The Orthopaedic Forum   |    
The Doctor-Patient Partnership*
Bridget Houlihan, †
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Denver, Colorado
*Welcome Address to the Class of 2000. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons, Orlando, Florida, March 15, 2000.
†3021 South Gilpin Street, Denver, Colorado 80210. The e-mail address for Bridget Houlihan is bhou3@aol.com.

J Bone Joint Surg Am, 2000 May 01;82(5):743-743
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Smart, skilled, compassionate, confident, perceptive, honest, straightforward, and trustworthy.
These are just a few words that come to my mind when I think about what an orthopaedic surgeon should be. As a person with cerebral palsy, I am no stranger to orthopaedic surgery. When I look back at the eight surgeries I've had throughout my childhood, and when I think of those that might come my way sometime in the future, I realize that the relationships I have had with my orthopaedic surgeons have had a big impact on my overall medical care. Of course, the most important part of an orthopaedic surgeon's job is based strictly on skill and medical know-how. As surgeons, you already have the education and experience you need to help your patients deal with their physical challenges. The general public seeks and relies on your expertise. But I think there is more to being a good orthopaedic surgeon than having the ability to perform medical procedures. I think it is important to establish a partnership of sorts with your patients in order to make their medical care as effective as it can be. This partnership is based on simple things, like looking at an x-ray with your patient and explaining what you see or listening carefully to your patient's concerns and addressing them honestly. For your patients, having surgery is a big deal, not an everyday occurrence. It is essential that the lines of communication between patients and doctors are open and in good working order.
When I found out that I would be speaking with you today, I decided to talk to my family, friends, and doctors about their perceptions of the doctor-patient partnership. I'm an expert surgery patient in my own right, but there are countless aspects of orthopaedic surgery that I have never faced. So, I asked others about their surgical experiences, sewing together a colorful patchwork quilt of varying opinions to share with you.
Practicing medicine is both an art and a science, and there is a delicate balance between the two. Patients need medical care and doctors can help them, but mutual understanding through effective communication is the only way to bridge the gap that often exists between patients and their doctors. Communication is the key to the doctor-patient partnership.
The first step in the partnership is realizing that both patients and doctors have shared responsibilities in medical care. To be a good patient, I have to disclose all of the information I know about my condition to my doctor and I must be truthful. I have to give the relationship with my doctor a chance to grow. Now, sometimes that can be hard to do with a specialist I only see three or four times, but I still have the responsibility to ask questions of my surgeon, like "How many procedures like this have you done before?" and "Why do you think this procedure will work best for me?" In turn, I expect honest and thorough answers from my doctor. I want my orthopaedic surgeon to act with the highest level of professional competency and to stay on the cutting edge of the field. At the same time, I want my surgeon to admit to me if he or she doesn't know the answer to one of my questions, and then I want him or her to take the initiative to find the answer.
In pediatric orthopaedic care, it is the parents' responsibility to ask these questions of their child's surgeon. As doctors, encourage your patients and their families to ask questions. Maybe ask them to write down questions or fill out a questionnaire to help facilitate discussion during their appointment. Then, when families and patients come in to meet with you, take the time to sit down and talk with them. Try not to keep them waiting, and if you are running late have someone let them know how long you will be.
Listening has been a key part of the medical profession from the very beginning. Before medicine made the technological leaps that are evident today, one of doctors' primary roles was to listen to patients because sometimes there was little else they could do for them. I encourage you not to let technology get in the way of your listening skills. As a patient, I can tell you that it is very comforting to know that I am being heard.
I remember one time when I wish I'd been listened to a little more seriously. I was in the fourth grade and had two full-length casts on my legs with a bar in between because I had had my hamstrings and adductors lengthened and my Achilles tendon reimplanted. I was thirty-six inches from toe to toe, and I had to be turned sideways to fit through most doorways. The best part about the whole thing was that I got to sleep in my parents' queen-sized bed because I didn't fit in my own twin bed. Still, it wasn't a pleasant time for me because the suture in my heel hurt so badly. I told my doctors about it again and again, but they didn't cut the cast away to see what was putting pressure on my heel. Six weeks later, when the casts finally did come off, it turned out that the suture had eaten a hole an inch deep, and about the size of a quarter, in the bottom of my heel.
Working with children can be particularly complicated when it comes to effective communication because the entire family is involved. Sometimes parents might not follow your instructions, there may be hygiene or nutrition issues, or relatives may give conflicting medical advice. So, it is vital to interact with parents in an effective way. Oftentimes, you will have very complex information that must be understood, and you will have to figure out a way to convey it in layman's terms. Be aware of different learning styles so that you can present the information using a variety of different modes. Use written instructions, diagrams, and hand-drawn pictures for the visual learner; use 3-D models for the kinesthetic learner; and explain what you want to do as clearly as you can for the auditory learner. Do whatever it takes to get your point across. My orthopaedic surgeon says that one of the most important things he does every day is talk to people on their level. He works hard to get the family and the patient involved in decision-making.
I think it is important to master your communication skills and to identify your strengths when it comes to dealing with patients. I think it's just as important to identify your weaknesses. Do you feel awkward or uneasy around a patient? Do you have a good bedside manner? If you don't, recognize it and surround yourself with people who will enhance your practice. Your support staff can complement your weaknesses with their strengths. The hospital you are affiliated with, the nurses who take care of your patients, and the way your patients are treated before and after surgery all reflect on you. Make sure that the people who work with you represent you well. I can think of one physician's assistant, from my orthopaedic surgeon's office, whom I always looked forward to seeing. He had a gentle manner, he always told me exactly what he was doing, and he even came to visit me after surgery. I appreciated the extra time he spent with me more than I can express.
A friend of ours named Patti, whose daughter Holly has cerebral palsy and some developmental delays, agrees that an orthopaedic surgeon's support staff can do a lot to foster good communication. She said that one of Holly's orthopaedic surgeons did not always communicate with her, which made her very uncomfortable. "One doctor would always talk to my husband and not to me," she said. "Even if I asked a question, he would look right past me and address the answer to my husband." Patti said she was able to overlook this rift in communication after three surgical nurses assured her that this particular surgeon was the best in his field. Patti went on to say that the surgeon had an obvious passion for his work and made a concerted effort to communicate with Holly despite her developmental delays. She said he was extremely attentive to Holly before, during, and after surgery, which made a big difference to the entire family.
For pediatric orthopaedic surgeons in particular, I think it is important to remember that, although you must address the needs of the entire family, the child is your patient. I remember taking a tour of Children's Hospital in Denver, before I had surgery, to look at the operating room and to meet key personnel. I was told what to expect on the day of surgery, and I even got to pick out a flavor for my anesthesia. This helped to put my family and me at ease. I felt like I knew what was going to happen and that I had some control over it. I like that. Not all patients like to be in control, though. I have discovered that there is a fine line between how much patients want to feel empowered and how much they want to be taken care of. A friend of my mother would prefer not to hear the details of a surgical procedure at all. Thus, it is essential that you recognize the fullness of your patients. They are individuals with varying values and lifestyles. It helps to be aware of your patient's family, job, finances, cultural background, and mental and spiritual health. In times of emergency, this will not always be possible and the best you can hope for is to make the situation better.
From my perspective, the most important element after surgery, besides the success of the surgery itself, is pain management. I think it is what patients tend to worry about most - at least I do, and I'm very open with my surgeon about my concerns. I appreciate when my surgeon is honest about how much a certain procedure will hurt and how recovery from surgery will affect my lifestyle. I also appreciate getting the medicine I need when I need it. That can mean the difference between a good day and a bad day. An orthopaedic surgeon I know recently had his hip replaced, and he told one of his patients that he was stunned at the amount of pain involved. He said the experience would make him a more empathetic doctor.
I have to admit that, as a child who continually had surgery over a period of fifteen years, I eventually became a different kind of patient. I started out as a youngster who was eager and positive about surgery because I knew it would help me. As I got older, I recognized the pain and rehabilitation involved with surgery and it got a lot harder for me each time I had an operation. I get very nervous and nauseated before surgery, just anticipating what lies ahead. On the other hand, my experience does have its advantages. Now I know how my body reacts to different surgical situations and anesthesia, and I know how to handle them well because I've been through them before. I often find that my surgeon asks me what kind of pain management I prefer, and I feel like I play a much more active role in my preoperative and postoperative care.
Both doctor and patient must learn to have a good sense of humor. Although a surgeon should never make light of surgery's risks, I have found that a shared laugh always makes things run a little more smoothly. For example, my surgeon and I made a bet whether or not the wire he had put in my knee during one surgery had broken like we planned. I thought it had. After he took the wire out, the first thing I heard when I woke up in recovery was that I had won the bet. My surgeon even took the time to put a special purple cast with a pink heart on my foot once. Granted, these are things you would do for a child, but regardless of whether you are operating on children or adults it's the small kindnesses that matter the most.
In a world where communication technology is growing, more and more medical information is available to patients. They can access information about doctors and surgical procedures from their desktop computers. Some patients are even shopping for doctors on the Internet. I think you should be aware of what is on the Internet so you can address the information your patients collect and not feel threatened by it. Patients and doctors can work together to gather information, giving patients a chance to actively participate in their own care.
A doctor told me that people generally expect the family physician to have a good bedside manner, but a good bedside manner is not necessarily expected of the specialist that only sees a patient for a short time. As a patient who saw her orthopaedic surgeon much more often than she saw her family doctor, I would say that the doctor-patient partnership is important for all physicians. I have put my life in the hands of orthopaedic surgeons many times, and because of their hard work, their dedication, and their willingness to work with me for my own well-being, I am more physically independent today. I am so grateful for all they have done. So, what do I think an orthopaedic surgeon should be?
Smart, skilled, compassionate, confident, perceptive, honest, straightforward, and trustworthy.

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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