Managing Patient Expectations For Elective Reconstructive Surgery

William Fishco DPM FACFAS

I had a conversation with a longtime friend and colleague about the stresses of our job as podiatrists. The laypeople or even other medical specialists who are reading this may say, “Oh, it’s just a foot. How difficult could that be?”

As a general rule, we can divide our profession into non-surgical, elective reconstructive surgeons, trauma surgeons and limb salvage/reconstruction specialists. I consider myself to be an elective reconstruction specialist. Yes, I do all aspects of the job including non-operative care, some trauma and wound care. Since I do not do any ER calls, trauma case referrals come to me from an urgent care physician or other podiatrists. All podiatrists will see their fair share of diabetes-related wounds. I do treat them as well but I have limited resources in my office and would rather have patients go to a wound clinic where they can get advanced wound care treatments if necessary.

When we talk about the stress of surgery, there is no question in my mind that the real pressure cooker involves elective reconstructive surgery. Not that we should compare ourselves to plastic surgeons but there is a real common thread of the expectation.

When a patient presents to a plastic surgeon, typically there is no pain. Do you think there is a lot of stress for the plastic surgeon to take a non-painful part of the body, do surgery on it and achieve the expectation of a perfect looking (which is subjective) and non-painful result? The plastic surgery patient wants a part of the body enhanced such as returning the body part to its original, more youthful appearance. So how is that any different than a patient with a bunion deformity or hammertoes on the foot that are minimally painful at best?

To illustrate, let us use an example of the patient who is 25 years old and wants her bunion fixed. We all know that most bunions are painful to a degree but the driving force for most people is to have a deformity fixed and be able to wear shoes comfortably. For women, it is going to be dress shoes. The expectation is very high in this group of patients. The expectation is that you are a surgeon, a doctor and a specialist, who is going to do a perfect job … period. The toe is going to be straight, the nasty looking bump is gone and the scar is going to look like a pink scratch that will fade over time and become nearly invisible.

For the trauma surgeons, the pressure is off. Certainly, I am generalizing and I am not talking about life- or limb-threatening conditions. So let us take the pilon ankle fracture as an example. A patient is in a motor vehicle accident and sustains a pilon fracture. You are on call and do the case. You do the best you can and the expectation is you are going to do the very best you can, but you can only work with what you have.

How often have you overheard a surgeon saying to a patient’s family (or used this line in your own work): “We are all done and I did the best that I could. His or her bone was awful. It was soft, crushed, crumbs, a real mess” or “Probably the worst bone/fracture that I have ever seen.” Maybe I am embellishing a little but you get the drift. So now you have set the expectation that at the very least, the patient won’t lose the leg but likely will have problems with it in the future. In trauma surgery, close enough is okay but not in elective reconstructive surgery.

For the limb salvage podiatrist, the pressure is off as well. The expectation is that you are treating a patient with out-of-control diabetes and a wound that may or may not be infected, and you are trying to prevent the worst possible consequence of amputation. However, all patients who have diabetes know there is a risk of amputation. They know somebody, either a friend or family member, who has had an amputation due to diabetes.

The limb salvage expert lays down the law at the first office visit. “Mr. Jones, you have a serious wound and if we do not get very aggressive with treatment, you will lose part of your foot or the leg.” With this scenario, most of the onus is on the patient. Therefore, the patient takes more of the responsibility of a bad outcome. The patient did not maintain tight sugar control, did not remain non-weightbearing, did not quit smoking, did not wear the accommodative shoe gear, missed appointments at the wound clinic, did not dress the wound at home, was non-adherent, etc. So right away, and rightfully so, you have lowered the bar for the expectation that you are going to have an amputation unless there is an intervention pronto and that the patient is going to follow your instructions and recommendations to a T.

We all know the foot is a complicated structure with 28 bones, 33 joints and over 100 muscles, tendons and ligaments. To make matters more challenging, you walk on the structure, have it confined in a tight-fitting apparatus called a shoe and, many times after a surgical procedure, one cannot put weight on the foot for an extended time. No wonder there is a specialty called podiatry that embraces the challenges and frustrations of treating this part of the skeleton.

I am not tying to downplay any aspect of our profession as it is all stressful. In fact, if you are not stressed out, concerned or worried or do not have sleepless nights, then you probably should be doing something else.

The bottom line is this: it is all about the expectations of surgery. During the preoperative consultation with my patients, I am a firm believer in setting the story straight that I am going to do my best to do a perfect job. However, many things can go wrong. It is always best to tell patients they should have surgery when they cannot live with it anymore. The best example is an orthopedic surgeon telling patients they will “know” when they need to have the hip or knee replaced. Until then, they live with it.

In the case of doing surgery when you can’t live with it anymore, it makes the outcome better. Even if the hip or knee is a little stiff or has mild pain, the overall relative improvement is so great that the patient is thrilled. If you take a bunion deformity, for example, that really doesn’t hurt unless the foot is in a 3-inch heel, and the postoperative result leads to joint stiffness and pain even in athletic shoes, then that is a formula for a bad outcome.

The best surgeons not only have great hands and are technically proficient. They know when not to do surgery. It is a skill to read patients, understand what they want and expect from an elective reconstructive surgery. Remember, nobody ever died form even the worst bunion deformity. If you decide to do surgery on a patient who may have unrealistic expectations, then shame on you. When surgery goes bad, everyone involved loses.

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