It always strikes me as amazing what we remember from school.  Of the many thousands of terms, concepts, memories, and experiences, there’s one that for some reason has always stuck with me. I was in a podiatric surgery lecture, and my instructor advised my class to underplay the possible success of surgery to our patients.  “If you think it will take 6 weeks for your patient to heal,” he said, “then tell them it will take 8 weeks, and when they heal two weeks early, your patient will think you’re a hero.”  I think this statement has resonated with me for the past nine years - since my second year of school – because it’s about expectations.  Should we downplay our expectations?  Isn’t this dishonest?  Should patients’ expectations match ours?  Is there a time when dishonesty is the best policy?

Let’s start by looking at this from the other side of the coin: when patients have higher expectations than doctors.  We’d be hard pressed to find a surgeon who hasn’t performed surgery on a patient, only to find the patient was unhappy with the result because their expectations were higher than the surgeon’s.  This often seems to occur with patients who were not adequately consented preoperatively.  I once had a patient on whom I did a 3rd digit PIPJ arthrodesis.  Postoperatively, she was unhappy with the result because she couldn’t move the joint anymore.  This was in spite of a preoperative discussion in which I explained her toe would be stiff.  Perhaps I didn’t know my patient well enough.  Perhaps she was unrealistic, despite my consent discussion.  Either way, my expectations and hers did not match, and it caused some difficulty.  She eventually saw that her preop pain had improved and relaxed a bit, but was never really satisfied.  We all know that unrealistically high patient expectations are a recipe for disaster.

When Everybody's Expectations are Low

Let’s look, now, on the flip side: high risk situations.  There are some circumstances where low expectations are universal on the professional side.  Think about joint depression calcaneal fractures or comminuted pilon fractures.  In these situations, it’s very difficult, sometimes impossible, to assure these patients of a successful result without complications.  Patients with severe pilon fractures are told they’ll be lucky to keep their leg and they should expect ankle arthritis to occur at any time after surgery.  Many trauma experts will tell their patients it’s just a matter of time before the subtalar arthritis sets in, and their goal is to make the anatomy as close to normal as possible, so the future subtalar arthrodesis is made easier.  I had a patient a few years ago who sustained a motorcycle vs. car accident.  Guess which one he was driving.  The motorcycle, of course.  He had a dorsal degloving injury with open, comminuted fractures of metatarsals 2-5 and a hallux fracture.  Postoperatively, I was unsatisfied with the results (he ended up losing the 2nd toe when it was devascularized during the injury and had a nonunion of the 4th metatarsal fracture), but he was wildly happy with the results.  He was so happy to have a foot at all and minimal pain that he loved the result and couldn’t be happier with me as his doctor.  He really did think I was his hero. 

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My Advice to You

            So, after some experience and a little consideration here’s my algorithm when it comes to
patient expectations. 

1. Always treat patients for pain, instability, or worsening deformity, never cosmesis.
2. Know your patients before you do surgery whenever possible.  Learn their expectations.  Ask them up front, “What are your expectations for this surgery?”
3. Understand that reconstructive patients with true, long term pain are likely to respond better to surgery than those with only mild, short term pain.
4. Exhaust your nonsurgical options before you do surgery.  Many patients will get better with intelligent nonsurgical treatment and time.  Some get better no matter what you do.  If not, they can say they’ve tried everything possible before resorting to surgery.
5. Patients with high risk conditions (trauma, ulcers, Charcot, limb preservation, severe deformities, and multiple prior treatments) should be given LOW expectations and should be aware of the high risk for complications.
6. Never promise success with any surgery.  Give patients an honest, realistic assessment of the possible complications, and don’t leave anything out. 
7. In the average reconstructive patient, I generally lower my expectations.  This may not be the most forthright approach, but having the I-would-have-done-it-differently-if-I’d-have-known conversation is not one I’d care to repeat in the future.

Underplay the Success of Surgery as a Matter of Policy

Clearly, my personal trend is towards underplaying the success of surgery.  This differs for all doctors.  For many surgeons, the temptation is there to underestimate the complications and overestimate the success rates of procedures.  One might think if the patient truly understood the complications of surgery, he’d never undergo an elective procedure.  I can empathize with this train of thought, incorrect though it is.  In this surgeon’s view, an honest, slightly pessimistic appraisal will keep away the demons of “I wish I would have…”  Best wishes.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.

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

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