PATIENT PREFERENCES / SATISFACTION 9/24/2016. Marta Van Beek 1. I m always conflicted.but I have no conflicts

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1 Missouri Dermatological Society Surgical Reconstruction: Integrating Patient Preferences Marta J. Van Beek, MD, MPH C. William Hanke Associate Professorship in Dermatologic Surgery Director, Division of Dermatologic Surgery & Cutaneous Oncology Chief of Staff University of Iowa I m always conflicted.but I have no conflicts The content of this presentation does not relate to any product of a commercial interest; therefore, there are no relevant financial relationships to disclose. PATIENT PREFERENCES / SATISFACTION Correlates with provider satisfaction Correlates with patient compliance Correlates with provider / patient trust The Good The Ugly The Bad Is published in the public domain Ultimately will determine your level of payment Attribution may or may not be correct Marta Van Beek 1

2 PATIENT SATISFACTION & PROFESSIONALISM Professionalism* = putting the patient first Studies identifying behaviors in providers with high satisfaction have shown the obvious: Sincerity Not rushed Taking time to LISTEN Integrate patient s social factors into treatment plan *Kenneth Arrow, the Nobel Prize winning economist, and Talcott Parsons, a leading sociologist, independently defined physician professionalism and reiterated its vital nature to patients and society. PATIENT SATISFACTION & PROFESSIONALISM *&%$#@!!! Professionalism* = putting the patient first Studies identifying behaviors in providers with high satisfaction have shown the obvious: Sincerity Not rushed Taking time to LISTEN Integrate patient s social factors into treatment plan *Kenneth Arrow, the Nobel Prize winning economist, and Talcott Parsons, a leading sociologist, independently defined physician professionalism and reiterated its vital nature o patients and society. PATIENT SATISFACTION & PROFESSIONALISM Professionalism* HOW AM I SUPPOSED = putting TO DO THIS? the patient first With an EMR? Studies identifying behaviors in providers with Standardized scheduling templates? high satisfaction have shown the obvious: Under pressures to see new patients? Sincerity Not rushed With impossible prior authorization requirements? Taking time to LISTEN No transparency in drug costs? Integrate patient s social factors into treatment plan *Kenneth Arrow, the Nobel Prize winning economist, and Talcott Parsons, a leading sociologist, independently defined physician professionalism and reiterated its vital nature o patients and society. Marta Van Beek 2

3 ..PROVEN TACTICS Real time data / feedback Patient engagement in treatment plan Makes patient feel part of the team Patient-Centered care / decision-making Don t punt to someone else unless it really isn t your job Get er done mentality Don t be the wall treat the patient on the same day 1. Maatouk Bürmann, et al. Improving patient centered communication: Results of a randomized controlled trial. Patient Education and Counseling. Volume 99, Issue 1, January 2016, Pages Indovina, et al. (2016), Real time patient experience surveys of hospitalized medical patients. J. Hosp. Med.. doi: /jhm.2533 BOTTOM LINE Patients want. respect, good communication among staff, and happy employees during their stay.. Providers want the same thing Patient Preferences Why do they matter? Patient perspective differs from yours Physical features that bother them What they can tolerate pre and post surgery Compliance Wound Care Outcome Marta Van Beek 3

4 Topics for Today What we know Pre / Intra / Post surgery Simplifying complicated repairs Decreasing time and effort for patients Putting patient preferences first Giving patients skin in the game for their surgical outcome What Do We Know? Patients like: To eat before and after surgery To have distractions such as music, friends & family To be called after their surgery for a check in Fewer visits same day surgery / evaluation Patients don t like: Pain 2 staged procedures Hafiji J, et al. Patient satisfaction with post operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience. Br J Dermatol Sep;167(3) Locke MC, et al. Assessing the Correlation Between Patient Anxiety and Satisfaction for Mohs Surgery. J Drugs Dermatol Sep 1;14(9): Fernandez, et al. Do surgeons understand what their patients want? A comparison of patients' expectations and surgeons' perceptions of these expectations as a basis for effective communication. J of Am Col Surg. September 2011 Vol 213(3), supp s122 What Do We Know? Patients like: To eat before and after surgery To have distractions such as music, friends & family To be called after their surgery for a check in Fewer visits same day surgery / evaluation Patients don t like: Pain 2 staged procedures Hafiji J, et al. Patient satisfaction with post operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience. Br J Dermatol Sep;167(3) Locke MC, et al. Assessing the Correlation Between Patient Anxiety and Satisfaction for Mohs Surgery. J Drugs Dermatol Sep 1;14(9): Fernandez, et al. Do surgeons understand what their patients want? A comparison of patients' expectations and surgeons' perceptions of these expectations as a basis for effective communication. J of Am Col Surg. September 2011 Vol 213(3), supp s122 Marta Van Beek 4

5 Same Day Surgical Evaluations Retrospective Review of: 233 patients: Different-day eval patients Same-day eval patients No significant difference in: Rate of any surgical complications (p=0.84) Delay of surgery (p=0.29) Number of patients requiring an anxiolytic prior to surgery (p=0.14) Ferguson, et al. Comparison of Same Day Pre operative Evaluation to Different Day Pre operative Evaluation for Mohs Micrographic Surgery: Outcomes & Complication Rates. ACMS 2014 Pain with Anesthesia 30 gauge needle Buffered with bicarb Room temperature Subdermal injection into fat Slow infiltration One needle piercing Strazar AR et al. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg Sep;132(3): Be the Closer Marta Van Beek 5

6 54 y.o. male with DFSP, ortho repair: plan for wound vac and free flap Tamir G et al. Three point advancement closure for skin defects. J Cutan Med Surg Oct;3(6): Marta Van Beek 6

7 Tamir G 1 et al. Three point advancement closure for skin defects. J Cutan Med Surg Oct;3(6): day suture removal 1 year post op Marta Van Beek 7

8 Be the Closer Patients return to normal activity more quickly Many large wounds have more laxity than you expect Free flaps replace volume; sometimes volume doesn t need replacing Mercedes flap takes advantage of 3 vectors of tension 70 y.o. female with moderate differentiated SCC biopsied as an inpatient Marta Van Beek 8

9 Bilateral advancement flap Marta Van Beek 9

10 Be the Closer Algorithmic reconstruction would have called for an Abbe flap No general anesthesia Always consider dentures and hearing aids 1.Clear the cancer 2.Conserve the function 3.Make it look good 52 y.o. female well differentiated SCC; turned away by 3 surgeons because she smokes; languished for >8 weeks Marta Van Beek 10

11 Bilateral advancement; cheek interpolation Bilateral advancement; cheek interpolation Marta Van Beek 11

12 3 week take down 1 week suture removal Marta Van Beek 12

13 Be the Closer Your role is to educate the patient If she smokes, she needs to know the risks Necrosis / flap failure Bad cosmetic outcome You can proceed knowing the risks If patient accepts the risks Make it Better Than it Was 55 y.o. with SCC with PNI excised by local derm with + margins Marta Van Beek 13

14 Lip rotation; cheek interpolation Marta Van Beek 14

15 2 week take down 7 day suture removal Before After Marta Van Beek 15

16 2 Staged Procedures: Avoiding the Reconstruction Hammer 52 y.o. man with infiltrative BCC ; wears glasses 52 y.o. man with infiltrative BCC ; wears glasses Marta Van Beek 16

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19 Dorsal Nasal / Reiger / Rotation Flap Bitgood, et al. Arch Facial Plast Surg. 2007;9(5): Dorsal Nasal Flap: Take Home Points Align alar rims symmetrically Thin distal tip & sidewall Check profile Get a bird s eye view Most of the laxity comes from bilateral medial cheeks Marta Van Beek 19

20 Dorsal Nasal Flap: Take Home Points Align alar rims symmetrically Thin distal tip & sidewall Check profile Get a bird s eye view Most of the laxity comes from bilateral medial cheeks Get er Done: Embrace the Tight Schedule 56 y.o. 2ppk/day smoker; leaving the state in 6 weeks Marta Van Beek 20

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22 Take 3 weeks Take down 7 day suture removal Marta Van Beek 22

23 Moving Day 6 weeks post op Get er Done: Embrace the Tight Schedule Substantiation of surgical delays often based on folklore Use your patient s timeline to try new things Time between take down: 2 weeks for non smokers 3 weeks for smokers Thin distal aspect of pedicle at 1 st stage to reflect thickness of recipient site Thin proximal aspects of pedicle at 2 nd stage at inset No revisions Re align eyebrow Marta Van Beek 23

24 Cheeks are Better Than Foreheads 67 y.o. biker, wears goggles 67 y.o. biker, wears goggles Marta Van Beek 24

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26 2 week take down 2 week take down Marta Van Beek 26

27 7 day suture removal 7 day suture removal 77 y.o. female, wasn t expecting any stitches Marta Van Beek 27

28 Take 2 weeks post op 7 day suture 3 weeks post op 6 weeks out Marta Van Beek 28

29 Cheeks are Better Than Foreheads Use cheek interpolations in folks who wear glasses Tell your patient how much you care about their outcome 1 Week is better than 2 Marta Van Beek 29

30 7 day suture removal Marta Van Beek 30

31 Take 1 week 7 day suture removal Marta J. Van Beek, MD, MPH Marta Van Beek 31