Thomas S. Roukis, DPM, PhD, FACFAS
ACFAS President
Over time, I have become more aware that factors other than surgical skills frequently contribute to a patient’s outcome. These are most obvious when a patient decides to hold off on surgery and takes a “wait and see” approach, having chosen conservative care for their preferred treatment. I try to let patients have their care, like one fast-food company advertises, “your way,” and never force surgery unless problems exist that can only be treated with emergent care. I also pride myself in identifying trends in a patient’s care. I have noticed that many patients who did better than expected with conservative care had chronic conditions with most of their symptoms attributed to degenerative articular cartilage or tendon/ligamentous disruption. Many of these conditions, such as post-traumatic arthrosis of the subtalar joint, following calcaneal fracture and chronic peroneal tendon subluxation with partial tears, do not have a good natural history for the entire spectrum of care available.
Please understand that many foot and ankle conditions do benefit from surgical intervention, and I am not making light of our diagnostic skills, judgment or surgical prowess as foot and ankle surgeons. My point is that factors other than the technical performance of a specific surgical procedure can affect the patient’s outcome when the surgery itself gets the bulk of the credit. Personally, I recently developed three very severe bouts of diverticulitis over a six-month period of time, such that surgery was recommended if I failed antibiotic therapy. This process was very worrisome to me as I had never been that acutely ill or that close to a major surgery before. My subsequent colonoscopy revealed extensive diverticular disease, so the potential for further bouts of diverticulitis exists. If these bouts continue to be severe or repeated, I will have a choice between continuing conservative treatment with courses of antibiotics, knowing I could require emergent surgery or choose to undergo elective colon resection.
While permanent diet changes are in effect and I now imbibe more psyllium husk fiber than my 75-year-old father, I initially struggled with these options. After a heavy dose of personal reflection, I have come to realize that patients often seek our evaluation, desiring to obtain a clear explanation for their pain, and measures that can be taken to reduce or eliminate it while also improving their function. They want us to spend some quality time speaking with them about these matters, but equally important, for us to express interest in and understand how the condition impacts their day-to-day lives. They also want to know if their problem will get better by itself over time or if it is serious enough to warrant more immediate care. Finally, they want to know how often they should be seen to check for changes—and for us to intervene if things get worse. My general surgeon called me every day during my bouts until they subsided, showed interest in my wellbeing beyond what I expected, and provided me with enough information to make an informed decision about my future care. Because I am certain that the technical aspect of the surgery I will ultimately undergo will be sound, I fully expect to have a good outcome.
As foot and ankle surgeons, we should all continue to further our skill sets using any of the programs or publications the American College of Foot and Ankle Surgeons offers. However, by developing a trusting relationship with our patients and delivering evidence-based, cost-effective and timely care, we can all improve our patient’s outcomes.