Orthopedic surgeons need to set expectations, provide patients with hope after poor results
There is constant growth of information, tools and technology to help orthopedic surgeons provide patients with the best nonsurgical and surgical care. However, complications can be a part of any intervention despite a conscientious effort to avoid them.
Poor results can be defined as a result that does not meet patient expectations and is likely to seriously affect final functional outcomes or what patients perceive as their future. The impact of poor results cannot be truly appreciated until the orthopedic surgeon has a clear understanding of patient expectations.
Nobody accepts poor results lightly and they serve to motivate surgeons to improve care. Even so, poor results need to be discussed with patients and families. Discussing poor results is a complex task. It is never easy to explain to patients or their families why an infection occurred after a routine joint replacement or why a simple knee scope led to a life-threatening or fatal pulmonary embolus.
Patient communication is key
Anthony A. Romeo
In the discussion of poor results, not only does the orthopedic surgeon need to select the proper words, but he or she also needs other essential skills to effectively perform the task. This includes having the ability to listen to and interact with patients and their families, as well as the ability to respond to emotional reactions and include patients in the shared-decision making process going forward. They also need to be able to set appropriate expectations and provide hope for an improved resolution. The challenging nature of discussing poor results can lead to communication failure and a misunderstanding of concerns and expectations.
Patients want the truth and want to know what the problem is, how confident the orthopedic surgeon is in the diagnosis, and how poor results may be remedied. Furthermore, principles of informed consent, shared decision-making and the legal system have established clear obligations for the surgeon to provide patients with as much information as a competent peer surgeon would provide. This is typically more difficult for treating physicians who often have developed emotional commitments to patients and an “egocommitment” to believe poor results should not happen in their practice. Even when the truth is told, the surgeon has to disclose the information in a method that is perceived by the patient as sensitive and caring. Otherwise, the patient may develop a sense that the surgeon is not sharing all the facts.
An orthopedic surgeon’s ability to discuss poor results affects a patient’s understanding of the problem, which may lead to less effective shared decision-making, poor patient satisfaction and less successful future interventions. Good physician-patient communication is also a predictor of patient compliance and adherence to the recommended care program. Some physicians believe providing unfavorable information may cause additional psychological burden to the patient, but this is unsubstantiated and likely to have developed from the surgeon’s coping mechanism. Oftentimes during the management of a bad result, the surgeon has the opportunity to demonstrate the depth of his or her caring for the patient and the overall relationship is strengthened, not broken down.
Barriers to discuss poor results exist. While many have learned to hide their emotions, the awareness of a bad result and the subsequent need to discuss it with a patient can create anxiety, a burden of responsibility and concern that the patient will think unfavorably of the surgeon. This is likely to be witnessed by support staff, ancillary health care providers and peers. We have learned methods to cope with these stressors, with some methods more effective than others. As the leader of the health care team, we have to be the calm among the storm. Our personal anxieties must be subdued and our focus has to be on what is best for the patient. We need to put the patient at the center of the care model, then enlist a team dedicated to understanding not only patient expectations, but also the causes, treatments and strategies to prevent recurrence.
Set discussion goals
The goals of discussing poor results can be divided into key components. First, it is important for orthopedic surgeons to know their patients. When a poor result is identified, it is time to review what was gathered about the patient during the medical care process. Understand why the patient initially came to the office, the major complaints and the social, economic and medical factors that may affect their ability to deal with poor results. In the face-to-face discussion, begin with truly listening to the patient so you have a keen understanding of his or her knowledge of the problem and expectations. Ask patients directly what they understand about the current problem. Ask them what they think went wrong. With these questions and others, you can help correct misinformation and unrealistic expectations.
Second, provide clear information about the poor results using terms and concepts patients understand. A solid foundation in experience and evidence-based medicine helps one focus on the key facts patients need to understand before you can bring them to the point of a shared decision-making that matches patient expectations. However, start at their level of understanding and use non-technical words and patient-specific analogies. It is important to avoid the strong use of negative words and statements as that may lead patients to focus on incomplete and negative information.
Third, develop the ability to communicate with patients. Orthopedic surgeons need to establish a closer relationship with patients during crisis management, not a more aloof and dispassionate relationship. Have clear thoughts, avoid technological distractions and then sit face-to-face with patients. It is important to be honest, sincere and empathetic. Listen, feel and help manage their emotions, but stay focused on what you can influence. Patients will have many concerns – oftentimes more than one can address – so stay focused on the key components that can be impacted in a positive way. Patients generally value apology and expressions of empathy and caring. Physicians often believe the highest quality information compensates for deficiencies in empathy. However, studies have shown that patients expect high levels of empathy and information quality, no matter how bad the news. One does not readily compensate for the other.
Finally, develop a strategy. Even if the plan is to send the patient to another surgeon for their expertise, it is critical to provide hope that a better result is possible. Even when a better result seems impossible, never underestimate the power of the mind and human spirit. Also, do not underestimate the patient’s ability to adjust expectations. It may be tempting to say nothing else that can be done, but listen for adjustments in their expectations and develop a strategy to help achieve limited, but important, patient-perspective goals, such as pain relief or simply the ability to care for themselves.
Give patients hope
By nature of practicing in a major metropolitan area, developing a referral practice of complex patient problems, performing revision surgery in more than one-third of my cases and being human, I have had to discuss poor results with my patients at times. When it happens, I sit down and talk with the patient. I understand and care about them, and help them with their emotions. I have been fortunate to avoid medical malpractice proceedings after 20 years in practice. Still, it is probable that one day a patient and I will not be able maintain a healthy relationship and the area where this is most likely to occur will be because of a poor result.
Some may criticize my comments and strategies to discuss poor results as too idealistic. In today’s medical and legal climate, there is even more pressure to redirect or displace blame for poor results or results that do not achieve patient expectations. Maybe evasive, defensive and even deceptive strategies could be endorsed to deal with poor results. However, we all have internal moral compasses that help us follow a path in life and I cannot endorse such methods. Rather, I suggest orthopedic surgeons provide patients with a strategy. Give patients hope that you will sincerely do all you can to help them achieve a better result.
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Disclosures: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.