In the first-ever study to compare surgeon and patient expectations in foot and ankle surgery, research performed at Hospital for Special Surgery (HSS) in New York City has determined that two-thirds of patients have higher presurgical expectations than their surgeons.
That’s probably because they’re desperate for relief – especially nowadays when effective pain relievers are so hard to get. Plus, these surgeries and so profitable there may be some bias on the surgeon’s side.
Somehow, I can’t imagine a surgeon asking a patient what they expect the result to be; they’re too busy *telling* patients what the results will be. And they do the “telling” in vague language that doesn’t convey the full impact of this brutal assault on their body.
Patients aren’t informed how little or short-lived the improvements might be, or that surgery can often leave not just visible scars, but invisible internal scars that become the source of chronic pain later.
I can’t imagine a doctor telling a patient, in a way that really gets through to them, the critical message: “it will never be as good as the original“.
The paper, titled “Comparison of Patients’ and Surgeons’ Expectations in Foot and Ankle Surgery,” is available online as part of the AAOS 2020 Virtual Education Experience.
Patient expectations of orthopaedic procedures have been demonstrated to be strongly associated with clinical outcomes and postoperative satisfaction.
If patients have high expectations shouldn’t this create the placebo effect? Just like negative expectations (sometimes called catastrophizing) are alleged to worsen chronic pain and lessen functionality, shouldn’t positive expectations lead to less pain and more functionality?
If “patient expectations” determine the outcome of treatment, this would apply to all treatments; the placebo effect either is or isn’t a factor. A placebo can’t have different effects for different treatments like surgery where a placebo doesn’t work and chronic pain where a placebo supposedly does work.
If higher expectations don’t lead to better results, the placebo effect is not.
In reviewing the operative schedules of seven foot and ankle surgeons at HSS, Dr. Ellis and his colleagues hypothesized
- that patients would have greater expectations for their outcomes than their surgeons,
- that there would be greater differences in preoperative expectations between patients and surgeons in major versus minor foot or ankle surgery, and
- that greater differences between patient and surgeon expectations would be associated with worse preoperative physical and mental health.
“Although most surgeons do their best to engage in open conversations with their patients about what they can expect from surgery, many find it difficult to tell patients that they are not going be as good as new postoperatively,”
…patients completed Patient-Rated Outcomes Measurement Information System (PROMIS) computer adaptive tests in Physical Function, Pain Interference, Pain Intensity, Depression and Global Health prior to their procedures.
“We determined that
- 66.3% of patients had higher expectations than their surgeons,
- 21.3% had concordant expectations, and
- 12.4% had lower expectations,” said Dr. Ellis.
“In addition, the study showed that the majority of patients who had worse preoperative PROMIS scores had higher postoperative expectations.
That makes sense because people who are worse off are more desperate for surgery and also more likely to see at least some improvement from it.
We also found that depressed and anxious individuals had greater expectations than their surgeons, as did patients with a higher body mass index.”
Again, these are the desperate ones, not the ones who can still tolerate their pain. Because their condition is so bad, there’s a lot of room for improvement so their high expectations seem logical.
Going forward, said Dr. Ellis, future research should delve into other potential factors such as medical literacy and patients’ knowledge of their condition, as well as the bond between surgeon and patient.
What “bonds” can there be within standardized Evidece-Based Medicine? Can a guideline be written to standardize the doctor-patient bond?
Would such a guideline be ike the scripts they give to flight attendants, the ones they are required to recite at the start of every flight?
I went with my mother to an appointment with her PCP at Kaiser which was unnecessary but required because she takes 2 Vicodin a day.
The doctor had to speed read to us over a dozen questions from her screen and quickly type in or select the answers (a click and a delay meant she was scrolling through a drop-down menu).
She wasn’t talking to us, she was reading. Everything my mother said was met with an utterly ineffective and obvious suggestion.
- Pain? take more Tylenol.
- Fatigue? You’re just old.
- Hips so painful can’t walk? Do more walking exercise (!)
- Piriformis pain? Here’s some Voltaren Gel. (I looked it up and there’s no way it can penetrate deep into a buttock where that muscle is but, hey, at least it’s not an opioid!)
I feel sorry for the doctors that are forced to “practice” like this because it’s clear they can be replaced by data entry clerks (and eventually robots). No medical knowledge or treatment is required, literally only the ability to read questions and transcribe answers.
In the meantime, we suggest that a preoperative educational class for foot and ankle patients would go a long way towards a rapprochement between patients and surgeons when it comes to expectations.