Tag Archives: surgery

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.

Study Shows Surgery Reduces Chronic Opioid Use

Surprising Finding: Study Shows Surgery Reduces Chronic Opioid Use – Pain Medicine Newsby Michael Vlessides – May 2020

Among chronic opioid users, having surgery seems to be associated with a faster time to opioid discontinuationcontrary to popular belief.

I’m very curious about what they consider “contrary to popular belief”. It doesn’t make much sense to believe that having surgery leads to a “longer time to opioid discontinuation.”

“Of patients coming to our operating rooms, 23% will already be on an opioid by the time they see you on the day of surgery, and 3% will be chronic opioid users,” said Naheed Jivraj, MD.   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

Undiagnosed Osteoporosis in Spine Fusion Surgery

Study: CT Scan Prior to Spine Fusion Surgery Finds Significant Number of Patients Had Undiagnosed Osteoporosis – Mar 2019

For patients contemplating spinal fusion surgery to alleviate pain, bone health is an important consideration.

If a patient is found to have low bone density prior to surgery, it could affect the treatment plan before, during and after the procedure. A study at Hospital for Special Surgery (HSS) in New York City found that a CT scan of the lumbar spine prior to surgery indicated that a significant number of patients had low bone density that was previously undiagnosed.

And I assume they then had the surgery in spite of it.  Continue reading

IV APAP of Little Benefit for Cardiothoracic Post-op Pain

IV APAP of Little Benefit for Cardiothoracic Post-op Pain – Pain Medicine Newsby Kenneth Bender – Aug 2019

This is an amazingly honest negative evaluation of IV Tylenol, which some people claimed was just as effective as opioids. But this study is a reality check and brings more science and less hype to the overcrowded field of opioid/pain studies.

Intravenous acetaminophen provided little benefit in multimodal analgesia regimens for cardiothoracic postoperative pain and posed a risk for hypotension, according to a study of outcomes in a real-world population.

I’m thrilled to hear it stated so definitively after so many years of hearing how great of a pain killer Tylenol is.  Continue reading

Invasive Surgery to Relieve Chronic Pain?

Invasive Surgery: Effective in Relieving Chronic Pain? By Sunali Wadehra, MD – Feb 2019

Invasive surgery may not be any more effective than sham procedures in reducing chronic pain, according to a meta analysis published by Wayne B. Jonas, MD, in Pain Medicine last September.

Dr. Jonas and his team performed a systematic review of 25 randomized controlled trials published between 1959 and 2013, involving 2,000 patients undergoing surgery for chronic pain.

This article explains a concept I haven’t seen elsewhere: chronic pain versus protracted pain. Especially in the case of EDS, this means we can hurt every day, but still not have true “chronic pain”. Continue reading

FDA Safety Alert About Intrathecal Delivery of Pain Meds

FDA Issues Safety Alert Regarding Intrathecal Delivery of Pain Meds – Diana Ernst, RPh – November 15, 2018

The Food and Drug Administration (FDA) has issued a safety communication regarding the risks associated with implanted pumps for intrathecal administration of pain medications

Reports of pump failure, dosing errors, as well as other possible safety issues have prompted the Agency to issue an alert to make prescribers aware of the dangers associated with using medications not specifically approved for intrathecal administration with the implantable pump.

Examples of drugs not identified in implantable pump labeling include hydromorphone, bupivacaine, fentanyl, clonidine, as well as any mixture of 2 or more different drugs; compounded medicines are also not included in the current labeling for implanted pumps.   Continue reading

Surgery for Chronic Pain: Real or Sham?

Surgery for Chronic Pain: Risky and Costly  by Christopher Cheney, HealthLeaders Media – September 23, 2018

While I agree with the basic results of this study, I have great qualms about how these studies (and there are apparently more than a few) are conducted.

There is inadequate evidence to justify surgical procedures to treat chronic pain, recent research shows.

“Given their high cost and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain, researchers reported in Pain Medicine.

Most pain specialists and researchers now understand chronic pain as a bio-psycho-social disorder and involving central sensitization, ruling out any structural or biochemical problems. This kind of pain, by definition, cannot be treated with surgery. Continue reading

Spinal Surgery Does Not End Opioid Use for Pain

Expectations Versus Reality: Spinal Surgery Does Not End Opioid Use for Pain – RELIEF: PAIN RESEARCH NEWS, INSIGHTS AND IDEAS By Stephani Sutherland – July 2018

People seeking medical treatment for back pain often end up in a surgeon’s office.

Most of those individuals hope—and expect—that surgery will reduce their pain enough to make opioid painkillers unnecessary after the operation.

But that scenario seems to be the exception rather than the rule, according to a new report published in the journal PAIN.   Continue reading

The Pain Industry’s New & Dangerous Fall-Back

Opinion: The Pain Industry’s New & Dangerous FALL-BACK – June 27, 2018 – By Dennis J. Capolongo / Director ENDC

From my perspective, preventative measures to reduce iatrogenic harm should be among the list of alternatives to help reduce opioid consumption.

Recently published reviews authored by outspoken physicians Dr. Martin Makary of John’s Hopkins and Dr. Jana Friedly of the U.W. Medical Center have pointed a finger at an industry that has literally run amok.

Here’s the other nightmare being foisted upon pain patients: “interventional” pain management, with needles and knives that leave patients in even more agony afterward.   Continue reading