Orthopedic surgeons always want to provide the best care possible for their patients, whether the patient arrives at their office with a simple ankle sprain or debilitating arthritis. When patients arrive, establishing a successful physician-patient partnership is crucial to providing the best patient experience possible, even if your office isn't the last stop on the patient's quest for care.
The following article discusses one patient's quest for care after a debilitating and complex condition known as chondrolysis that rendered her arm useless and painful, and provides guidance for key steps orthopedic surgeons can take to build a positive patient-physician partnership that leaves both parties satisfied that quality care was rendered and received during encounters.
The first surgeon she saw performed an arthroscopic procedure to secure her capsule back into place because it had stretched. However, the pain persisted and she saw a second orthopedic surgeon, this time a shoulder specialist, who performed arthroscopic anterior labral stabilization. The second surgeon discovered part of Ms. Donmyer's articular cartilage had disappeared.
Ms. Donmyer and her family then independently found Dr. Romeo, who agreed to take on her case. After a review of her diagnostic images, Dr. Romeo found cartilage loss but no Bankart, Hill Sachs lesion or vascular necrosis. Upon further arthroscopy to gauge the possibility of a cartilage transplant in the joint, Dr. Romeo discovered that Ms. Donmyer's shoulder was completely devoid of cartilage. Dr. Romeo subsequently diagnosed his patient with chondrolysis and performed a shoulder hemiarthroplasty, which relieved the symptoms and eventually allowed Ms. Donmyer to regain motion and functionality of her arm.
The cause of Ms. Donmyer's chondrolysis continues to remain ill-defined. There are many possible contributors to her condition, as highlighted in one of Dr. Romeo's recent research publications entitled "Joint Chondrolysis" which was published last month in the Journal of Bone & Joint Surgery. In that article, Dr. Romeo and his co-authors share findings from their extensive systematic literature review on over 800 reported cases of chondrolysis worldwide across multiple joints, including the shoulder. The article highlights the difficulty in the literature in isolating a single cause for chondrolysis given the present state of medical evidence. The article also discusses misdiagnosis as a problem for this condition, requiring closer attention of the orthopedic community when examining patients.
1. Make a good first impression on the patient. Making a good first impression on patients is the foundation of a positive physician-patient partnership.
"The physician-patient relationship begins in your first meeting," says Dr. Romeo. "Just as the physician will oftentimes come to a conclusion about the patients' personality and motivation in the first 30 seconds of the office visit, so are the patients coming to a conclusion about their physicians. You never get a second chance to make a good first impression."
Starting the relationship off right means treating the patient respectfully and conducting a full patient history, diagnosis and treatment plan. If during the course of this process, the surgeon realizes the problem requires more complex treatment than he or she is comfortable providing, the best option for the surgeon would be to direct the patient to another colleague with the required level of expertise.
"When a surgeon is taking care of patients, they have to have confidence in their skills and capabilities, but they need to leave their egos outside of the relationship," says Dr. Romeo. "What I mean by that is that a surgeon has to recognize potential weakness and areas where he or she may lack expertise and on the behalf of the patient and be willing to direct the patient to another individual who could provide better care."
2. Listen to the patient as a partner in the healthcare decision making process. Although surgeons are typically very busy with their medical and academic responsibilities, it's important that they spend an adequate amount of time listening to their patients in the clinic. "The real critical aspect of the patient-physician relationship is the discussion about your recommendations for care," says Dr. Romeo. "You have to be straight forward, yet compassionate."
When patients are unable to describe their problem clearly, the surgeon should keep asking questions to get at the answers needed to direct the best care possible. "When patients can't articulate their symptoms, it's important to ask the right questions to determine what the problem is," says Dr. Romeo. "Do a careful physical exam and review results from all tests before giving the patient a diagnosis. And, if you are not clear about the diagnosis, consult with other informed colleagues and make referrals if necessary."
Patients seek out physicians as authority figures in healthcare, which means they listen when the physician makes treatment recommendations. However, when patients feel like their physicians aren't making an effort to connect with them personally, they are less likely to continue seeking care from that provider or to recommend that provider to other potential patients.
"You can tell when physicians are looking at you as the injury and not as the individual, which makes me pull back and not say as much," says Ms. Donmyer. "Dr. Romeo was fully invested in my treatment and helping me return to normal. He was able to relate to me and see me as someone who was frustrated and asking for help. He came across as genuine and honest, and I felt he would do everything he could to help me."
3. Don't be afraid to refer the patient to another physician. When patients present at a surgeon's office with a complex issue that the surgeon may not be comfortable treating, it's best to refer them to another suitable colleague. For example, a general orthopedic surgeon may want to recommend the patient see a subspecialist, and a subspecialist can refer the patient to another surgeon with expertise in the condition, if necessary.
"Once you develop a relationship with the patient, you have the responsibility to provide the best medical care possible," says Dr. Romeo. "If you recognize that the patient's problem is beyond your expertise, you have the responsibility to help that patient get to a physician who has that expertise. If it's an orthopedic problem, most of us are aware of colleagues who have special interest or expertise in a variety of areas and we can make a phone call to help move that patient's care to someone who is more comfortable treating the condition."
Patients will respect a surgeon who refers them to a more focused specialist if they understand the other surgeon could give them better care. "I really appreciated when the first orthopedic surgeon referred me to a shoulder specialist because he didn't have the experience to treat me," says Ms. Donmyer.
4. Use several tools to educate the patient. Patient education is an important part of the treatment process. Patients must understand their condition so they can participate in treatment decisions, but relaying this information to someone who hasn't gone to medical school is sometimes a challenge, especially during time pressures faced by surgeons. When Ms. Donmyer visited Dr. Romeo, he used models and pictures to describe what her anatomy looked like and why she was experiencing pain. He also provided his patient with literature on the shoulder anatomy and chondrolysis so she could further understand how her body worked and what was actually happening to her.
"The more education I had about chondrolysis, the more comfortable I became with what was going on," says Ms. Donmyer. "When I walked out of my appointment with Dr. Romeo, my parents and I knew what was happening and we could discuss the different treatment options. I was able to become part of my medical care."
5. Build realistic expectations with the patient. Once a diagnosis has been made, surgeons must discuss realistic outcome expectations with their patients. "When a surgeons try to finalize the expectations for a patient, they must favor a philosophy of under promising and over delivering with respect to the final outcome," says Dr. Romeo. "Even with the most basic diagnosis, there are factors that could affect the process or final results that may be outside of the surgeon's control. We do our best to achieve the goals patients are looking for, but we can't promise or guarantee the final result before medical care is delivered."
When patients have unmet expectations, they are generally less satisfied with their surgeons and could harbor negative feelings about their healthcare experiences. However, when patients feel their surgeons are upfront about the outcome possibilities, and their recovery exceeds expectations, they tend to be far more satisfied with their surgeons and overall healthcare experience. In Ms. Donmyer's case, Dr. Romeo was cautiously optimistic about whether her treatment would ultimately prove successful given the complexities of her condition.
"By simply telling me that the final surgery wasn't a guarantee to solve my problems, I was able to understand the reality of my situation," says Ms. Donmyer.
6. Have awareness that different communication patterns exist across patients. There are a growing number of studies recognizing differences in the way male and female patients respond to prompts about their condition and how they communicate with their physicians. There is also documented difference in recommended treatment patterns for male and female orthopedic patients.
For example, in a 2008 study led by researchers in Ontario, Canada, physicians made blinded assessments of standardized patients — males and females. The patients had moderate knee pain and differed only by sex. Approximately 42 percent of the physicians recommended total knee arthroplasty to male patients but only 8 percent of the physicians recommended TKA to female patients, even though the patients were comparable in their clinical needs and in their willingness to undergo surgery. As a result of differential treatment recommendations, the study concluded that male patients would have been more likely to receive needed orthopedic treatment earlier than female patients. This type of sex-specific bias has raised heightened concern among medical and public health researchers about inequality in access to care.
"The literature informs us that in orthopedics, women are often treated only after their disease has reached more advanced stages, due mostly to lack of adequate communication between the surgeon and the patient. Differences in treatment recommendation patterns that suggest gender bias at the surgeon level have been documented by research studies in orthopedics spanning more than 15 years. The problem is not going away. We need to face it and do something to fix it," says Maryam Navaie, Dr.P.H., President and Chief Executive Officer of Advance Health Solutions, an independent research consultancy firm, based in La Jolla, Calif who co-authored the "Joint Chondrolysis" study with Dr. Romeo.
"One solution to this problem is for the surgeon to recognize the different ways in which female patients often communicate and reveal their symptoms," she says. "Female patients are more likely to be interested in shared decision-making with their surgeons while male patients are more likely to come in and tell their surgeons what they want done for them. This is not an artifact. Research has repeatedly documented differences in communication styles between female and male patients across all therapeutic disciplines including orthopedics. My hunch is that most orthopaedic surgeons, and I know many, are unaware of these differences and their implications on patient care."
One of the issues with balancing gender bias and its effects in treating patients is the demographics of orthopedic surgeons: an overwhelming majority of practicing surgeons are men. The most recent American Academy of Orthopaedic Surgeons (AAOS) demographics report from 2005 showed that less than 4 percent of orthopedic surgeons were women in 2004, and an additional 2008 AAOS report documented that less than 10 percent of orthopedic residents were women. While growth in the number of female orthopedic surgeons is slow, the problem of treating female patients remains.
"The timing for intervention is crucial to achieving optimal health outcomes in patients," says Dr. Navaie. "It's important to have a quality relationship between the patient and physician, no matter what."
7. Continue learning throughout your career so you can offer the best care to the patient. After completing a subspecialty fellowship, it's important for surgeons to stay connected with their peers and continuously learn throughout their careers. Surgeons can expand contact with other local surgeons during social and professional networking sessions, which can also lead to new learning opportunities.
"Start networking with your local peers and then take the opportunity to learn from other experts at educational meetings," says Dr. Romeo. "At our regional and national society meetings, surgeons also have a chance to exchange information. These networks create an opportunity to improve our education and gain added expertise in a complex area."
The annual professional meetings are a great way to connect with surgeons from around the country who have the ability to solve complex problems, but staying on top of new developments requires more regular engagement. Surgeons can develop a routine of reviewing professional journals and visiting cadaver labs. As with any passion, practice makes perfect.
"Unique to our specialty, orthopedic surgeons need to develop a routine of getting back into the lab or surgical skills courses so that we can actually practice the surgeries that we do to improve our abilities to tackle complex cases," says Dr. Romeo.
Related Articles on Orthopedic Surgery:
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The following article discusses one patient's quest for care after a debilitating and complex condition known as chondrolysis that rendered her arm useless and painful, and provides guidance for key steps orthopedic surgeons can take to build a positive patient-physician partnership that leaves both parties satisfied that quality care was rendered and received during encounters.
The case: shoulder chondrolysis
About seven years ago, former competitive softball player Quinn Donmyer, then 20 years old, arrived at the office of Anthony A. Romeo, M.D., head of shoulder and elbow surgery at Rush University Medical Center. He was the third orthopedic surgeon she had seen in the two years since she began feeling pain in her shoulder.The first surgeon she saw performed an arthroscopic procedure to secure her capsule back into place because it had stretched. However, the pain persisted and she saw a second orthopedic surgeon, this time a shoulder specialist, who performed arthroscopic anterior labral stabilization. The second surgeon discovered part of Ms. Donmyer's articular cartilage had disappeared.
Ms. Donmyer and her family then independently found Dr. Romeo, who agreed to take on her case. After a review of her diagnostic images, Dr. Romeo found cartilage loss but no Bankart, Hill Sachs lesion or vascular necrosis. Upon further arthroscopy to gauge the possibility of a cartilage transplant in the joint, Dr. Romeo discovered that Ms. Donmyer's shoulder was completely devoid of cartilage. Dr. Romeo subsequently diagnosed his patient with chondrolysis and performed a shoulder hemiarthroplasty, which relieved the symptoms and eventually allowed Ms. Donmyer to regain motion and functionality of her arm.
The cause of Ms. Donmyer's chondrolysis continues to remain ill-defined. There are many possible contributors to her condition, as highlighted in one of Dr. Romeo's recent research publications entitled "Joint Chondrolysis" which was published last month in the Journal of Bone & Joint Surgery. In that article, Dr. Romeo and his co-authors share findings from their extensive systematic literature review on over 800 reported cases of chondrolysis worldwide across multiple joints, including the shoulder. The article highlights the difficulty in the literature in isolating a single cause for chondrolysis given the present state of medical evidence. The article also discusses misdiagnosis as a problem for this condition, requiring closer attention of the orthopedic community when examining patients.
Improving Patient Care
Dr. Romeo and his patient share tips on how orthopedic surgeons can promote positive relationships and build a successful physician-patient partnership.1. Make a good first impression on the patient. Making a good first impression on patients is the foundation of a positive physician-patient partnership.
"The physician-patient relationship begins in your first meeting," says Dr. Romeo. "Just as the physician will oftentimes come to a conclusion about the patients' personality and motivation in the first 30 seconds of the office visit, so are the patients coming to a conclusion about their physicians. You never get a second chance to make a good first impression."
Starting the relationship off right means treating the patient respectfully and conducting a full patient history, diagnosis and treatment plan. If during the course of this process, the surgeon realizes the problem requires more complex treatment than he or she is comfortable providing, the best option for the surgeon would be to direct the patient to another colleague with the required level of expertise.
"When a surgeon is taking care of patients, they have to have confidence in their skills and capabilities, but they need to leave their egos outside of the relationship," says Dr. Romeo. "What I mean by that is that a surgeon has to recognize potential weakness and areas where he or she may lack expertise and on the behalf of the patient and be willing to direct the patient to another individual who could provide better care."
2. Listen to the patient as a partner in the healthcare decision making process. Although surgeons are typically very busy with their medical and academic responsibilities, it's important that they spend an adequate amount of time listening to their patients in the clinic. "The real critical aspect of the patient-physician relationship is the discussion about your recommendations for care," says Dr. Romeo. "You have to be straight forward, yet compassionate."
When patients are unable to describe their problem clearly, the surgeon should keep asking questions to get at the answers needed to direct the best care possible. "When patients can't articulate their symptoms, it's important to ask the right questions to determine what the problem is," says Dr. Romeo. "Do a careful physical exam and review results from all tests before giving the patient a diagnosis. And, if you are not clear about the diagnosis, consult with other informed colleagues and make referrals if necessary."
Patients seek out physicians as authority figures in healthcare, which means they listen when the physician makes treatment recommendations. However, when patients feel like their physicians aren't making an effort to connect with them personally, they are less likely to continue seeking care from that provider or to recommend that provider to other potential patients.
"You can tell when physicians are looking at you as the injury and not as the individual, which makes me pull back and not say as much," says Ms. Donmyer. "Dr. Romeo was fully invested in my treatment and helping me return to normal. He was able to relate to me and see me as someone who was frustrated and asking for help. He came across as genuine and honest, and I felt he would do everything he could to help me."
3. Don't be afraid to refer the patient to another physician. When patients present at a surgeon's office with a complex issue that the surgeon may not be comfortable treating, it's best to refer them to another suitable colleague. For example, a general orthopedic surgeon may want to recommend the patient see a subspecialist, and a subspecialist can refer the patient to another surgeon with expertise in the condition, if necessary.
"Once you develop a relationship with the patient, you have the responsibility to provide the best medical care possible," says Dr. Romeo. "If you recognize that the patient's problem is beyond your expertise, you have the responsibility to help that patient get to a physician who has that expertise. If it's an orthopedic problem, most of us are aware of colleagues who have special interest or expertise in a variety of areas and we can make a phone call to help move that patient's care to someone who is more comfortable treating the condition."
Patients will respect a surgeon who refers them to a more focused specialist if they understand the other surgeon could give them better care. "I really appreciated when the first orthopedic surgeon referred me to a shoulder specialist because he didn't have the experience to treat me," says Ms. Donmyer.
4. Use several tools to educate the patient. Patient education is an important part of the treatment process. Patients must understand their condition so they can participate in treatment decisions, but relaying this information to someone who hasn't gone to medical school is sometimes a challenge, especially during time pressures faced by surgeons. When Ms. Donmyer visited Dr. Romeo, he used models and pictures to describe what her anatomy looked like and why she was experiencing pain. He also provided his patient with literature on the shoulder anatomy and chondrolysis so she could further understand how her body worked and what was actually happening to her.
"The more education I had about chondrolysis, the more comfortable I became with what was going on," says Ms. Donmyer. "When I walked out of my appointment with Dr. Romeo, my parents and I knew what was happening and we could discuss the different treatment options. I was able to become part of my medical care."
5. Build realistic expectations with the patient. Once a diagnosis has been made, surgeons must discuss realistic outcome expectations with their patients. "When a surgeons try to finalize the expectations for a patient, they must favor a philosophy of under promising and over delivering with respect to the final outcome," says Dr. Romeo. "Even with the most basic diagnosis, there are factors that could affect the process or final results that may be outside of the surgeon's control. We do our best to achieve the goals patients are looking for, but we can't promise or guarantee the final result before medical care is delivered."
When patients have unmet expectations, they are generally less satisfied with their surgeons and could harbor negative feelings about their healthcare experiences. However, when patients feel their surgeons are upfront about the outcome possibilities, and their recovery exceeds expectations, they tend to be far more satisfied with their surgeons and overall healthcare experience. In Ms. Donmyer's case, Dr. Romeo was cautiously optimistic about whether her treatment would ultimately prove successful given the complexities of her condition.
"By simply telling me that the final surgery wasn't a guarantee to solve my problems, I was able to understand the reality of my situation," says Ms. Donmyer.
6. Have awareness that different communication patterns exist across patients. There are a growing number of studies recognizing differences in the way male and female patients respond to prompts about their condition and how they communicate with their physicians. There is also documented difference in recommended treatment patterns for male and female orthopedic patients.
For example, in a 2008 study led by researchers in Ontario, Canada, physicians made blinded assessments of standardized patients — males and females. The patients had moderate knee pain and differed only by sex. Approximately 42 percent of the physicians recommended total knee arthroplasty to male patients but only 8 percent of the physicians recommended TKA to female patients, even though the patients were comparable in their clinical needs and in their willingness to undergo surgery. As a result of differential treatment recommendations, the study concluded that male patients would have been more likely to receive needed orthopedic treatment earlier than female patients. This type of sex-specific bias has raised heightened concern among medical and public health researchers about inequality in access to care.
"The literature informs us that in orthopedics, women are often treated only after their disease has reached more advanced stages, due mostly to lack of adequate communication between the surgeon and the patient. Differences in treatment recommendation patterns that suggest gender bias at the surgeon level have been documented by research studies in orthopedics spanning more than 15 years. The problem is not going away. We need to face it and do something to fix it," says Maryam Navaie, Dr.P.H., President and Chief Executive Officer of Advance Health Solutions, an independent research consultancy firm, based in La Jolla, Calif who co-authored the "Joint Chondrolysis" study with Dr. Romeo.
"One solution to this problem is for the surgeon to recognize the different ways in which female patients often communicate and reveal their symptoms," she says. "Female patients are more likely to be interested in shared decision-making with their surgeons while male patients are more likely to come in and tell their surgeons what they want done for them. This is not an artifact. Research has repeatedly documented differences in communication styles between female and male patients across all therapeutic disciplines including orthopedics. My hunch is that most orthopaedic surgeons, and I know many, are unaware of these differences and their implications on patient care."
One of the issues with balancing gender bias and its effects in treating patients is the demographics of orthopedic surgeons: an overwhelming majority of practicing surgeons are men. The most recent American Academy of Orthopaedic Surgeons (AAOS) demographics report from 2005 showed that less than 4 percent of orthopedic surgeons were women in 2004, and an additional 2008 AAOS report documented that less than 10 percent of orthopedic residents were women. While growth in the number of female orthopedic surgeons is slow, the problem of treating female patients remains.
"The timing for intervention is crucial to achieving optimal health outcomes in patients," says Dr. Navaie. "It's important to have a quality relationship between the patient and physician, no matter what."
7. Continue learning throughout your career so you can offer the best care to the patient. After completing a subspecialty fellowship, it's important for surgeons to stay connected with their peers and continuously learn throughout their careers. Surgeons can expand contact with other local surgeons during social and professional networking sessions, which can also lead to new learning opportunities.
"Start networking with your local peers and then take the opportunity to learn from other experts at educational meetings," says Dr. Romeo. "At our regional and national society meetings, surgeons also have a chance to exchange information. These networks create an opportunity to improve our education and gain added expertise in a complex area."
The annual professional meetings are a great way to connect with surgeons from around the country who have the ability to solve complex problems, but staying on top of new developments requires more regular engagement. Surgeons can develop a routine of reviewing professional journals and visiting cadaver labs. As with any passion, practice makes perfect.
"Unique to our specialty, orthopedic surgeons need to develop a routine of getting back into the lab or surgical skills courses so that we can actually practice the surgeries that we do to improve our abilities to tackle complex cases," says Dr. Romeo.
Related Articles on Orthopedic Surgery:
35 Orthopedic & Spine Surgeons on the Move
5 Principles of Rothman Institute's Innovative Orthopedic Practice Business Model
8 Quick Tips for Better Payor Contracts at Orthopedic & Spine Centers