You are just your leaving clinic after seeing a passel of postoperative follow-ups and you cannot decide what is hurting you worst. Is it the soon to be festering wound from the gluteal mastication you just took from a patient because she still has some swelling seven weeks after a complex reconstruction and she is “really irritated” because she is unable to participate in her yoga class? Or it may be the intracranial pressure building up to a near meltdown level inside your perspiring head from having to explain for the tenth time that there is nothing you can do about speeding up the time it takes for an osteotomy to heal.
Face it. The surgery part is easy. It is the postoperative care that can absolutely drain the life out of you. It is not even a handful of patients who do it to you. Maybe, it is just one or two of them. When you see their name on the schedule, the little hairs on the back of your neck start to bristle and tingle. It is maybe a couple of percent of them that account for nearly all the volumetric depletion of that corpuscle we call life. That few percent can taint the other 97 percent who have absolutely no complaints quicker than you can get the digital photo up on the monitor to show them what their foot used to look like.
After more than 25 years of operating on people, I still have not figured out how to make my “postoperative life” easier in any substantive way. The one or two difficult patients are always perpetually on the schedule. Their names are different but I really believe they are just reincarnations of the first ones you had at the beginning of practice. “John the Bunion” is now “Helen the Hammertoe” but they are the same person.
The most common traits these patients share is that they are unrealistic and can only hear what they wanted to hear prior to surgery. Foot and ankle surgery is frankly very difficult and the postoperative management is imperative to ultimate patient satisfaction and outcome. I reflect back to my first blog where I boiled down the “holy grail” of podiatric surgery into a mathematical equation (see http://bit.ly/9I3OwU  ). This equation seems to become more scientific each month I progress down that constantly changing tunnel of postoperative patient care. So this month, I decided to call in an expert, a biological psychiatrist.
Robert Williams, MD, is a biological psychiatrist who practices in Phoenix. He has helped me over the last several years with chronic pain patients and patients I have identified as having more global issues. He has generously gave me some insight via an interview for this blog so I can not only try to integrate a better way of decreasing the postoperative headaches I continually suffer but hopefully pass on his insights to my colleagues as well.
The fact of the matter is that no matter what you do, the result is only as good as what that electric flicker of neurons occurring on the cortical surface of that patient tells that patient. Remember that the cortex has all those deep little areas of neuronal dark matter pulling at it. These neuronal dark matter swim in emotion, a subconscious variable flux, with unbalanced neurotransmitters that are trying to short circuit every one of those 12 billion cortical neurons.
This is what you are fighting, my surgeon friend. That little nerve entrapment, the hammer digit, the bunion or the plantar fascia pain does not exist unless the cortex says its so. Likewise, the outcome is purely cortical, not radiographic. It is not even tied to functional improvement directly.
Also remember that human memory is extremely weak. If you do not believe that, just think back and recall that patient who had a complete forefoot reconstruction. You transformed this pterodactyl-like monstrosity into a really normal looking foot only to have the patient disgruntled because the third toe is closer to the fourth than the second toe. The patient had unrealistic expectations. When you show her the preoperative digital photo of what her foot looked like before and jog her memory — to recall that she sometimes had to cut a hole in the shoe because of the contracted overlapping digits — sometimes the patient come back to planet reality and thanks you. Often, the patient will say: “Wow, I didn’t remember how bad it was.”
Pain patients are notorious for this. They come in with pain at level 10 out of 10 and cannot walk more than five minutes. Then you render your magic to bring them down to a 3 out of 10 with the ability to walk now for two hours. What do they invariably say? “Doctor, I still have pain. The other day, when I walked at the mall for two hours, my foot really started to hurt. I do not think the surgery worked.” Really? Now you are thinking to yourself that you may have to adjust your surgical technique because if you did the right thing surgically, certainly the patient would be ready to try out for the 4 x 400 meter Olympic relay team.
How do you combat this lack of patient memory and reality? After my discussion with my biological psychiatrist friend and colleague, I have only some integral insight. (Dr. Williams needs to teach me much more and I know there are some absolute rock solid nuggets still tucked away in his cranial vault.) Take digital photos, document the patients’ level of function, ask what patients do at work, determine their depression level and assess what they want their outcome to be.
I am convinced that the best surgeons in any specialty — or at least those with the lowest level of postoperative surgeon stress syndrome (POSSS) — could be Las Vegas oddsmakers. In reality, the best surgeons will likely have the most stress, simply because of their skill level, which allows them to take the hardest, most difficult cases. This is certainly true in neurosurgery. Their best surgeons have the lowest level of successful outcomes. Interestingly, as Dr. Williams told me: “Although neurosurgery has the highest percent of malpractice suits, there is a low percentage payout. Social attitudes play a part in neurosurgery. The neurosurgeon is there to help the ‘underdog’ and many cases are ‘hopeless,’ thus expectations are low.”
So how can you “game” the system in your favor to decrease your susceptibility to POSSS? Consider the following ideas.
Find out what the patients do for employment. If they work, are they happy at work? Do they own their own business? Do they demonstrate a real passion for what they do? Folks who are managers or own their own business tend to have other things on their minds rather than focusing incessantly and obsessing on normal postoperative symptoms such as swelling or normal post-op pain.
Implement the use of the PHQ-9. What is the PHQ-9, you may ask? It is a nine-point questionnaire, which is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV). This helps clinicians determine if a patient is depressed. We have been using this questionnaire for many years now. I am not ready to say that we have benefitted from it to the level I know we can, only because of not knowing how best to implement the tool. Are patients depressed? Well, they often are depressed because they have a foot problem that is altering their lifestyle or creating pain. When we do see someone with a score that shows significant depression, I refer the patient to Dr. Williams for psychiatric evaluation. This is the time to get the patient plugged in so the big nerve can better able understand what the little pedal ones are telling it.
Digital photos. If you are doing any type of reconstruction, take a lot of photos and import them into the electronic medical records. Show the post-op patient the photos at every visit and they will then have a better reference point in how they really were and where they are today.
Ask patients what they want. Buzzwords or phrases that are surgeon buzzkills include: “pretty,” “better looking,” “smaller,” “shorter,” “straighter,” “can fit into shoes with higher heels,” etc. You get it. When they say “relief of pain,” smile and nod, thinking to yourself that you may actually have a “keeper” here.
Document a level of function. How long could patients stand, walk or play sports before surgery? Use this as a reference point when they are not happy postoperatively when they hurt after several hours at the mall.
Preoperative education. Educate, educate and then do it some more. Get them a proper belief system. Dr. Williams told me that the more you can get patients to have a belief system that will help them postoperatively, the better off they are for following a treatment plan and that means less POSSS for you.
I want to thank Dr. Williams, our biological psychiatrist, for starting me off on a better path to decrease my post-op stress. If you add a psychiatrist to your posse, you will see the benefit that I have. Dr. Williams has greatly helped several patients whom I never would have operated on without his help. Those patients, believe it or not, have not caused any bristling or tingling of neck hair, and have had great outcomes.
Remember though, the best surgery you ever perform may be the one you do not perform.