Technological advancements and media coverage on successful cases invariably contribute to higher expectations among patients. When these expectations – realistic or unrealistic – are not met, patients may feel let down. Routine identification and addressing of patients’ expectations have become an important clinical risk management strategy in preventing complaints or claims.

As an illustration, we have experienced dramatic advances in the field of minimally invasive surgery (MIS) over the last two decades. Nowadays, surgeons can remove tissues or solid organs without leaving long and ugly scars. Surgical incisions are getting fewer in number (eg, single-port laparoscopic surgery) and shorter in length (eg, needlescopic surgery); the natural orifice endoluminal surgery makes scarless operation a reality.

Although numerous scientific studies have confirmed the benefits of MIS in terms of faster recovery, less pain and even better survival in some cancer surgery when compared to conventional open surgery, there are caveats and limitations in practice. As surgeons, we understand clearly that MIS is not for everyone or every disease. The challenge is: some patients may not appreciate or fully understand this.

Expectation handling - in practice

Let’s examine the following fictional case and see how the encounter could have been improved.

Miss C, a 45-year-old lady, was referred by her family physician to see Dr L, a laparoscopic surgeon, on a Saturday morning. She presented with dyspepsia, and was found to have gallstones on ultrasound examination. Dr L was quite certain her symptoms were caused by gallstones. After physical examination, which was unremarkable, Dr L explained the diagnosis and the proposed treatment – laparoscopic cholecystectomy. Dr L said: “You probably need a laparoscopic cholecystectomy.” “That’s what my family doctor told me,” Miss C replied. “The operation will be done under general anaesthesia, and it will take 60 minutes to finish. You need to stay in the hospital for two days,” Dr L said. “There is a 5% chance that the operation cannot be done by laparoscopic means and, if that happens, I will make an incision, around eight inches long, to remove your gallbladder.”

Pausing here, Miss C frowned and then said: “Google said patients go home almost immediately after laparoscopic cholecystectomy. My family doctor told me you are the expert in this area, and that’s the reason why I am here today. How could you possibly say that you cannot finish the operation and want to cut me open? You are unprofessional. We are done here.”

Miss C left the clinic without paying any consultation fee. Six months later, it came to Dr L’s attention that Miss C has lodged a complaint against another surgeon for failing to inform her of the risk of conversion during a laparoscopic cholecystectomy.

Shaping expectations

Different patients come with different expectations. In the internet era, patients often arm themselves with all sorts of information – valid or invalid – before they come to visit their doctors. Patients are particularly vulnerable to misguided information. Inaccurate information or personal influence may become a real source of unrealistic expectations among the sick. Equally, as clinicians, we also play a part in shaping patients’ expectations.

Family physicians often play a pivotal role in shaping patients’ expectations. They are familiar with their patients’ background, disease pattern and, most importantly, beliefs. Proper patient education and counselling would usually ‘correct’ most of the misguided information or unrealistic expectations at this stage before referral to consultants.

In return, patients would generally expect their family physicians to choose the best qualified and skilled surgeons for their operations. In order to reinforce patients’ confidence, it is usually appropriate for family physicians to express an opinion on the consultants. It is not uncommon to hear comments like: “Dr L is an expert in laparoscopic surgery and, to him, laparoscopic cholecystectomy is a simple operation.”

Despite your good intention, you should be mindful when talking about colleagues to patients. When the patient equates that comment with a ‘perfect’ operation, it may create unrealistic expectations about the consultant. In this regard, in order to enhance professional interactions and minimise communication risks, it is prudent for referring family physicians to include the following additional information in the referral documents:¹

• The patient’s expressed preferences regarding treatment
• Information provided to the patient about the condition and the referral
• Special issues of concern for the patient.

As a practising surgeon, I am very grateful to colleagues who alert me about any issues and concerns raised by the patient in prior consultations. This information is very useful in addressing the patient’s expectations during my own consultations.

Let your patients talk

In Hong Kong, the Medical Council of Hong Kong stipulated in the Code of Professional Conduct that doctors should provide “proper explanation of proposed treatment and risks” to patients.² It goes without saying that a surgeon has legal and ethical duties to inform their patient of risks and benefits associated with an operation. Surgeons are trained to explain details of proposed operations candidly, and patients expect the same.

At times, this may become a daunting task when the patient is preoccupied with contradictory ideas or unrealistic expectations. Failure to uncover and address patients’ unrealistic expectations has long been identified as a significant risk for complaints or claims. In the MPS series of risk management workshops, available to members free of charge, clinicians are encouraged to routinely ask patients for their expectations, to respectfully correct patients’ unrealistic expressions, and to pay particular attention to patients who resist having their unrealistic expectation corrected.³

In practice, we must be sensitive enough in order to do this well. First and foremost, we need to establish trust. How? My strategy is to let patients talk first.

In the anecdote, it would have been easier for Dr L to uncover and address Miss C’s expectations if he had asked: “Can you please tell me how much you learned about the disease and possible treatments?” Such a generic and open-ended question would allow Miss C to tell Dr L what information, queries and concerns she had in her mind. Early patient involvement is a powerful way to build up trust, as enunciated in the shared decision-making model.⁴

Effective communication should allow a two-way dialogue between the surgeon and the patient; a one-way information delivery from the surgeon to the patient can become dogmatic and should be avoided.

Colleagues should be reminded that being able to deliver a fluent account on various risks associated with a particular treatment does not necessarily help to gauge the patient’s concerns and expectations. Failure to establish a trustworthy doctor–patient relationship and adequately address patients’ unrealistic expectations are two important precipitating factors in many medicolegal disputes that I have been involved with.

Summary

• In the era of MIS, patients have higher expectations for the outcome of their surgery
• Clinicians play an important role in shaping patients’ expectations
• Failure to identify and address patients’ unrealistic expectations could be a significant risk for complaints and claims
• Effective professional interaction would enhance early identification of patients’ unrealistic expectations
• "Let patients talk first” would be a good strategy to establish a two-way dialogue and trust between doctors and patients.

References

1. MPS Education and Risk Management, Mastering Professional Interactions Workbook, p7 (2010)
2. The Medical Council of Hong Kong, Consent to Medical Treatment, available at www.mchk.org.hk/code_section2_e.pdf (accessed 16 February 2015)
3. MPS Education and Risk Management, Mastering Your Risk Workbook, p4 (2009)
4. MPS Education and Risk Management, Mastering Shared Decision Making Workbook, p6 (2011)