Every Patient Counts: N = 1

In today’s surgical arena, much has been said about the importance of practicing EBM, or evidence-based medicine. Evidence-based medicine incorporates science, surgeon experience, and patient satisfaction. While knowledge of science and surgeon experience are important, I find it especially critical to focus on managing patient expectations and optimizing patient satisfaction. As a clinician and surgeon in private practice, I live by the mantra that n=1. This means that every patient is unique in their subjective history, activity levels, ability to be compliant in their care, healing potential, and so on. In order to consistently meet the goal of a successful patient outcome, I think we have to pay closer attention to our patients and manage their expectations before and after surgery.

Infection is an inevitable outcome of the surgery. A former professor of Infectious Disease and current colleague Dr. Warren Joseph taught me that infection can be due to several factors, which can vary in every single patient. Again, n=1. These factors include the number of bacteria present, their virulence (how infectious an organism or disease is to your body’s immune system), and the host’s response to the infection. No two infectious organisms are exactly alike, just as no two patients and their immune responses are alike. Through the work of Charles Darwin, I’ve come to appreciate how genetic predisposition plays a major role in how our bodies respond to infection, viruses, and diseases.

In my residency, I trained under the guidance of Dr. Luke Cicchinelli, who had a major impact on my growth as a Surgeon and as a scholar who continues to ask questions in order to grasp the “bigger picture” of the healing arts. He always expressed the importance of being the best listener and continuing to compete with oneself to do more, learn more, and teach more.

I’ve learned over the years that in order to provide the best care possible, the doctor must seek to become an astute listener. I used to do more of the talking, but I have realized that if you’re patient and actively listen to the patient’s subjective findings, they will tell you their diagnosis. We demand a lot out of our patients to be compliant with our therapeutic regimen. When a patient calls to tell me they dropped their laundry basket on their surgical foot or experienced pain when he or she went for a light jog one week after bunion surgery (!!!), we become quick to blame the patient for being non-compliant and destroying our hard work. The truth is, sometimes these things will happen – sometimes it leads to a poor outcome, sometimes it doesn’t.

I think it’s our job to carefully identify our patients as either being good, fair, or poor surgical candidates. Taking that a step further, we must be asking better questions about their lifestyle, habits, stress indicators in order to have a better gauge on possible post-operative complications. Questions such as:

Do they live in a house or apartment? Do they have to climb steps to their bedroom? Who do they live with? Do they have help at home? What does a typical day during the week look like? How did they fare with any other surgeries in the past? How active are they?

If you ask careful and guided questions while patiently listening, you will get a better understanding of which patients are more fit to undergo surgery from a compliance standpoint and which need more direct coaching about their post-operative protocol.

I take great pride in teaching my patients about the anatomy and physiology of their problem. I do my best to enable them to take charge of their recovery. I give them handouts about post-operative care as a way of positively reinforcing the importance of abiding by the post-operative guidelines. Every human being is unique in its ability to heal and recover. I believe that if Physicians continue to practice the imperative Primum Non-Nocere, “First do no harm,”, and take a moment to better understand who their patients are outside of the clinical setting, we will be able to advance in medicine and surgery while also exceeding patient expectations.