A 2017 study published in the Current Reviews on Musculoskeletal Medicine stated that patient education prior to joint replacement surgery has been shown to decrease anxiety, improve post-operative pain control, provide more realistic expectations of surgery, and increase the patient’s understanding of their surgery. As a result, the incorporation of preoperative education programs for elective joint replacement can lead to lower hospital length of stay, higher home discharge, lower readmission, and improved cost.1
In this article, Ari Youderian, MD shares his personal experience with preoperative patient education and provides valuable insights for fellow orthopaedic surgeons to expand their preop protocols and incorporate patient discussions of advanced technology.
Talk us through your preoperative protocols and your expectations of patients prior to surgery?
We must recognize that all patients are different in their expectations, knowledge, background, and education. To that end, I have created a multi-modal approach to my patients’ preoperative education, with a lot of reinforcing repetition.
My patients initially meet with me to discuss their condition, previous treatments, medical history, and candidacy for shoulder replacement. We review their initial imaging studies as well as the overall treatment process from preoperative to full recovery six to 12 months later. I also present an initial recommendation for either outpatient or inpatient surgery, based on their health status.
All patients attend a preoperative visit guided by my physician assistant. They review the process, day of surgery details, wound care, obtain DME, and sign paperwork. I then answer any remaining questions and obtain informed consent. We also provide and review a set of initial post-operative exercises.
Inpatient surgical patients are recommended to attend a shoulder-specific joint class provided by the hospital’s joint surgery coordinators. We have tailored and simplified the program (which I helped develop) for my shoulder patients with specific protocols and expectations. Approximately 90 percent of my patients attend these classes.
Outpatient surgical patients are linked with a nurse navigator who provides preoperative shoulder replacement education, preoperative testing, day of surgery details, and outpatient return-to-home planning. The navigator follows up with the patients after surgery via phone calls. All outpatient patients are required to participate.
My expectations for my patients are centered on understanding what their disease is and the procedure that I am planning to perform. After surgical decision making and planning is complete, the expectations shift toward preparation for surgery and, most importantly, after surgery. Setting the goals for length of stay, typically 0-1 night, is critical. Patients must understand their rehabilitation plans, post-operative medications, and prepare for any post-operative restrictions. The ultimate goal is to have them comfortable when they return home to alleviate any anxiety and eliminate any surprises.
What do you think the impact of preoperative education has been on your overall clinical outcomes?
Clinical outcomes are a combination of both patient satisfaction and physical assessment. I believe that in both of these categories preoperative education is a winner.
We know that early range of motion after shoulder replacement is most important for a successful outcome. The patients learn early on that exercises starting on post-operative day one are expected. These are taught and reviewed by my physician assistant as well as reviewed at the preoperative education class. Handouts are provided in both instances, and patients are ready to perform these from the start.
The patient satisfaction outcome scores are typically based on patient perception of post-operative pain and function. When the process is clear, the people they meet are helpful and informative, and their expectations are met or exceeded; their outcomes are mostly positive. I am confident that as the preoperative expectations are set early on and repeated often, they drive higher patient satisfaction scores.
We have minimized the hospital length of stay to under one day, as well as lessened the need for post-operative home health requirements. My findings are anecdotal at this point but in addition to these truths, we see less patients calling after surgery with questions.
Do you have any tips for explaining complex surgeries or advanced technologies to your patients in a way that’s easy to understand?
Tip #1 Keep it Simple
Promoting advanced technology doesn’t mean explaining the gritty details (unless the patient wants or asks for them). It does mean getting the points across but with simple language. For example, when I explain to patients that I like to use the ExactechGPS® shoulder preoperative planning application, I don’t say, “I am planning to use a software optimization program that incorporates your DICOM images from a computed tomography scan.” I typically say, “I plan your surgery to be more accurate2 with a computer program that lets me see your bone in 3D and figure out what size implants would be best for your shoulder.”
Tip #2 Keep an Open Dialogue
Some patients can follow what you are saying and like the details and some would rather not know them all. Ask your patients throughout the process about their level of understanding and if they are satisfied with the information that you have provided during their visit. Remember – Long, one-way lectures are rarely well-absorbed.
Tip #3 Use Visual Aids
Some patients may learn better with visual aids such as joint models, images or videos. I often use models and even compare them to the patient’s 3D reconstructions while explaining shoulder replacement. There are many aids that can be used, and I often refer them to my own website and the company website for more detailed videos and procedural guides.
What advice would you give to a new orthopaedic surgeons on first developing preoperative education plans?
Tip #1 Don’t try to reinvent the wheel. Most hospitals and surgery centers have developed some of these processes already. You can easily implement some of your own ideas and practices as well as guidelines from your training programs into these programs. New surgeons do not have to do this alone. Partnership with a hospital or surgery center can help provide the resources you need. They typically want the business and will make efforts to provide services for your patients, including joint classes and materials.
Tip #2 Spend the extra time yourself with your patient. Especially in the beginning of your practice, your patients will trust you and appreciate the extra time and effort that they might not get from other, busier surgeons. You can tailor your education efforts to be more efficient as you yourself become busier.
Tip #3 Gather appropriate brochures, handouts, or leverage corporate vendors to help provide materials for your patients to reiterate and expand upon the information you provide.
Tip #4 Continue to connect with your patients after surgery to gain feedback on the entire process. This way you can adjust your education programs or processes to maximize your patient satisfaction and clinical outcomes.
Interview conducted by Allison Downey, APR, CPRC, Exactech, Inc.
DISCLAIMER: The opinions expressed in this article are that of one surgeon. Individual results vary. With any surgery, there are potential risks and recovery times may differ depending on the patient. Exactech, as the manufacturer, does not practice medicine, and is not responsible for recommending the appropriate surgical technique for use on a particular patient. These guidelines are intended to be solely informational and each surgeon must evaluate the appropriateness of these guidelines based on his or her personal medical training and experience.
- Edwards, PK, Mears, SC, Lowry Barnes, C. Preoperative Education for Hip and Knee Replacement: Never Stop Learning. Curr Rev Musculoskelet Med 10, 356–364 (2017). doi.org/10.1007/s12178-017-9417-4
- Data on file at Exactech.