Jarrod Shapiro, DPM Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

Patient Psychology and the Red Flag

We’ve all heard many times that surgery is both a science and an art.  But we spend so much of our time, whether in school, residency training, fellowships, or in clinical practice, focusing on the science aspect...and not enough time on the art.  Evidence based medicine, appropriate procedure choices for flatfoot reconstructions or hallux valgus, classification systems for trauma take up a significant proportion of our attention.  What we spend very little time on is (no matter what level of training or practice) patient choice and the contribution of psychology to surgery - the other side of the art of surgery. 

The first side of surgery’s art has to do with manual dexterity, that “touch” the best surgeons have, the knowledge of when and how to manipulate the surgical field in such a way as to create successful results.  The other side I mentioned is as important - if not perhaps more important - than the technical side of a procedure: choosing the right patient for surgery.  How do we improve our understanding of patient psychology and human nature to increase our surgical success rates?  Conversely, how do we identify that “red flag” patient?  This is the real art of surgery.

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Now, I’m going to state a disclaimer here.  By no means am I an expert on human nature or patient psychology.  I don’t even think I’m any better skilled at determining which of my patients are good surgical candidates than any other physician in practice 4 years.  My intention in writing this is to stimulate discussion that will lead to a greater understanding of our patients and, hopefully, avoid some of the headaches in dealing with our patients.

Speaking of headaches…approximately four months ago I performed a Lapidus arthrodesis on a middle-aged lady with hallux valgus.  The procedure went well and she healed with what I thought was a good result.  However during the postoperative recovery period, she was constantly apprehensive about every small detail, whether it was some swelling or the aches and pains that come with foot surgery.  Unfortunately for me, I had used a dorsal plate which became an irritant.  After verifying adequate bony union, I removed her plate uneventfully.  During her recovery, I found myself feeling drained by this patient’s generally poor affect and whinny attitude.  After leaving the exam room each time, I had to give myself a pep talk, and I thought more than once, “I wish I had never touched this patient.” 

Approximately two months prior to this, I performed the same procedure on a slightly older female patient who I was, frankly, concerned about doing a procedure on more significant than an Austin.  After discussing the issue with her, she chose the Lapidus, I performed her surgery, and she did just fine afterwards.  I’ve had no problems with her postoperative course. 

These two patients are illustrative of the difficulties and variations we physicians have choosing not only the right patients but also the right procedure for each patient.  So how do we improve our understanding of patient psychology?  How do we determine that red flag patient?  How do we become better “artists?”  After my short 4 years of practice here are some methods I use when evaluating patients preoperatively.

1. Get to know the patient as well as possible.  I try to see my patients more than once before I schedule surgery.  During these visits, I attempt to evaluate how well the patient can understand instruction.  Do they actually follow my directions?  Do they appear to make appropriate decisions?  Are they engaged in their own care? Do they have family who will be able to help with their postop care?  Will family hinder the postoperative course?
2. How much of my time does this patient require?  I have found that there seems to be an “appropriate” amount of time to spend with each patient.  The red flag for my Lapidus patient mentioned above should have been the sheer volume of questions she asked and the inordinately long time I had to spend with her each visit before her surgery.  The average “non-headache-causing” patient asks a normal amount of questions preop.  What’s normal?  I’m not sure – it seems to be a subjective number.
3. The mental status exam might come in handy.  Assess the patient’s appearance (hygiene, grooming, general appearance, clothing attire), behavior (abnormal movements, eye contact, overall appropriateness), and speech (fluency, rate, clarity, tone).  Throughout the interview, assess the patient’s affect or emotional state (are they excitable, flat, inappropriate, or constantly shifting).  How is the patient’s attention span?  Are they focused or wandering? 
4. Ancillary diagnoses and allergies.  It may not be scientific, but if a patient has more than 3 allergies or has multiple pain medication allergies, I become suspicious.  Additionally, in patients with diagnoses of chronic pain conditions like fibromyalgia, I’m suspicious.  Is the patient on depression medications? I don’t mean to sound discriminatory, but chronic pain conditions often have a psychological component to them. 
5. Has this patient been to multiple doctors for the same condition?  If I have a patient who has seen another podiatrist for a problem I am now treating, I start asking questions.  Why is the patient changing physicians?  What did the other doctor do or not do that this patient disliked? 
6. What are the patient’s expectations for surgery?  Are they realistic?  Will they match my expectations?  What do they consider success?  Do they want a purely cosmetic result like a rectus hallux after bunionectomy or simply improvement in their pain?  Does that postcalcaneal fracture subtalar fusion candidate want 100% pain relief? 

Clearly, there’s no science behind my method of preoperatively evaluating patients.  It often boils down to that “gut feeling,” that sense that there’s something wrong with this patient.  Unfortunately, my gut isn’t 100% accurate.  Perhaps we need a new evaluation tool that can help us create a biopsychological profile of our presurgical patients, allowing us to make better choices.  I would refer the interested reader to the bariatric literature, where this does exist.  Because obesity has such significant psychosocial issues, patients pending weight loss surgery undergo not only a medical evaluation, but also a psychological one which identifies and manages factors that may become risk issues in the postoperative period.  What we need in podiatry is a short form method to objectively evaluate preoperative risk of postoperative psychologically related complications. Wouldn’t it be nice to predict that patient most likely to weightbear their triple arthrodesis against your advice?  I would love to have better predicted my Lapidus patient!  Until then I’ll just have to rely on my gut (as inaccurate as it is).

For those of you who have mastered this art of patient choice and psychology write in and educate those of us looking for the magic formula.  What tricks and pearls keep you out of trouble?  Good luck with your next surgical patient.  Watch out for those red flags!

LETTER TO THE EDITOR:

Just fyi, I belong to an orthopedic group and have won over the mds in the group with my knowledge and training and performance.  I am now the go to guy for anything below the knee.

I would add to your response that some podiatrists like myself do NOT want to be like MDs bc we are better than them in managing foot and ankle problems.  Even my vascular surgeon friend told me he wishes he was a podiatrist.

Anyway, keep your head high and we all need to keep educating the public and our MD peers and colleagues about our expertise.

—Dr Andrew Belis
    Podiatrist/Foot & Ankle Surgeon
    Orthopedic Center of Florida

Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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