Published: September 2021
The information in this article was correct at the time of publishing
Transitions in care are inevitable on the surgical journey, and each transition adds potential for misunderstanding or confusion. As the surgical journey progresses, breakdowns in patient-provider communication in particular increase the risk that expectations will misalign.
Inconsistent messaging about surgical care or a failure to mention certain details can confuse a patient’s understanding of what will happen during surgery or the recovery phase. Outcomes that a patient doesn’t expect—such as a large incisional scar or prolonged post-operative pain—might erode the trust between patient and physician and lead to a patient complaint or legal action.
To identify opportunities for better communication with patients, the CMPA analyzed 1,217 cases (civil legal, regulatory authority [College], and hospital matters). The cases closed between 2015 and 2019 and involved non-urgent in-hospital surgeries.1 Over one-third of the cases (461/1,217=38%) resulted in peer expert criticism2 of a physician’s communication or coordination of care. The cases highlight the importance of clarifying patient expectations and the need for reliable and consistent messaging throughout surgical care.
Strategies for improving a team’s approach to patient communication
1. Discuss expectations with the patient pre-operatively
Among the CMPA cases reviewed, the top criticism of physicians by peer experts (in 20% of cases; 242/1,217) was an inadequate informed consent discussion. This was also a frequent reason for patient complaint (in 37% of cases; 450/1,217).3 A recurring problem that peer experts identified with respect to informed consent was the surgeon not adequately discussing the possibility of relevant surgical outcomes or complications.
Case scenario: An orthopedic patient does not expect a long post-operative journey 4
A 40 year-old patient consults with an orthopedic surgeon about pain and stiffness in one shoulder. The surgeon diagnoses a rotator cuff tear and recommends physiotherapy along with an arthoscopic repair. At a later visit, the surgeon describes the benefits and material risks of the surgery and rehabilitation plan, and the patient provides consent to proceed with surgery.
During the operation, the surgeon notes that the tear is larger than expected from pre-operative imaging, and he proceeds with the repair. Multiple times in the following weeks, however, the patient reports excruciating pain and is unable to work. The surgeon recommends more physiotherapy, which results in some improvement. Months later, the debilitating pain recurs in the same shoulder, and re-imaging shows that the tear has recurred. The patient—frustrated and no longer trusting the surgeon’s ability—undergoes revision surgery by a different orthopedic surgeon, and the pain resolves quickly.
The patient files a College complaint alleging that: the initial surgery caused more pain than expected; the initial tear was never properly repaired; and the surgeon was dismissive of the patient’s ongoing pain. The College noted that the surgeon met the standard of care but expressed concerns about his communication. College reviewers could not discern what steps the surgeon had taken pre-operatively to explain the anticipated recovery, likelihood of success, and risk of recurrence, or to clarify the patient’s expectations. The College cautioned the surgeon to discuss these topics more carefully in the future and to document those discussions.
Questions about surgical delays, such as those during COVID-19?
Surgical delays, such as those due to COVID-19 restrictions, raise concerns among patients and providers. For more information, see the CMPA article, “Deferred care during the pandemic.”
Research shows that surgical patients want details of what to expect, and they want to be heard and feel cared for.5 Pre-operative visits are windows of opportunity to provide this. They are also moments for physicians to understand patients’ expectations and key aspects of their daily routine in order to inform clinical decision-making. Furthermore, some patient expectations may be unachievable, and knowing this can help physicians reframe expectations as needed.
The FIFE mnemonic6 can guide these discussions as follows:
- Feelings – What are your feelings (fears, anxiety, concerns) about your health problem? Is there anything else that concerns you?
- Ideas – What do you think is causing your health problem and how do you expect the surgery to help?
- Functioning – How does this problem affect your daily activities and what do you expect of your return to function after the surgery?
- Expectations – What are your expectations for this visit (or this procedure)?
At the end of a pre-operative visit, physicians should take reasonable steps to confirm patient understanding of the discussion and document those steps.
2. Check previous communication and confirm information with the patient and peri-operative team
In some of the CMPA cases reviewed, peer experts were critical of surgeons for not reviewing pre-operative documentation. In other cases, they were critical of surgeons, anaesthesiologists, trainees, nurses, or office staff for failing to transmit key information to other members of the team.
Case scenario: An anaesthesiologist’s clinical decision deviates from expected practice 4
A 45 year-old man consents to the surgical removal of a pilonidal cyst. On the day of surgery, an anaesthesiologist meets with the patient in hospital. She suggests that a spinal block may be a safer option than general anesthesia. By the end of the discussion, the anaesthesiologist believes the patient has verbally agreed to the spinal block.
As the team completes the surgical safety checklist, the anaesthesiologist states her intent to use a spinal (saddle) block. The surgeon replies that he typically uses general anesthesia for this type of case, but he understands her decision. An anesthesia resident attempts to administer the block without success. The anaesthesiologist takes over and successfully administers the block, and the surgery proceeds uneventfully. Later in the PACU, a nurse comments to the patient that she has never before seen a spinal block used for this type of procedure. The patient leaves the hospital hours later after recovering from the regional anesthesia.
The patient files a hospital complaint alleging that he never consented to a spinal block. He explains that the surgeon had discussed general anaesthesia at the consult visit and that nurses in the PACU had similarly expected general anaesthesia. He adds that an unknown individual made multiple attempts to administer the spinal block, which was painful, and his recovery in the PACU was long. Although the hospital committee had no concerns about the anaesthesiologist’s clinical decision-making, the hospital reviewers were critical of the quality of documentation, as well as verbal communication with the patient and within the peri-operative team.
Mixed messaging confuses patient expectations and can signal a lack of cohesiveness in the team approach, affecting patient confidence. Standardized processes—such as clinical pathways, protocols for confirming patient information, and verbal checklists—promote consistency within teams.
Family physicians in the circle of care
Integrating a family physician into post-operative care can help foster patient trust. As a surgeon, ask patients whether they have access to a family physician and, if so, include the family physician in the post-operative plan. Confirm patient understanding of the plan and who will be providing follow-up care.
- Enhanced Recovery After Surgery (ERAS) programs are evidence-based care pathways that support consistent practice and communication between members of the peri-operative team. ERAS may also lower the rate of surgical complications for some patient populations.7,8
- The briefing and time-out phases of the surgical safety checklist,9 before the first incision, are opportunities to confirm details from the informed consent discussion.
- The debriefing phase, before leaving the OR, and handover of care from the OR team are chances to communicate key information for the recovery room team. This information can include any unexpected or unusual aspects of surgery, such as the choice to use a spinal block instead of general anaesthesia in the case scenario above.
3. Have a reliable system for managing patient expectations after hospital discharge
When patients have difficulty accessing post-operative care, they may feel abandoned by the surgeon. In some of the CMPA cases reviewed, peer experts identified unreliable systems contributing to these difficulties. Their criticisms supported the following practice improvement strategies for surgeons:
- Optimize office procedures for receiving, documenting, and responding to phone calls, faxes, and referrals.
- Arrange and document a formal handover of post-operative care when you are going to be unavailable for follow-up.
- Promptly send discharge summaries and clear follow-up instructions to the health professional providing follow-up care, especially when follow-up is not with you as the initial surgeon.
The bottom line
Aligning patient-provider expectations and successfully coordinating care throughout the surgical journey benefits both patients and physicians.
- When surgery is an option, leverage the consent discussion to manage expectations. Confirm patient understanding of what to expect of surgical care, the material risks, and the anticipated recovery time. Address any misalignment in expectations and document what you discuss.
- Adopt standardized processes for peri-operative management, and engage peri-operative teams in consistent messaging and patient safety.
- Assess the approach and availability of your office and hospital systems for responding to patient concerns after hospital discharge, and take steps to ensure they are reliable.
The CMPA analysis excluded non-urgent in-hospital cosmetic surgeries and some obstetrical surgeries, such as non-urgent C-sections, given their unique communication challenges.
Peer experts refer to physicians retained by the parties in a legal action to interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. These individuals are typically of similar training and experience as the physicians whose care they are reviewing. Peer experts are also involved in reviewing complaints to regulatory authorities (Colleges) and hospitals, where committees of patient safety and risk management may have oversight.
Of the 450 CMPA cases with a patient complaint of inadequate informed consent, peer experts concurred with the concern approximately one-third of the time (154/450, 34.2%).
This case scenario is based on an actual medico-legal case. However, certain facts were omitted, changed, or added for illustrative purposes and to protect the confidentiality of the parties involved.
Webster CS, Jowsey T, Lu LM, et al. Capturing the experience of the hospital-stay journey from admission to discharge using diaries completed by patients in their own words: A qualitative study. BMJ Open. 2019 Mar 12;9(3):e027258. DOI: 10.1136/bmjopen-2018-027258
Stewart M, Belle Brown J, Wayne Weston W, et al. Patient-centered medicine: Transforming the clinical method. 3rd ed. CRC Press; 2014
Bisch SP, Jago CA, Kalogera E, et al. Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology: A systematic review and meta-analysis. Gynecol Oncol. 2021 Apr;161(1):46-55. DOI: 10.1016/j.ygyno.2020.12.035. Epub 2020 Dec 30
Arrick L, Mayson K, Hong T, et al. Enhanced recovery after surgery in colorectal surgery: Impact of protocol adherence on patient outcomes. J Clin Anesth. 2019 Aug;55:7-12. DOI: 10.1016/j.jclinane.2018.12.034. Epub 2018 Dec 21
Surgical Safety Checklist: Download [Internet]. Edmonton (CA): Healthcare Excellence Canada; [cited 2021 Mar 26]. Available from: https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/SurgicalSafety-Checklist-Resources.aspx