance. We must first remember that on a day-to-day basis, our patients do not regularly experience things like ulcers, surgery, and all the myriad disorders that can affect the lower extremity. As experts in this field, we see a skewed representation of these disorders in the population, and it is easy for us to fall prey to an availability bias. Recovering from a bunionectomy is, hopefully, a once in a lifetime experience for a patient, while for us it is a daily occurrence.
Recovering from a bunionectomy is, hopefully, a once in a lifetime experience for a patient, while for us it is a daily occurrence.
The Patient’s Point of View
Willful ignorance is a different beast and may be more difficult for many of us to understand. Put yourself in the mind of a poorly controlled diabetic. It’s a scary disease, you may have had a bad experience when you found out your diagnosis, and it may be easier to simply not check your sugars. Remember, this disease takes years to develop, and it happens to other people, right? Right? The next thing you know there is a hole in your foot where that callus used to be.
Of course, it doesn’t hurt since you can’t feel your feet. The wound is enlarging so you finally decide to see a podiatrist. They then explain what it is, why it’s there, and then they drop the bomb that this painless hole in your foot has a life expectancy worse than some cancers. “My foot ulcer is like cancer?” Oh boy. The podiatrist then describes what is needed to treat the ulcer (a cast or boot, cutting the wound to make it bleed, dressing changes, and many times the need to stop work) and that you must get better control of your blood sugar, among several other activities. This may require a complete lifestyle change. Can you blame a person for putting their head in the sand? How overwhelming.
You tell the patient, “Due to this painless hole in your foot, you have a life expectancy worse than some cancers.”
Combine these phenomena and you have a powerful force to prevent patients from fully appreciating what it means to go through treatment of the lower extremity.
Managing Mismatched Expectations
Obviously, it is not in our patients’ best interest to have expectations that are different from ours, so how do we manage our patients’ expectations?
First, this requires a lot of patience. It may take a while for a patient to accept life-changing situations or what it takes to recover fully after a foot surgery. It may take more than one discussion. For my elective surgery patients, I will ask them to return for a second visit even if they know they want a surgical procedure. This gives them a chance to think over things and ask more questions.
Second, empathy is a must. That “golden rule” should guide how we interact with all our patients, but those about to undergo a complex intervention such as a surgery may require even more understanding.
Third, understanding our patients requires more than just clarity on the medical issues. It is imperative to appreciate their psychosocial situation. Where do they live? What is the work environment? Will they have to take off time? Will they be able to afford to be off work? What kind of support do they have at home? Do they live in a house or apartment? Are there stairs? Are there barriers to non-weightbearing after surgery if this is necessary? Do they drive? You get the picture.
Fourth, comes communication. It would seem obvious that we should communicate with our patients, but busy clinics and offices often lead us to cut this part short because of the extra time it can take. The other benefit of having a second and sometimes third preoperative appointment is allowing patients to ask more questions but also permitting time to explain everything we think they should know. This is more than just the “risks, benefits, and potential complications” of the consent process. It allows the doctor to explain things like, “This treatment is going to require me to put your right foot in a boot to take the pressure off the wound. This means you will not be able to drive. How do you feel about that?” A very useful tip I learned years ago is to define out loud to your patient exactly what your expectations are. For instance, “My goal with this surgery is to decrease your pain so you can walk longer in athletic shoes. I’m not expecting you to return to dress shoes.”
Fifth, and just as important, make sure to document all of this in the chart notes. Yes, it takes extra time, but medicolegal protection is an unfortunate necessity in today’s world.
Finally, consider that this process empowers our patients to be active participants in their medical care and allows for shared decision-making. Having even some control over a difficult situation will decrease anxiety, improve adherence to medical advice, and further build a strong patient-doctor relationship for improved outcomes.
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