President's Perspective October 2014

Roukis

Unicorns and Tiger Stripes
Thomas S. Roukis, DPM, PhD, FACFAS
ACFAS President

My seven-year-old daughter believes in unicorns. Complete, unwavering, without question belief. She has created myriad drawings in vivid colored markers proving it.

I, too, see things as either black or white and have little ability to appreciate, or frankly tolerate, the gray middle ground. I need hard facts when making a decision involving patient care. I need to ask pointed questions that result in answers supported by factual data (with a cause and effect) and progress through a rationale path from one point to the next. Once I have this information, I process it, determine if additional confirmatory testing would be worth the patient’s time and finances and then present a treatment plan involving the full spectrum of conservative and surgical cares. Emphasis is placed on the likelihood of each treatment reaching the patient’s desired outcome.

The most important question I ask new patients is, “What are your expectations from me for today’s visit?” I always prepare for new patients the same way. I review all available information provided in extreme detail looking for that “ah-ha” comment in their clinic notes, operative report or imaging studies. New patients with no information are my favorite because, as I have heard, “You can learn a lot from a good history and proper physical exam.”

For second opinions and similar consultations, it can take me an hour or an entire evening to review and summarize their information prior to their appointment. Although this time is not billable, the patients universally recognize these efforts, and patient satisfaction with my care usually hovers in the low-90th percentile (based on questionnaires my employer randomly sends following office visits).

I am very critical of my patient outcomes and will apologize for the conservative or surgical cares taking longer than expected to improve their problem or for not achieving their desired expectations fully. I frontload my conversations with patients so they understand the rationale for the care plan undertaken, as well as the most common risks, complications and expected recovery course. Informing patients in this manner takes time. Pamphlets, surrogate provider dialogue and “after visit summaries” will not suffice; it must be face-to-face time.

To do this properly, I have had to limit my practice to complex foot and ankle pathology since these problems are well suited for a 30-minute, face-to-face office visit compared with general foot and ankle pathology. My inability to differentiate the appropriate time hat truly needs to be spent counseling a patient, for example, an ankle replacement versus a fifth toe arthroplasty, is completely a result of my black or white viewpoint. This has followed me from private practice, to federal government work and finally to hospital-based multispecialty salaried employment. Like a tiger, I have sharply defined stripes that cannot change.

For those in residency, fellowship or first few years of practice, do not be like me. Ask your mentors questions, attend practice management courses, keep an open mind and cater to what the patient (consumer) wants, not what is best or most convenient for you. Spend the appropriate amount of time needed to properly diagnose their problem and to develop a treatment care plan. For my contemporaries and mentors, maybe this is the place where we can share opinions, concerns and protocols via social media efforts or during local division or national educational venues the College offers. Unlike my daughter, I am not sure if unicorns exist. And maybe tigers can change their stripes. Right?

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