Expectations: Put it in Writing

The quality of wound healing following surgical or aesthetic procedures depends to a large extent on the patient’s compliance with post-procedural wound care. This is especially true for large excisions, Mohs and reconstructive surgery, but is true any time that a dermatologist creates a skin wound. For this reason, most of us have post-surgical wound care handouts; I shared mine in the last edition of Practical Dermatology® magazine (available online at PracticalDermatology.com/2018/02).

Also important to the success of a surgical procedure is the surgical or treatment consultation, when certain types of post-operative/post-procedure expectations should be established. These types of conversations becomes a good barometer to judge the patient’s disposition and temperament, which in some cases may steer you away from proceding in their care. Most often, however, these conversations serve to build trust and rapport. I feel it is important to document our patient’s understanding of specific issues aside from the informed consent. We have patients sign off on specific, often sensitive matters line by line. See accompanying “Expectations” handout, as well, our “Cigarette Smoke Policy.”

Why an “Expectations POlicy”?

The pre-surgical “Expectations Policy” is distinct from the informed consent. The informed consent must be specific to the procedure in question, whether it be surgery, injections, or laser treatment. The informed consent is a legal necessity, whereby the patient agrees to undergo the procedure in question, having been made aware of the risk, benefits, alternatives, etc. The “Expectations Policy” is a simplified and general handout intended to emphasize critical aspects of healing (such as scarring) and stress to patients their critical role—and establish their partnership with their physician—in ensuring a successful outcome.

We have all patients sign a “Cigarette Smoke Policy” to increase their awareness and establish expectations about the detrimental effects of cigarette smoke on skin health and wound healing. In my experience, our most unfortunate (but to some degree avoidable) surgical outcomes (scarring, wound necrosis, and dehiscence) occur in smokers. Smoking has long been known to impair wound healing; recent research has confirmed the detrimental impact of cigarette smoking on wound healing.1,2 Patients should be counseled to discontinue smoking, as well as avoid exposure to second-hand smoke, prior to procedures and until the skin is fully healed. Ideally, the patient will quit smoking indefinitely. We give patients separate resources for this as well.

The impact of smoking on minimally-invasive procedures, such as injectable fillers or neurotoxins is likely clinically negligible, or this has not been a significant area of research. However, smoking contributes to signs of skin aging, which may have prompted the patient to seek the procedure in the first place. The consulation visit is a great opportunity to address the health as well as the aesthetic implications of smoking with these patients.

Additional Considerations

Even the most attentive patients will absorb only so much information at a given time. The informed consent, which outlines all possible outcomes of a surgical or aesthetic procedure, can be lengthy and overwhelming. Therefore, it is helpful to highlight key considerations, including the risk for scarring, asymmetry, and infection, on the Expectations Policy. These issues are, in my experience, some of the most relevant to patient concerns during the post-operative period.

Always Improving

A final important aspect of the form is that it explicitly asks patients to inform us how we can improve. This builds upon a standard of service that we establish for the practice on multiple levels, and it acknowledges to patients that they are partners with us in ensuring their success.

Patients who perceive their physician (or other health care professional) is genuinely interested not only in providing optimal care, but also an optimized experience, will have more trust in and communicate more freely with that physician or professional, as well as the medical staff. Finally, in today’s Internet culture, a patient who is invited to provide live feedback may bring the (hopefully rare) concern directly to us so that we can address it, rather than post negative comments on a public-facing review site.

1. Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012 Jun;255(6):1069-79.

2. Avishai E, Yeghiazaryan K, Golubnitschaja O. Impaired wound healing: facts and hypotheses for multi-professional considerations in predictive, preventive and personalised medicine. EPMA J. 2017 Mar 3;8(1):23-33.

Form courtesy of Adam M. Rotunda, MD. Download a PDF version at PracticalDermatology.com/2018/03