Tag Archives: doctors

Higher Expectations from Patients than Doctors

Study Reveals Presurgical Expectations of Foot and Ankle Patients Exceed Those of Their Surgeons – by Hospital for Special Surgery – June 2020

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.

How to Talk to Your Doctor About Pain

How to Talk to Your Doctor About Pain – Health Essentials from Cleveland Clinic – June 2020

This article contains an excellent list of many descriptive words to help us describe very specific aspects of our pain.

There are many causes and types of pain, and everyone experiences it differently. Effective communication with your doctor is a key piece of the pain management puzzle.

“While most people think pain is all the same, there are actually several different types of pain,” explains pain management specialist Robert Bolash, MD.  

It seems most scientists, researchers, and even doctors assume that chronic pain is some generic entity, and that’s a ridiculous assumption.  Continue reading

Doctors fired for pointing out out problems

Medical Societies Issue Bold Statement of Physician Support – Medscape – by Sheila Mulrooney Eldred – April 05, 2020

At least one physician has been fired for speaking out about the lack of personal protective equipment (PPE) in his hospital.

I thought this only happened in China.

Another was informed he couldn’t wear a mask brought from home for fear of scaring the patients.

Again, this is exactly what they did in China, punish anyone who showed evidence of concern.  Continue reading

The most dangerous trend in spine surgery

The most dangerous trend in spine surgeryby Laura Dyrda | August 16, 2019

Spine surgeons reveal the trends in healthcare that could have a negative impact on spine surgeons and care delivery in the future.

  • Timothy Witham, MD. Johns Hopkins Bayview (Baltimore)

The usual issues, mainly insurance companies dictating the way we care for patients and limiting the opportunities for patients to receive certain treatments.   Continue reading

Provider Beliefs May Affect Pain Relief

Provider Beliefs May Affect Pain Relief | NIH News in HealthJanuary 2020

How your health care provider interacts with you is important. Their style can shape how you feel about your treatment.

A new study found that people experienced less pain when the treatment provider expected a pain reliever to work. This may have been due, in part, to the provider’s facial expressions.

This goes completely against what I and many other pain patients have experienced: Our doctors always believe that whatever treatment they are prescribing or providing will work and most patients do too. “Hope springs eternal” until patients face the reality that this placebo treatment isn’t working. Continue reading

Opioid Prescribing and Physician Autonomy

Opioid Prescribing and Physician Autonomy: A Quality of Care Perspective  free full-text /PMC6384205/ Feb 2019

As one article published in American Family Physician in 2000 stated: “Despite recent advances in the understanding of pain management, patients continue to suffer needlessly, primarily because of improper management and inadequate pain medication”

This article evaluates the effectiveness of recent legislative mandates and restrictions on opioid prescribing and proposes alternative frameworks for combatting and preventing harms caused by the misuse of prescribed opioids.   Continue reading

Big Medicine is Putting Small Practices Out of Business

How Big Medicine is Putting Small Practices Out of Business – MedPage Today – by John Machata, MD – Apr 2019

Recently, the CEO of a large health care network stated: “Market forces don’t apply to healthcare.”

What an idiotic statement! If this were true, CEOs wouldn’t be receiving astronomical salaries while their cost-cutting leaves everyone doing the real work broke.

These CEOs manipulate their corporations to generate the maximum profit (which is actually their job) and their calculations definitely depend on market forces to raise prices by eliminating competition.  Continue reading

Moral injury and burnout in medicine

Moral injury and burnout in medicine: a year of lessons learned – STATBy WENDY DEAN and SIMON G. TALBOT – Jul 2019

When we began exploring the concept of moral injury to explain the deep distress that U.S. health care professionals feel today, it was something of a thought experiment aimed at erasing the preconceived notions of what was driving the disillusionment of so many of our colleagues in a field they had worked so hard to join.

As physicians, we suspected that the “burnout” of individual clinicians, though real and epidemic, was actually a symptom of some deeper structural dysfunction in the health care system.   Continue reading

When the standard of care is bad medicine

When the standard of care is bad medicine – KevinMD.com – Myles Gart, MD | Physician | July 2019

This article explains that when you are in the hospital with acute pain, there’s a simple formula for prescribing pain medication (opioids) according to your stated pain level. No wonder so many patients inflate their numbers!

However, even though this article was published in July 2019, it assumes pain will be treated according to a patient’s report of their pain. That’s not what I’m hearing from pain patients who are sent home with aspirin or Tylenol even after major surgeries.

For the last three decades, the numeric pain score has been the go-to assessment for acute pain in the hospital setting. Since this methodology was developed for research purposes to see if drug “A” had an effect on patient “A,” its clinical utility is not just worthless but dangerous.

Continue reading

Rx Opioids: Culprits or Scapegoats?

Are Rx Opioids the Culprits or Scapegoats for Opioid Crisis? — Pain News Network – By Dr. Lynn Webster, PNN Columnist – Aug 2019

The Washington Post recently published a series of stories about the volume of opioid medication distributed over the past several years in the United States. Over 76 billion pills were distributed from 2002 through 2012.

That sounds like a huge amount, but it is difficult to know what the number means. What is clear is that the stories are meant to suggest the number of pills is excessive and responsible for the rise in opioid overdose deaths.

It sickens me to see how the media sensationalizes the huge numbers of individual pills without putting them into context.  Continue reading