Satisfied Surgeon, Depressed Patient

Dr. Jones is pleased with his work on that open tibia fracture. It was messy, but he salvaged the leg. Mrs. Smith, now hobbling down the hall, has a less positive opinion of the situation.

Dr. Robert O’Toole, Assistant Professor of Orthopaedics at the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, thinks surgeons should pay attention to this discrepancy.

Detailing the background on his work in this area, Dr. O’Toole says, “This study on patient satisfaction after lower extremity trauma emanated from the LEAP (Lower Extremity Amputation Prevention) project, work done by numerous dedicated individuals. The team, led by Dr. Michael Bosse and Ellen MacKenzie, Ph.D., looked at 463 patients treated at eight level-I centers for limb-threatening lower-extremity injuries. Along with these and other authors, we looked at the data in an attempt to answer new questions.”

Proving that research abhors a vacuum, Dr. O’Toole and his colleagues found a niche. “Using the original LEAP paper, I worked with a team that included Renan Castillo, Associate Professor at the Johns Hopkins Bloomberg School of Public Health, to examine the data comparing patient and surgeon perception of outcomes. We found wide disagreements between these two parties. For example, patients and surgeons disagreed on the cosmetic appearance of the limb. Various entities are increasingly interested in patient satisfaction, but there has been virtually no work done in this area regarding high energy, lower extremity trauma.”

The researchers then set out to determine which factors go into patients’ overall satisfaction with the outcomes of their surgeries. Dr. O’Toole: “What was the clinical picture, how was the person functioning, what was their level of physical and psychological impairment, what was their pain level…we wanted answers to all of these questions. In addition, we looked at the sociodemographic characteristics of the patient, the nature of the injury, and the treatment decisions that were made.”

With a nod to his colleagues, Dr. O’Toole notes, “The original LEAP designers had considered these questions, and pertinent information had been sitting in the database since 1994. The central idea was to examine factors related to negative outcomes. One such measure was performance on the Sickness Impact Profile (SIP) scale, which ranges from 0 to 100. A normal score is 2 or 3, whereas these patients averaged 12. The factors involved in a bad SIP score were high school level education, being poor, nonwhite, lack of insurance, Medicaid, little or no social support, and a low level of self sufficiency.”

Interestingly, ” says Dr. O’Toole, “We didn’t find that these things mattered when it came to patient satisfaction. The real issues were more along the lines of, ‘Was the person in pain?’ and ‘How fast could he or she walk?’ This was not only surprising, but encouraging because unlike the socio-demographic variables, we might actually be able to help with these outcome variables. Theoretically, we could do something about their pain whereas we couldn’t change the fact they never completed high school.

Leader or follower, emotional or rational…things of this nature were found to be inconsequential. Dr. O’Toole explains, “We looked at personality profiles, none of which had an effect on patient satisfaction. What did come into play at the two year mark was whether or not someone could return to work, and whether or not they become depressed. Overall, however, it was the physical functioning of the SIP that was relevant.”

Nothing about the injury mattered, nor did the treatment. There was quite a mixed bag of injuries so it was shocking that the injury type didn’t matter, although all of the injuries were high energy in nature. I would say that these patients are not typical. Anyone can have trauma but it has been shown that these patients seem to have a high rates of substance abuse and some atypical personality tendencies. There was something about them that was more homogenous in that way…they were predominantly low income, with not much education, evidence of more neuroses, and less ‘agreeable’ than the average patient.

The Underlying Issues

There remains a controversy about how much to emphasize patient satisfaction, says Dr. O’Toole. “Some people argue against using patient satisfaction to measure quality of care, saying, ‘Well, people are just responding to how much they like the doctor.’ Others say that using patient satisfaction as a marker of quality of care is reasonably accurate, but this might depend on the disease process and the nature of the care. For example, it might be very difficult for a patient to determine the technical competence of a surgeon. Generally speaking, patients choose a treatment facility based on satisfaction, so hospitals—and insurers—are very interested in these data.

Renan Castillo, Ph.D., who, among other things, did the data analysis for this study, likes understanding the underlying issues. He says, “What exactly is patient satisfaction measuring? Patients may not always be aware of all the clinical implications of the care they are receiving. For example, they might have unrealistic expectations or may be focused only on the acute care they received. It seems, however, that surgeons are focused on how they are doing following the injury. We actually need better measures of patient satisfaction for trauma. When you use standard measures of functional outcomes such as return to work and physical pain, you are not specifically measuring patient satisfaction.”

The divergence of surgeon and patient opinions on satisfaction is significant, says Dr. Castillo. “It seems that patients evaluate things differently and that patients consider different sort of information. For example, surgeons seemed to value return to work and complications more than patients. The surgeons were more dissatisfied with recovery than the patients if the patient did not get back to work within a given amount of time. Similarly, if there was a clinical complication, the surgeons were less satisfied, even though the patients were not. On the other hand, the patients were dramatically less likely to be satisfied than the surgeon if they were unhappy about the care they received.”

What’s Next?

Going forward, adds Dr. Castillo, the team will not only focus on research, but try to assist patients with education. “We are now looking more deeply into the discrepancies between patient and surgeon opinions. Specifically, we want to look more at pain as a predictor of satisfaction. In these studies, pain and satisfaction with care were the strongest predictors of patient satisfaction with recovery. Additionally, we are working with the Trauma Survivors Network at the University of Maryland in an effort to improve patient satisfaction. Using observations from the LEAP study, we have helped to create an online community to encourage peer support, and will soon be creating a family handbook.”

Renan Castillo concludes, “We presented these and other findings at the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association. Because there is a paucity of literature on patient satisfaction after trauma, we are hoping that our work will encourage others to get involved in this arena.”