A Need for “Best Practices”

More than 12 years ago, as we (John B. Tebbetts, Terrye Tebbetts—J.B.T., T.T.) focused on expanding and refining our patient education and informed consent practices,⁶ we adopted a “best practices” approach to help us and our personnel address specific clinical issues or problems. Problems or situations that arise rarely can often be the most challenging for patients, surgeons, and surgeons’ personnel, because patient interaction, management, and clinical “solutions” are less defined compared to everyday clinical situations and issues. We realized that when faced with an issue or a difficult clinical situation or problem, if we had carefully prospectively defined and documented a process of addressing and managing the problem, management was much easier, more refined, less costly, and more comfortable to us, our patients, and their families. Predefined management templates (decision and management algorithms) also allow surgeons to focus on more sophisticated concerns and innovative solutions instead of having to rethink an entire process each time a problem occurs.

Decision and Management Algorithm Flowcharts

As a first step to develop a “best practices” approach to managing issues and problems, we developed decision and management algorithms for specific clinical problems or issues that we have encountered over the past two decades. Developing decision and management algorithms is a stimulating and challenging process. Despite the fact that alternative approaches to every clinical problem or issue exist, a flowcharted, algorithmic approach demands a “solution” compared to a list of alternatives that stimulate endless debate. A decision algorithm flowchart is a visible template that depicts one process that has proved clinically useful and can be easily changed or adjusted when new facts or data become available. Graphically representing thought processes, decisions, and actions stimulates alternative thinking about problems or issues. A graphic algorithm flowchart helps surgeons define the sequence of decisions, and the logic of management alternatives. In addition, the process stimulates surgeons to reexamine sacrosanct “answers” and develop even better solutions.

When issues or problems occur, the patient usually speaks first with a surgeon’s personnel, and the information they receive in response to their problem, concern, or issue can have a critical impact on the patient’s comfort and confidence as the surgeon and the surgeon’s staff address the problem. Decision and management algorithms are invaluable to train personnel—not necessarily to deliver definitive answers, but to develop a basic knowledge of how we will approach problems when they arise. Consistency in decision making and management processes builds confidence in a surgeon’s personnel, and that confidence transmits directly to patients when they most need confidence to deal with issues and adversity.

Defined processes to manage issues and problems are most effective when patients are aware of how an issue or problem will be managed before the issue or problem arises. As we (J.B.T., T.T.) implemented our decision and management algorithms, we learned that their value increased exponentially when we used them to help educate our patients preoperatively about how we would manage each issue or problem postoperatively, offering them alternatives of management and an opportunity to help make sometimes difficult decisions.

Patient Education and Informed Consent

When a clinical situation or problem arises postoperatively, the more a patient knows from preoperative education about the problem, how it will be handled, who is responsible for costs, and the chances for correction, the more comfortably the patient can face the challenges. Preoperative informed consent materials and documents addressing the most common potential postoperative problems are available online from a previous publication,⁶ and are also included in the Resources folder on the DVDs that accompany this book. When a reoperation may be necessary, patients are often more stressed and face additional costs and risks compared to the primary operation. Before undertaking any reoperation procedure, detailed information and informed consent documentation are arguably more critical and more challenging compared to the primary operation. Detailed decision and management algorithms—which contain essential summary information of potential benefits and risks to help clarify the realistic choices or alternatives, and contain spaces for the patient to document her understanding and acceptance of choices at each decision making stage—are invaluable to assure optimal informed consent and guarantee the patient’s involvement in the decision making process. According to Mark Gorney, M.D., “It is the prerogative of the patient and not the physician to determine the direction in which it is believed his or her best interests lie”,⁷ emphasizing that informed consent law mandates that patients be involved in the decision making process. An integrated document that defines alternatives, provides potential risk and benefit information, and documents the patient’s choices and decisions helps surgeons assure optimal informed consent before a reoperation. More importantly, the documents can sometimes prevent unnecessary reoperations such as implant size exchange by providing patients more definitive information about the risks and tradeoffs they may incur. By demanding that the patient accept responsibility for her decisions, optimal informed consent documents sometimes encourage patients to reconsider their requests and decisions.