Setting expectations - are we making promises another professional was never meant to keep?

Introducing Dr Kofi Afari

At Phoenix Occupational Medicine, we are an accredited site for Registrar Training with RACP. and we have a number of trainees who spend time with us, learning the Occupational and Environmental Medicine ropes,. This year we are fortunate to have a different kind of trainee, Dr Kofi Afari, from the specialty of Rehabilitation Medicine.

Dr Afari’s training has seen him working with people with catastrophic illness and injuries involving inpatient rehabilitation and a lengthy recovery. For these people, the RTW journey can be a much longer one, yet the same principles of good communication ring true in both his inpatient roles as well as the work he undertakes at Phoenix with injured workers. Dr Afari has shared his reflections on expectation management, in the insightful article below.

‍

Making promises another professional was never meant to keep?

In this modern era we live in, most people go to a doctor expecting to get an answer for why they are experiencing their symptoms.

Not only is the doctor meant to have all the answers, they are also meant to produce results. Results must be in line with what the patient wants and anything outside of that might land the doctor with a scathing review on RateMD.com.

As doctors, most of us work hard to provide the best management for our patients and only suggest treatments that we think will work. An aspect of our management plans that is sometimes overlooked, is setting accurate expectations for our patients.

As a rehabilitation medicine registrar, I often encounter mismanaged expectations.

Patients are referred to rehab with interesting ideas of what they have been told they will be able to do once the program is over. They can be quite disappointed when the reality of their changed function is discussed and often say that this is quite different from what they were previously promised. Sometimes, this disappointment even hinders their recovery; since the outcomes that I am projecting are different from those of the previous specialist, they are less convinced of our knowledge and credibility as a rehabilitation specialist and less keen to participate.

‍

"[Patients] can be quite disappointed when the reality of their changed function .... is quite different from what they were previously promised."

‍

The case of an expectation mismatch

I recently reviewed a middle aged woman for inpatient rehab who had undergone a below knee amputation. I saw her on the acute ward a few days after her surgery and slowly went through the typical amputation journey – from surgery to using a prosthesis. I told her that because her stump would not be ready for a prosthesis for a while, she would ideally need inpatient rehab to learn how to transfer into a wheelchair and learn to function from it.

She was both surprised and angry upon hearing this.

Surprised because her surgeon has told her she would likely be fitted for a prosthetic in 6-8 weeks after the surgery and that she would be an inpatient until then. This is an incredibly short amount of time for a limb to be fitted for a prosthesis and with her other co-morbidities, was frankly impossible. She was angry because she had recently purchased a smaller house in anticipation of walking into it with a prosthetic leg. She yelled back at me saying her new house was not wheelchair accessible and that none of what I was telling her had been mentioned by anyone else.

"the patient was already dealing with pain and grief of losing a part of her body, so the sudden additional burden of ‘new information’ compounded her experience."

This example is less about blaming someone for providing incorrect information and more about pointing out the importance of providing true expectations, and early on in management. In this case, the patient was already dealing with pain and grief of losing a part of her body, so the sudden additional burden of ‘new information’ compounded her experience.

‍

A better way?

I think for every treatment or management plan we suggest, we should have a decent idea of the various experiences the patient should expect. We should be careful not to exaggerate or overstate the good possibilities while skimming through the difficult and often more likely one.

"We need to explain all the possible outcomes, the emotions and sensations they might experience and very importantly, what to expect from the other health professionals they are referred to. "

It is also important to have a decent understanding of the roles other health professionals play in the patient’s treatment, so we are not making promises another clinician was never meant to keep. I think as doctors we have the tendency to focus solely on the role we play and anything that isn’t our job is referred to someone else. When it comes to proper expectation management, I think we need to understand other practitioners’ limits as much as we understand our own.

How does rehab medicine parallel occ medicine?

Incorporating a multidisciplinary team in management of work related injuries and return to work plans is just as important in occupational medicine as it is in rehabilitation medicine. Occupational medicine doctors work with many other medical and surgical specialists and often have the added pressure of working with employers, lawyers and claim officers to name a few. Often, each stakeholder is focused on a different aspect of the same case and provide patients their thoughts on potential outcomes from their perspective. This can skew a patient’s expectations regarding recovery and returning to work without possibly fully understanding the whole picture.

Both rehabilitation physicians and occupation and environmental physicians, draw the all-important ‘big picture’, for the patient/worker, to see the forest through the trees, and use all the information from the various sources to provide realistic expectations.