David G. Armstrong, DPM, MSc, PhD
Professor of Surgery
Chair of Research and Assistant Dean
Dr. William M. Scholl College of Podiatric Medicine at
Rosalind Franklin University of Medicine and Science
Director, Center for Lower Extremity Ambulatory Research (CLEAR) at
Rosalind Franklin University of Medicine and Science

I have had the pleasure and honor of participating in the education of quite a number of students, residents, and fellows in my career. I am quite sure that most might remember me telling them this-- repeatedly. It is perhaps one of my most frequent "doorside chats" on the hospital floor, often outside the door to the patient's room.

One of my good friends and mentors, Larry Harkless, often tells pupils under his charge that most problems with interpersonal relationships arise from an "ambiguity of expectations." When your expectations are different than your patient's, he is fond of saying, then you're in for a world of trouble. While I certainly subscribe to this philosophy, I would suggest that doctor-patient communication is even more subtle than that.

I believe that a clinician's ability to communicate is, frankly, just as (if not more) important than any other single skill he or she has-- in or out of the operating room. When the clinician communicates with the patient, he or she should always be trying to "move forward". In other words, the patient should be prepared for an eventuality that may be far less positive than what the clinician expects. In that manner, the clinician retains a partner in care both when the expected-- and the unexpected-- occur.

A good example is the art of the surgical consent before a debridement or amputation. I am amazed and disappointed to see how poorly some clinicians communicate this most frightening event to their "partners" on the other side of the therapeutic aisle. The patient is often at his or her most fragile at this point, and will cling on to any glimmer of hope that is communicated to him or her. It is at this time that the most common error in therapy is made.

If, let us suppose, the surgeon expects to perform a single ray amputation on the patient, I would suggest that he or she should not approach the patient (almost apologetically) saying "Ms. Jones, I am sorry. We're going to try to take this toe off today...but that's all we're gonna try to do."

While this result may come to pass-- and the surgeon may resect just a toe, he or she is now (figuratively if not legally) bound by that pledge-- no matter what the actual consent says and no matter what the findings are intraoperatively and no matter what happens to that patient in the postoperative period. If something occurs that is unexpected-- and it will, from time to time, that clinician will be compelled to "backpedal". This is a horrible place to be clinically, because it effectively emasculates the clinician, making him or her ineffective from that point forward.

A very simple approach from the beginning can effectively mitigate this problem. Let us call this approach #2:

"Ms. Jones, you have a very severe infection in your foot. While I am happy you came in when you did, it is still pretty far along. Our goal is to keep your leg on and get you out of the hospital as soon as possible. While I don't know if we will be successful, we will do our best. Now, this is going to be a long road-- and it's a two way street-- and you and I and the whole team will have to work together."

Now, with approach #2, one is in much better position to be potentially effective no matter the initial result. If the outcome is expected, then both doctor and patient are able to move forward. If, though, let us say, the patient has a transmetatarsal amputation at the first or subsequent surgical settings, then the therapeutic partnership is still intact and can remain so for many years afterward. This is in contradistinction to the first approach, where the clinician is perceived by the patient to have failed. Furthermore, the clinician is not compelled to (as I often see) do less than he or she believes is necessary simply because of the initial doctor-patient interaction.

We used amputation/debridement as an example, but I do hope you can see that this approach can and should be applied to all therapeutic settings.

This is a philosophy that one can take beyond the operating room and clinic to life in general. If one is prepared and prepares those around him or her to any eventuality, then the path ahead is effectively cleared-- no matter where it leads.
 

Rumble Roars to a Start

We had 59 programs participate in the 1st round Scholl Edition of the Residency Challenge Tournament that concluded at 9PM last night.  Check out the challenge ladder for a full full of the results.  This round’s questions, submitted by the Scholl College of Podiatric Medicine, were apparently quite a bit more challenging than any rounds that we encountered last year.  Only 2 programs answered all 5 questions correctly (Genesys Regional Medical Center and, no surprise,  the reigning champions St. Joseph’s Hospital - Bluemound) this time. Last year, we had many programs getting perfect scores in each round.   6 programs only got 1 out of 5 questions right.    Remember that the scoring is based first on the number of correct responses and second on the time in which the response is made.  With harder questions, speed becomes less important, and accuracy becomes paramount.

Congratulations to the 38 programs moving on to Week 2.  Check out your matchups for the next round.  We'll be matching up the 4 unmatched programs before the next round.