2. BOSCON 2013 ORATION
THE UNHAPPY PATIENT
MY PERSPECTIVES
DR UDAY KUMAR
MS(ORTH),DNB(ORTH)
31ST March 2013

3. HAPPY PATIENTS
--ARE LOYAL
--WILL REFER OTHER PATIENTS TO
YOU
--THEY GIVE YOU PROFESSIONAL
SATISFACTION
--IF YOUR PATIENTS ARE HAPPY, YOU
WILL BE HAPPY TOO

4. PLENTY OF HAPPY PATIENTS
BUT
SOME ARE UNHAPPY
5% TO 15%

5. A happy patient will tell two of his friends
An unhappy patient will tell the whole PLANET
through word of mouth/internet

6. WHAT DO THEY DO

7. WHAT COULD THEY DO
They could go to ---police
--media
-tv
-press
-internet
--consumer forum

8. INTERNET BLOGS
-just avoid Dr X at this hospital
as he is incompetent
-Dr Y is fooling patients
with false degrees— ?Mch(orth)USA
-please avoid Y hospital—WORST EXPERIENCE
—20 year old equipment
-uncaring nurses etc

9. UNHAPPY means-----sad, unlucky, depressed
(webster dictionary)
first used in 14th century
Patients do not care how much you know
They ONLY want to know how much you care.

10. Why is the patient unhappy?
-communication gap in doctor-patient
relationship
-mismatch between expectations
and reality

11. “You are as strong as your weakest link”
Unhappy with -- hospital/clinic
-- doctor
-- nursing care
-- surgical result
—good/bad
--cost
-- re-surgery/rehab

12. HOSPITAL
--APPROACH ROADS POOR
--DIFFICULT TO PARK
--TOO FAR
--WOULD LIKE HOSPITALS NEAR
HOME

13. --INEFFICIENT RECEPTION
--INSURANCE SECTION-- PILLAR TO
POST
-POOR AMBIENCE
-LONG WAITING TIME

14. Times of India

15. doctor
-DOCTOR HAS
-- NO TIME TO LISTEN TO ME
-- NOT EXAMINED ME IN DETAIL
--NOT EVEN TOUCHED ME
--NOT EXPLAINED MY PROBLEM
OR THE SURGERY PROPERLY
--LACK OF TRANSPARENCY ABOUT
COSTS

16. NURSING CARE POOR
FOOD VERY BLAND—NOT TASTY
AMBIENCE---BED NOT CLEAN
----BED BUGS
---AC NOT WORKING
---TOILET NOT CLEAN
---ETC ETC

17. UNHAPPY FOLLOWING SURGERY
SURGERY—UNINDICATED
--INADEQUATE/IMPROPER
--ON WRONG SIDE/SITE—CATASTROPHIC
--POOR/GOOD RESULT
--POOR PHYSIOTHERAPY
--NEEDS RESURGERY FOR VARIOUS
COMPLICATIONS

18. EXAMPLES
UNHAPPY PATIENT AFTER A BAD RESULT
UNHAPPY PATIENT AFTER A GOOD RESULT

19. UNHAPPY PATIENT AFTER POOR SURGICAL TECHNIQUE
OH MY GOD ! XRAYS
Disclaimer: No ill will meant to any orthopaedic surgeon

20. IATROGENIC DISTAL HUMERUS # FOLL I/L NAILING.

21. PROXIMAL PART NAIL OUTSIDE BONE
SCREWS OUTSIDE NAIL

22. ORIF

23. I/L NAILING

24. VOLAR BARTON’S #

25. ORIF

26. PFN

27. PFN RESULT

28. UNDISPLACED MEDIAL MALLEOLAR #

29. FOLLOWING ORIF

30. THR

31. ACL RECON

32. BILATERAL HIP FRACTURES

33. HEAD INJURY---I/L NAILING—NO PROXIMAL LOCKING

34. 4 weeks later

35. LONG PFN

36. PFN

37. TBW ???

38. BIMALLEOLAR #--ORIF

39. LOST SCREW

40. ORIF HUMERUS

42. CASE DISCUSSIONS
UNHAPPY PATIENT AFTER A BAD RESULT
RESURGERY
HAPPIER

43. CASE 1
• 40 yr old male
• # shaft L femur mid third
• Underwent open K nailing & cerclage wiring
elsewhere
• After 1 and half yrs --

44. AP LAT

45. 1st Exchange nailing closed—I/Lnail (9mm)
– 3 & 6 months later

46. -2nd exchange
nailing (10 mm)
-BG
-6 months later
BG absorbed
nail broken

47. 3rd exchange nailing---broken nail and screws
Very unhappy---multiple surgeries—poor result

48. r

49. Nail removal --Orif with LCP--Bone graft

50. 6 MONTHS LATER
FINALLY UNITED

51. Happy patient

52. CASE 2
• 60 year Female, Domestic helper
• Pain Both hips few months
• Walks with walker
• Medically fit

54. AMP LEFT HIP

55. SCREW & WIRE FIXATION RIGHT HIP

56. NO PAIN RELIEF LEFT HIP-------AMP TO THR

57. THR DISLOCATED

58. CR LEFT HIP
NO PAIN RELIEF RIGHT HIP-----SCREW/WIRES REMOVED--BIPOLAR

60. PATIENT PRESENTED LIKE THIS
BILATERAL LOOSER’S ZONES
AFTER MANY SURGERIES-
NO PAIN RELIEF-VERY UNHAPPY
BILATERAL ADDUCTOR
TENDINITIS – PAIN RELIEVED
WITH SIMPLE LOCAL INJ &
OSTEO-MALACIA TREATMENT
---HAPPY

61. CASE 3
• Male 55Years
• RTA 2 years ago . Gr III B comminuted
fracture Right Leg
• debridement-
• minimal Internal fixation+ Ex-fix,
Vascularised free flap.

62. X-Ray
NON-UNION
PAINFUL
UNABLE TO WEIGHT
BEAR
VERY UNHAPPY

63. OR+ Locked Nail+ BG+ Fibulectomy

64. HAPPY PATIENT

65. Case 4
•19 YEAR OLD MALE
•AC COMPRESSOR BLAST
•SUPERFICIAL BURNS OF BODY
•COMPOUND # BOTH BONES UPPER I/3RD RIGHT LEG
•TREATED ELSEWHERE –DEBRIDEMENT
-UNILATERAL EXT FIX
-SSG

66. ONE MONTH POST OP

67. UNHAPPY

68. AP LAT

69. ILIZAROV BONE TRANSPORT
1 MONTH POST DISTRACTION

70. HAPPY

71. CASE 5
45 YEAR OLD MALE
UNDERWENT CEMENTLESS THR FOR OA HIP
4 YEARS AGO

72. He dislocated his THR 3 times within 6
months---treated by CR 3 times—patient
very unhappy

73. Open reduction and insertion of a head with a longer neck
Now patient is happy

74. CASE 6—Neglected trauma
- 25 YEAR OLD MALE
- ROAD TRAFFIC ACCIDENT
- CLOSED INJURY TO RIGHT ANKLE
- TREATED BY A NATIVE BONE SETTER FOR 4 ½ MONTHS
WITH BANDAGES
- NO NEURO-VASCULAR DEFICIT

75. XRAY ANKLE—AP /LAT---4 ½ MONTHS POST INJURY

76. CT

77. 3D CT
ANTERIOR MEDIAL LATERAL

78. 4 ½ MONTH OLD NEGLECTED TALAR #
DISLOCATION
PAINFUL DEFORMITY
DIFFICULTY IN WALKING
Unhappy

79. LATERAL APPROACH
OPEN REDUCTION
TRIPLE FUSION

80. POST OP ---1 YEAR

81. POST OP ---1 YEAR
So far happy

82. UNHAPPY PATIENT INSPITE OF GOOD RESULT

83. 75 yr old lady -3 wk old displaced
osteoporotic # neck humerus.
AP LAT

84. ORIF with osteoporosis treated

85. 1 year POST OP----FRACTURE UNITED---FULL ROM
INSPITE OF WHICH PATIENT IS UNHAPPY--??

86. CASE 2
63 YEAR OLD LADY
DM/HTN/COPD
OA LEFT KNEE
HTO (L) KNEE—2004
STAPLE REMOVAL JULY 2012

87. POST HTO

88. TKR NOV 2012

89. PATIENT IS VERY COMFORTABLE WITH LEFT TKR
BUT IS GENERALLY UNHAPPY FOLLOWING
SURGERY DUE TO PSYCHO-SOCIAL PROBLEMS

90. MANAGEMENT

91. General Guidelines
• Give the very best medical care possible
• Respect the patient’s dignity
• Listen to the patient’s and family’s
concerns
• Always be compassionate and caring

92. Don’t hide from unhappy patients

93. HOW TO MANAGE UNHAPPY PATIENTS
-Listen to the patients and they will tell you what is wrong.
Lawson Smith
-Welcome the complaints.
“If you’re happy with the way we treat you, tell your
friends.
If you’re unhappy with the way we treat you, tell us.”

94. Do not run away from unhappy
patients.
-see patient repeatedly
-make house calls
-refer patient to your friends for second opinion
(you may have missed out something)
-take patent’s permission
- discuss his problem
on internet eg. Indiaorth

95. Inform patients about
-- limitations of surgery
Eg “If you had a hip replacement, you are not going to run a
marathon next day”.
-- inform that, despite our best efforts,
no treatment is without risk or
carries a 100% guarantee of
success

96. PREOPERATIVE STAGE
--- Discuss entire procedure in detail with
patient
Informed consent
-Talk in numbers and give percentages
eg, ’Twenty percent of patients may need
an adjustment with this procedure.’
--- Stress the time required to heal.

97. POSTOPERATIVE STAGE
-- never disagree with what a patient sees is wrong
-- Remind the patient that healing takes time
eg: from 6 months to a year.
-- See the patient with increased frequency
- show that you care
- Don’t send the patient away for a month and
hope that they will cool down.

98. DEALING WITH ANOTHER SURGEON’S UNHAPPY
PATIENT
--Never say anything bad about another surgeon.
“If you see a little fire,
put a little water on it,
not a little gasoline.”
-- Make a friendly call to the other surgeon who did the original
surgery.
Let him know you have seen the patient.
Mention that you supported his original work.

99. CONCLUSIONS---FOR UNHAPPY PATIENTS
-WHEN IN TROUBLE--STAY CALM
-LISTEN TO THE PATIENT- RE-ESTABLISH RAPPORT
-KNOW YOUR LIMITS
-DON’T COMMENT ON ANOTHER DOCTOR

100. -WHEN IN DOUBT, REFER AND TAKE HELP
-EXPLAIN LIMITATIONS OF SURGERY
-PROVIDE OPTIONS
-TREAT THE unhappy PATIENT LIKE A VIP