Patients Need to Know What to Expect
I have been sitting on this data for three years because it is not ready for prime time. This is a pilot project I did in 2016 as a proof of concept that it is possible to keep track of patients with full thickness rotator cuff tears and to separate them into two groups: 1) a cohort of people that have chosen conservative management based on a shared decision making process that includes the surgeon’s opinion that the patient is likely to achieve their desired relief of pain and restoration of function without an operation¹, and 2) a second cohort of people who have chosen to undergo rotator cuff repair.
For the first cohort, it is possible at some point that they fail conservative management and decide to undergo surgery, which is an attrition rate that is potentially predictable and verifiable — more on this later. For the surgical cohort, there is an inherent uncertainty in the expected outcome, since each and every rotator cuff repair surgery is a unique confluence of many variables.
It is for this reason that for each patient that undergoes rotator cuff surgery, I think we should be able to share with the patient our expectations for their result, including how long it will take for them to recover, what their symptoms are going to be once fully recovered, and what the likelihood is that they will achieve a successful outcome. This information is shared with the patient in their conversation about informed consent for surgery, and recorded in their presence on an automated form.
For example, I recently had a 57 year old woman who failed conservative management, and wished to consider rotator cuff repair. We filled out the questionnaire together as follows:
- Is surgical repair time sensitive? (Surgeon) yes/no/MAYBE
- Will surgical repair result in a significantly better result than conservative management? (Surgeon) YES/no/maybe
- How long will it take to fully recover from surgery? (Surgeon) 1 year
- What do we expect for a final result from surgery? (Surgeon) “Your sleep at night and the pain will daily activities will significantly improve, but your overhead strength will improve somewhat, but you will probably still have some weakness with any use of your arm above your head.”
- How does the patient rate this expected result? (Patient) Based on the expectation of the surgeon for what a reasonable surgical result will be once fully recovered, the patient rated the result as Very Good, choosing from a Likert scale of Poor, Fair, Good, Very Good, or Excellent.
- What are the chances the surgeon thinks the patient will achieve this result? (Surgeon) 75%
This may seem complicated at first glance, but my experience with it has been that patients appreciate the information, and almost all of them are able to at least follow the most important part, which is “this is what your final result will probably look like” and “if I do this same surgery on 20 people just like you, 15 of them will be very happy because they will get this result, and the other 5 people may not be so happy because … [insert conversation here about complications, reasons for poor outcomes, ways to avoid this outcome, etc.].” It may not be a perfect conversation, but in the very least it gives me the structure I need for what I believe to be a proper conversation about informed consent, and it helps me to record for the patients the details of the conversation, so when they are signing their shoulder away to me, we are actually keeping track of what they are signing up for.
I know you’re on the edge of your seat. You’re wondering “did this actually work? There is no way your predictions were correct.” To be honest, I wasn’t sure how accurate I would be, and even with these surprisingly favorable results I wonder what the numbers would look like with a larger patient population.
That being said, even if the numbers are anywhere close to this, the patients will have benefited from an honest conversation that helped them to decide whether or not to have the operation based on what the surgeon expected their result to be once they are fully recovered. The dual gifts of honesty and expert advice are what we hope to give to our patients in the office, regardless of whether or not they need our technical expertise in the operating room.
This concludes a series I started in August 2018 with Shoulder Snowflakes, even though the preliminary data above is from a consecutive series of full thickness rotator cuff tears I saw in the office in the six months from April 2016 to September 2016, with one year followups finalizing in September 2017. It took me this long to share because I have been trying to figure out a way to scale this and operationalize it, but I am realizing that this will require resources beyond my capabilities at this point in time. I hope that this is not the last thing you ever read about the Patient Expectation Database.
