This study is the first to undertake a mixed-methods analysis to explore patients’ feelings and experiences following an adverse outcome after a range of foot and ankle surgeries. It found that the majority of patients who feel that they have sustained an adverse outcome report disabling levels of persistent foot and ankle pain. Patients feel that a range of factors may have led to their adverse outcome, but these are generally directed towards the care that they received. They often regret their decision to have surgery, feel that patient-doctor communication and management of expectations could be improved, and they do not recall being provided with alternative care options.
Participants reflected that the absence, or delivery, of information presented to them during their preoperative consultation(s) had a negative impact on their postoperative recovery. They frequently referenced that the lack of continuity of care contributed to their poor outcome. Being a public-sector, teaching-hospital service, it is highly likely and inevitable that patients will see a range of clinical staff throughout their surgical journey. Furthermore, this service is high-volume and manages complex elective and trauma surgery from across the region. The introduction of decision-aid tools could help (a) standardise the patient experience, (b) engage the patient and surgical team and (c) may be especially useful for surgical disciplines, where training in the shared decision-making process may be lacking [13]. Critical communication points often recognised by the participants included the transfer of care and postoperative consultations [14]. Participants noted that verbal and written information would have been beneficial between surgeon and patient, surgeon and GP, and operative team and other health services.
The issues surrounding communication for patients may be symptomatic of the structure of the Australian public health system: The high number of patients allocated to surgical clinics results in brief consultations. There is also heterogeneity between doctors regarding their level of training and experience for managing musculoskeletal foot and ankle complaints. This situation is further compounded by the fact that foot and ankle orthopaedic patients often have symptoms for years prior to referral for surgery in the public sector, and routinely do not access allied health for the provision of non-surgical care prior to referral [15]. Patients may feel it necessary to make a rapid decision to have surgery, without fully appreciating the potential benefits and harms, as they do not want to be returned to a waiting-list. Furthermore, patients suffering with chronic pain may also prefer surgical interventions, perceiving them to be more aggressive and thus, more impactful. These patients may therefore benefit from both comprehensive triaging or screening clinics prior to their orthopaedic consultation where they could be afforded more time and education before meeting with surgeons.
The participants in our study reported that the information presented to them was often in communication poor environments, with limited time to consider their treatment options, which may have contributed to an increase in regret levels [14]. It is crucial to understand the consequences and impact of not communicating important information on the patient’s decision and feelings [14]. The readability of information sheets and the consent form is also an important aspect of care for these patients. A recent study from our unit also found that found that whilst a selection of foot and ankle procedural information sheets were below the recommended reading age (between the 6-8th grade level), the consent form was above the recommended reading age [16] – meaning that some patients may not entirely understand what they are consenting to.
Unsurprisingly, regret was prevalent in this group, especially amongst those with persistent pain. Regret is associated with future decision-making and can influence future behaviours [14]. However, during the interviews, the participants suggested that they were still open to further surgical procedure(s) as a means of solving their adverse outcomes regardless of what has occurred in the past. The willingness to undertake another operation, even despite regret on the original procedure, may reflect the impact of chronic pain has on decision-making and the desperate desire for resolution. Their confidence in surgery as a treatment option remained, but they would request more communication.
Overall, these findings are in accordance with previous research which found that patient satisfaction can be achieved if preoperative expectations have been met and satisfactory pain relief is achieved for patients undergoing lower-limb arthroplasty [17]. Moreover, modifiable factors such as communication and the provision of tailored information can increase patient satisfaction scores [18]. Interestingly, other studies have shown that patient satisfaction was independent of the rate of complications and suggested poor surgeon communication can lead to increased dissatisfaction regardless of the presence of complications [19]. Evidence elsewhere highlights the need for considering patient preferences when making the decision for surgery, such as the need for postoperative support which may lead to lower levels of regret [20]. Identifying patients more likely to report decision regret or complain of poor outcomes, preoperatively, would clearly be worthy of further study.
It is important that the results of this study be considered in light of its limitations. Firstly, it is important to note that this study has focused only on patients’ personal reflections and not on surgeons’ experiences and feelings following adverse outcomes. Views on improving communication are important throughout the entire process of operative care and by only including people who have had an adverse outcome, their reflection on the remembered events as opposed to the actual events may be clouded. Secondly, the single-centre design may have been a limitation, as patients from different hospitals networks and services may have different experiences with adverse effects from foot and ankle surgery. Thirdly, qualitative data is also subject to recall bias, where participants were asked to report on their past exposure which may be subject to omissions or external influences that may compromise the accuracy.
The study has several strengths. To our knowledge this is the first report to explore the patients’ perspective in foot and ankle orthopaedic surgery setting. The findings of this study suggest adverse outcomes following foot and ankle surgery place a heavy burden on patients, and when asked to reflect on their experiences a key theme is one of communication. How surgeons deliver this communication and obtain informed consent, especially in the public-sector where continuity with a practitioner is not guaranteed may require further thought, and may be improved through the use of digital resources [21]. The study highlights that when reflecting on their experiences, patients consider (mis)communication or misunderstanding to be a decisive factor in whether they are prepared for surgery, but even in the face of perceived inadequate communication, patients still underwent surgery. Interestingly, the conduct of the study also resulted in some participants voicing positive feelings about participating – specifically, that they were able to express their emotions about their experiences, which raised the possibility that the interview had some therapeutic effect. Future enquiry, via a clinical trial, may indeed determine if this could be an effective therapy. Collectively, the results provide evidence for the importance of effective communication throughout the operative process.
Adverse outcomes can occur following surgery, but surgical teams should look to make improvements. This study adds to a growing body of research highlighting the importance of patient-doctor communication, ensuring patients are clearly aware of what they should expect during their episode of care, and what the alternatives to surgery are. Future research could investigate the effect of implementing strategies e.g. digital consent that improve communication with patients during the preoperative period. Furthermore, surgeons and patients discuss risk (the chance of something happening) in the preoperative period but perhaps a more meaningful and enlightening area of research is to determine what an adverse outcome e.g. deep infection or non-union, or lack of improvement e.g. persistent pain, actually means to someone, and the impact it has on their life. This would enable a more meaningful discussion between surgeons and patients as they make the decision of whether they are prepared for an operation. Interestingly, no participant questioned the surgeons’ skills or technical competence, and while surgical error should always be considered, these participants focussed their attention on the care they received outside of the operating theatre. Research into how surgeons may identify and educate patients at risk of adverse outcomes following foot and ankle surgeons should be considered.
In conclusion, surgeons and patients may benefit from strategies designed to minimise time stressors, ensure they provide timely and easy to understand instructions, and present clear alternatives and advice regarding expectations. Importantly, other than the provision of more time, ways to improve the patient experience may be low- or no-cost to the health service.
