Setting Expectations

• I was told my vision would improve in a few days.
• It’s been three months, and I still can’t run.
• He told me it wouldn’t be painful.
• I didn’t realise how bad an iron stain would be.
• She never even looked at my wrist; didn’t even touch or feel it once to check for mobility.
• Without asking he took two photos of my back – I only realised because I heard the familiar iPhone camera sound.

Communication is the key to creating realistic expectations

Expectations are especially important with elective and private surgery. A survey found that three in four patients seeking bariatric surgery would be disappointed with long-term weight loss of 20% and two-thirds would be disappointed with an excess weight loss of 50%, although these levels are considered successful outcomes clinically^.1

Unrealistically high expectations have been linked to decreased patient satisfaction with spinal surgery, joint arthroplasty and plastic surgery. ^{2,3,4,5,6,7,8} Patients seeking cosmetic surgery may have underlying psychological conditions such as body dysmorphic disorder, which can prevent them ever being satisfied with a surgical outcome.

Expectations are formed by what patients have:

• experienced themselves or heard from others
• read and seen on the internet or in the mass media, including TV shows such as Grey’s Anatomy and images created with filters and AI enhancement
• seen on practice websites or social media
• heard during the consultation and consent process.

Before the consultation

Practice information

Give clear information about practice processes on the practice website, online booking system, waiting room signage and/or information sent to a new patient prior to their appointment. This is particularly important for things that may seem unusual to patients, such as:

• independent medical examinations where the traditional doctor–patient relationship does not exist
• long wait times for an appointment such as an ADHD assessment
• requirements for telehealth appointments to attract a Medicare rebate.

Advertising

Provide balanced and accurate information, and promote realistic outcomes on your website, social media and other advertising. Note that the Health Practitioner Regulation National Law prohibits advertising that is misleading or deceptive, or which creates an unreasonable expectation of beneficial treatment. Cosmetic surgery advertising has specific requirements, with one example being that single images must not be used when the use of the image is likely to give the impression that it represents the outcome of a surgery.⁹

During the consultation

Understand

Seek to understand patient expectations:

• Let patients talk and actively listen.
• Ask open questions, e.g. "What do you hope the operation will achieve?"
• Check that they’ve understood by asking questions, e.g. “From the information I’ve given today, what will you tell your family when you get home?”; “What do you think of the plan we have discussed today?”; “Is this what you thought would happen today?”

For cosmetic surgery, Medical Board guidelines¹⁰ require the patient’s expectations to be discussed to ensure they are realistic. A validated psychological screening tool must be used to screen for body dysmorphic disorder, and the process and outcome of the assessment and screening must be documented in the patient’s record.

Explain

Explain things such as why you need to do an examination and what it will involve; why tests are or aren’t necessary; what will happen if the tests are inconclusive; what the consequences will be if risks materialise; and what the patient should do if symptoms worsen. Use plain language and avoid medical jargon. Provide written information and/or use visual aids such as before-and-after photos or diagrams to illustrate potential results.

Address

Address unrealistic expectations:

• Explain what can be realistically achieved, e.g. “The pain will likely get much better, but your range of motion won’t improve enough for you to play professional basketball.”
• Explain the clinical rationale – “antibiotics don’t work for viruses”.
• Don’t be persuaded by patients who are desperate to “have something done”, especially if it’s a last resort for a longstanding problem.
• If it becomes clear that your expectations and those of your patient cannot be aligned, consider referring the patient to another practitioner.
• Ending the doctor–patient relationship is a last resort but may be necessary.

Consent for procedures

Inform patients about:

• their condition and its likely course
• alternative options for treatment, including the option of doing nothing
• what the result is likely to be, given their particular circumstances
• what the procedure involves
• the course of recovery and their role in it
• risks (general, specific and material risks)
• the consequences should one of these risks eventuate, e.g. further surgery or antibiotics
• what follow-up is involved
• the total cost, any rebates from Medicare, health funds, etc.

Use language the patient can understand and check their comprehension. Provide printed material or information on your website so patients can think about it further at home. Having patients sign a procedure-specific consent form can provide evidence of what information was provided to and discussed with the patient.

There are specific requirements which apply to consent for patients seeking cosmetic procedures.¹⁰

Informed financial consent should occur prior to a procedure or treatment being performed so that the patient knows what their out-of-pocket costs may be.

References

1. Wee CC, Hamel MB, Apovian CM et al. Expectations for weight loss and willingness to accept risk among patients seeking weight loss surgery. JAMA Surg. 2013 Mar; 148(3): 264–271.
2. McGregor AH, Hughes SP. The evaluation of the surgical management of nerve root compression in patients with low back pain. Part 2. Patient expectations and satisfaction. Spine 2002;27:1471–6; discussion 6–7
3. Iversen MD, Daltroy LH, Fossel AH, et al. The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis. Patient Educ Couns. 1998;34:169–78
4. Davidson D, Noonan VK, Dvorak MF et al. The impact of patient expectations on outcome following treatment for spinal trauma: Part 1: What are spine surgeons telling their patients? Spine. 2010;35(19):1807-1811
5. Eisler T, Svensson O, Tengstrom A & Elmstedt E. Patient expectation and satisfaction in revision total hip arthroplasty. The Journal of Arthroplasty, Volume 17, Issue 4, 457 – 462
6. Hafkamp FJ, Gosens T, de Vries J, den Oudsten BL. Do dissatisfied patients have unrealistic expectations? A systematic review and best-evidence synthesis in knee and hip arthroplasty patients. EFORT Open Rev 2020;5:226-240
7. Neuprez A, Delcour J-P, Fatemi F et al. Patients’ expectations impact their satisfaction following total hip or knee arthroplasty. PLoS ONE 11(12): e0167911
8. Avcu M & Metin M. Evaluation of the relationship between patient expectation, patient expectation coverage rates and patient satisfaction in open primary septorhinoplasty surgery: a prospective randomized study. Rhinology. 2021; 278:2337-2346.
9. Medical Board of Australia. Guidelines for registered medical practitioners who advertise cosmetic surgery. medicalboard.gov.au/codes-guidelines-policies/guidelines-for-registered-medical-practitioners-who-advertise-cosmetic-surgery.aspx
10. Medical Board of Australia. Guidelines for registered health practitioners who perform cosmetic surgery and procedures. medicalboard.gov.au/codes-guidelines-policies/cosmetic-medical-and-surgical-procedures-guidelines.aspx