In the first-ever study to compare surgeon and patient expectations in foot and ankle surgery, research performed at Hospital for Special Surgery (HSS) in New York City has determined that two-thirds of patients have higher presurgical expectations than their surgeons. The paper, titled "Comparison of Patients' and Surgeons' Expectations in Foot and Ankle Surgery," is available online as part of the AAOS 2020 Virtual Education Experience.
“An in-depth understanding of what factors contribute to preoperative patient expectations is especially critical in foot and ankle surgeries, as there are a wide variety of surgeries in our subspecialty, each of which comes with different expectations,” said Scott J. Ellis, MD, a foot and ankle orthopedic surgeon at HSS and author of the study.
Patient expectations of orthopaedic procedures have been demonstrated to be strongly associated with clinical outcomes and postoperative satisfaction. While efforts to quantify the difference between patient and surgeon expectations have been undertaken in spine and total knee arthroplasty, among other subspecialties, few attempts have been made to measure this in foot and ankle surgery.
In reviewing the operative schedules of seven foot and ankle surgeons at HSS, Dr. Ellis and his colleagues hypothesized that patients would have greater expectations for their outcomes than their surgeons, that there would be greater differences in preoperative expectations between patients and surgeons in major versus minor foot or ankle surgery, and that greater differences between patient and surgeon expectations would be associated with worse preoperative physical and mental health.
“Although most surgeons do their best to engage in open conversations with their patients about what they can expect from surgery, many find it difficult to tell patients that they are not going to be as good as new postoperatively,” said Dr. Ellis. “It is challenging to get patients past the belief that surgeons have a magic wand.”
Working with researchers from Weill Cornell Medicine, the HSS team examined data from 202 patients, administering a 23-item survey that assessed expectations regarding pain, physical function, shoe wear, appearance, work, social activity and psychological factors. Surgeons were given the same survey and asked how much improvement they expected their patient to gain in those areas.
In addition, patients completed Patient-Rated Outcomes Measurement Information System (PROMIS) computer adaptive tests in Physical Function, Pain Interference, Pain Intensity, Depression and Global Health prior to their procedures.
“We determined that 66.3% of patients had higher expectations than their surgeons, 21.3% had concordant expectations, and 12.4% had lower expectations,” said Dr. Ellis. “In addition, the study showed that the majority of patients who had worse preoperative PROMIS scores had higher postoperative expectations. We also found that depressed and anxious individuals had greater expectations than their surgeons, as did patients with a higher body mass index.”
Going forward, said Dr. Ellis, future research should delve into other potential factors such as medical literacy and patients’ knowledge of their condition, as well as the bond between surgeon and patient. “Ideally, we could construct a study that could follow patients out to one or two years so as to determine amongst those whose expectations were met, how they were fulfilled. In the meantime, we suggest that a preoperative educational class for foot and ankle patients would go a long way towards a rapprochement between patients and surgeons when it comes to expectations.”
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the tenth consecutive year), No. 3 in rheumatology by U.S. News & World Report (2019-2020), and named a leader in pediatric orthopedics by U.S. News & World Report “Best Children’s Hospitals” list (2019-2020). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 130 countries. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu