BOSCON 2013 ORATION

THE UNHAPPY PATIENTMY PERSPECTIVES

DR UDAY KUMARMS(ORTH),DNB(ORTH)

31ST March 2013

HAPPY PATIENTS

--ARE LOYAL

--WILL REFER OTHER PATIENTS TO YOU

--THEY GIVE YOU PROFESSIONAL SATISFACTION

--IF YOUR PATIENTS ARE HAPPY, YOU WILL BE HAPPY TOO

PLENTY OF HAPPY PATIENTS

BUT

SOME ARE UNHAPPY

5% TO 15%

A happy patient will tell two of his friends

An unhappy patient will tell the whole PLANETthrough word of mouth/internet

WHAT DO THEY DO

WHAT COULD THEY DO

They could go to ---police

--media -tv-press -internet

--consumer forum

INTERNET BLOGS

-just avoid Dr X at this hospital as he is incompetent

-Dr Y is fooling patients with false degrees— ?Mch(orth)USA

-please avoid Y hospital—WORST EXPERIENCE—20 year old equipment-uncaring nurses etc

UNHAPPY means-----sad, unlucky, depressed (webster dictionary)

first used in 14th century

Patients do not care how much you know

They ONLY want to know how much you care.

Why is the patient unhappy?

-communication gap in doctor-patientrelationship

-mismatch between expectations and reality

Unhappy with -- hospital/clinic

-- doctor

-- nursing care

-- surgical result—good/bad

--cost

-- re-surgery/rehab

“You are as strong as your weakest link”

HOSPITAL

--APPROACH ROADS POOR

--DIFFICULT TO PARK

--TOO FAR

--WOULD LIKE HOSPITALS NEAR HOME

--INEFFICIENT RECEPTION

--INSURANCE SECTION-- PILLAR TO POST

-POOR AMBIENCE

-LONG WAITING TIME

Times of India

doctor

-DOCTOR HAS

-- NO TIME TO LISTEN TO ME

-- NOT EXAMINED ME IN DETAIL

--NOT EVEN TOUCHED ME

--NOT EXPLAINED MY PROBLEM OR THE SURGERY PROPERLY

--LACK OF TRANSPARENCY ABOUTCOSTS

NURSING CARE POOR

FOOD VERY BLAND—NOT TASTY

AMBIENCE---BED NOT CLEAN

----BED BUGS

---AC NOT WORKING

---TOILET NOT CLEAN---ETC ETC

UNHAPPY FOLLOWING SURGERY

SURGERY—UNINDICATED

--INADEQUATE/IMPROPER

--ON WRONG SIDE/SITE—CATASTROPHIC

--POOR/GOOD RESULT

--POOR PHYSIOTHERAPY

--NEEDS RESURGERY FOR VARIOUS COMPLICATIONS

EXAMPLES

UNHAPPY PATIENT AFTER A BAD RESULT

UNHAPPY PATIENT AFTER A GOOD RESULT

OH MY GOD ! XRAYS

UNHAPPY PATIENT AFTER POOR SURGICAL TECHNIQUE

Disclaimer: No ill will meant to any orthopaedic surgeon

IATROGENIC DISTAL HUMERUS # FOLL I/L NAILING.

PROXIMAL PART NAIL OUTSIDE BONE

SCREWS OUTSIDE NAIL

ORIF

I/L NAILING

VOLAR BARTON’S #

ORIF

PFN

PFN RESULT

UNDISPLACED MEDIAL MALLEOLAR #

FOLLOWING ORIF

THR

ACL RECON

BILATERAL HIP FRACTURES

HEAD INJURY---I/L NAILING—NO PROXIMAL LOCKING

4 weeks later

LONG PFN

PFN

TBW ???

BIMALLEOLAR #--ORIF

LOST SCREW

ORIF HUMERUS

UNHAPPY PATIENT AFTER A BAD RESULT

RESURGERY

HAPPIER

CASE DISCUSSIONS

• 40 yr old male

• # shaft L femur mid third

• Underwent open K nailing & cerclage wiring elsewhere

• After 1 and half yrs --

CASE 1

AP LAT

1st Exchange nailing closed—I/Lnail (9mm) – 3 & 6 months later

-2nd exchangenailing (10 mm)-BG

-6 months laterBG absorbednail broken

3rd exchange nailing---broken nail and screwsVery unhappy---multiple surgeries—poor result

r

Nail removal --Orif with LCP--Bone graft

6 MONTHS LATER FINALLY UNITED

Happy patient

CASE 2

• 60 year Female, Domestic helper

• Pain Both hips few months

• Walks with walker

• Medically fit

AMP LEFT HIP

SCREW & WIRE FIXATION RIGHT HIP

NO PAIN RELIEF LEFT HIP-------AMP TO THR

THR DISLOCATED

CR LEFT HIP NO PAIN RELIEF RIGHT HIP-----SCREW/WIRES REMOVED--BIPOLAR

PATIENT PRESENTED LIKE THIS

BILATERAL LOOSER’S ZONES

AFTER MANY SURGERIES-NO PAIN RELIEF-VERY UNHAPPY

BILATERAL ADDUCTORTENDINITIS – PAIN RELIEVEDWITH SIMPLE LOCAL INJ & OSTEO-MALACIA TREATMENT---HAPPY

• Male 55Years

• RTA 2 years ago . Gr III B comminuted fracture Right Leg

• debridement-

• minimal Internal fixation+ Ex-fix, Vascularised free flap.

CASE 3

X-Ray

NON-UNION

PAINFUL

UNABLE TO WEIGHT BEAR

VERY UNHAPPY

OR+ Locked Nail+ BG+ Fibulectomy

HAPPY PATIENT

Case 4

•19 YEAR OLD MALE

•AC COMPRESSOR BLAST

•SUPERFICIAL BURNS OF BODY

•COMPOUND # BOTH BONES UPPER I/3RD RIGHT LEG

•TREATED ELSEWHERE –DEBRIDEMENT-UNILATERAL EXT FIX-SSG

ONE MONTH POST OP

UNHAPPY

AP LAT

ILIZAROV BONE TRANSPORT1 MONTH POST DISTRACTION

HAPPY

CASE 5

45 YEAR OLD MALE

UNDERWENT CEMENTLESS THR FOR OA HIP4 YEARS AGO

He dislocated his THR 3 times within 6 months---treated by CR 3 times—patient very unhappy

Open reduction and insertion of a head with a longer neckNow patient is happy

CASE 6—Neglected trauma

- 25 YEAR OLD MALE

- ROAD TRAFFIC ACCIDENT

- CLOSED INJURY TO RIGHT ANKLE

- TREATED BY A NATIVE BONE SETTER FOR 4 ½ MONTHS WITH BANDAGES

- NO NEURO-VASCULAR DEFICIT

XRAY ANKLE—AP /LAT---4 ½ MONTHS POST INJURY

CT

3D CT

ANTERIOR MEDIAL LATERAL

4 ½ MONTH OLD NEGLECTED TALAR # DISLOCATION

PAINFUL DEFORMITY

DIFFICULTY IN WALKING

Unhappy

LATERAL APPROACH OPEN REDUCTIONTRIPLE FUSION

POST OP ---1 YEAR

POST OP ---1 YEARSo far happy

UNHAPPY PATIENT INSPITE OF GOOD RESULT

75 yr old lady -3 wk old displaced osteoporotic # neck humerus.

AP LAT

ORIF with osteoporosis treated

1 year POST OP----FRACTURE UNITED---FULL ROMINSPITE OF WHICH PATIENT IS UNHAPPY--??

CASE 2

63 YEAR OLD LADY

DM/HTN/COPD

OA LEFT KNEE

HTO (L) KNEE—2004

STAPLE REMOVAL JULY 2012

POST HTO

TKR NOV 2012

PATIENT IS VERY COMFORTABLE WITH LEFT TKR

BUT IS GENERALLY UNHAPPY FOLLOWING

SURGERY DUE TO PSYCHO-SOCIAL PROBLEMS

MANAGEMENT

General Guidelines

• Give the very best medical care possible

• Respect the patient’s dignity

• Listen to the patient’s and family’s concerns

• Always be compassionate and caring

Don’t hide from unhappy patients

-Listen to the patients and they will tell you what is wrong. Lawson Smith

-Welcome the complaints. “If you’re happy with the way we treat you, tell your friends.

If you’re unhappy with the way we treat you, tell us.”

HOW TO MANAGE UNHAPPY PATIENTS

Do not run away from unhappypatients.

-see patient repeatedly

-make house calls

-refer patient to your friends for second opinion(you may have missed out something)

-take patent’s permission - discuss his problem

on internet eg. Indiaorth

Inform patients about-- limitations of surgery

Eg “If you had a hip replacement, you are not going to run a marathon next day”.

-- inform that, despite our best efforts,no treatment is without risk orcarries a 100% guarantee of success

PREOPERATIVE STAGE

--- Discuss entire procedure in detail with patient

Informed consent

-Talk in numbers and give percentages eg, ’Twenty percent of patients may need

an adjustment with this procedure.’

--- Stress the time required to heal.

POSTOPERATIVE STAGE

-- never disagree with what a patient sees is wrong

-- Remind the patient that healing takes timeeg: from 6 months to a year.

-- See the patient with increased frequency

- show that you care

- Don’t send the patient away for a month and hope that they will cool down.

DEALING WITH ANOTHER SURGEON’S UNHAPPY PATIENT

--Never say anything bad about another surgeon.

“If you see a little fire,put a little water on it,not a little gasoline.”

-- Make a friendly call to the other surgeon who did the original surgery.

Let him know you have seen the patient.

Mention that you supported his original work.

-WHEN IN TROUBLE--STAY CALM

-LISTEN TO THE PATIENT- RE-ESTABLISH RAPPORT

-KNOW YOUR LIMITS

-DON’T COMMENT ON ANOTHER DOCTOR

CONCLUSIONS---FOR UNHAPPY PATIENTS

-WHEN IN DOUBT, REFER AND TAKE HELP

-EXPLAIN LIMITATIONS OF SURGERY

-PROVIDE OPTIONS

-TREAT THE unhappy PATIENT LIKE A VIP