Decisions, Decisions…

by Henry C. Hsia, MD, FACS

With Breast Reconstruction Awareness Day (http://www.bra-day.com) approaching this month, a timely article appears in the October 2014 issue entitled “Helping Patients Make Choices about Breast Reconstruction: A Decision Analysis Approach” by Sun et al. The authors adapt techniques which originated in business management, and which have been increasingly applied in medical decision making, to the purpose of helping a breast cancer patient decide whether and how to undergo reconstruction.

“… a Google maps-like personalized reconstruction decision guide would be returned…”

In my practice, the initial patient visit (IPV) for a patient contemplating breast reconstruction is by far the most time-consuming type of patient encounter, often extending an hour or longer. And with the inexorable pressure to cram more patients into my office hours, I have long sought the “holy grail” of time management solutions to make these visits somehow happen more efficiently through brochures, websites, adjunct counseling by staff members… you name it. And while these measures are helpful in educating patients about breast reconstruction, in the end they haven’t significantly reduced the amount of time I spend talking to a patient, and my office staff knows never to schedule a “breast reconstruction IPV” for only 15 minutes.

Perhaps the approach offered by Sun et al will change that. Although the authors never explicitly state this, their approach, with its need for computation-intensive analysis of probabilistic outcomes and use of equations with values weighted based on individual circumstances and preferences, does lay the basic groundwork for a future computerized application where patient-specific information could be entered and a Google maps-like personalized reconstruction decision guide would be returned, telling patient and surgeon the best way to get from the present office visit to the future goal of a restored breast with a minimum of complication.

“…the initial consultation is to help the patient understand my role in her recovery and to get her to see me as not only a surgeon but also a guide for her healing process. “

Yet I spend much of the visit time not in outlining probabilities but in reassuring patients, an especially difficult task given that these patients often come in already scared and anxious, still in the process of coming to terms with the reality of their recent diagnosis. And as we go over the various alternatives for reconstruction and the potential pitfalls, it can take a great deal of effort and time to help my patient keep her anxiety level in check, while also being forthright about potential complications and managing her expectations appropriately. It’s a delicate balance, and I often find that the information I say matters much less than the manner in which I say it, as well as the patience with which I listen, often at length, to my patient’s fears and concerns.

I’ve learned over time that the most productive use of the initial consultation is to help the patient understand my role in her recovery and to get her to see me as not only a surgeon but also a guide for her healing process. I try to get her to understand that proper healing requires not just my technical proficiency but also her cooperative efforts (and that of her support network) to help her body to heal well. That my technical skills as a surgeon cannot “make” her body heal and become whole again any more than a gardener can “make” a plant grow and bloom or bear fruit. Restoring a garden ravaged by disease and drought requires not just the gardener’s technical expertise but also an effort, often collaborative, to get the environment and conditions just right to promote the proper growth. To restore a women’s body requires not just my skill but also substantial efforts on her part. And I find that getting a patient to understand and buy in to this, especially if she is already afraid and anxious, takes time. And so while I welcome efforts like Sun et al, I don’t think I’ll be telling my office staff any time soon that I will be squeezing my breast reconstruction IPV’s into a crisp 15-minute encounter.

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