26 Managing Expectations/Factitious Disorders

Randy Bindra and Luke McCarron

Abstract

As a surgeon, it is not always easy to gauge if an operative procedure has been completely understood by the patient—this can lead to a gap in patient expectations. Patients are primarily concerned about getting better and often their considerations of the final aesthetic and functional outcome are not adequately voiced or discussed preoperatively. After surgery, this can lead to disappointment for the patient, even though the surgeon considers the surgery successful. Understanding the patients’ needs and setting the expectations are critical to procedure selection and the consent process. Unmet or unrealistic expectations lead to dissent and can progress to litigation even after a seemingly minor complication. Involvement of a hand therapist in the process is advantageous.

Over the past two decades “consumer experience” has emerged as a major contributor to patient perception on their care following surgery.1 Clinicians have a dual responsibility of providing a high standard of clinical care, while also meeting the individual expectations of each patient.

Surgery to the hand is a team approach that involves the surgeon, the therapy team, and the patient. Greater postsurgery satisfaction is obtained when recovery expectations and roles of the care team are clearly defined, and then carried out to the preagreed standard.² Therefore, a detailed understanding of the patient’s individual expectations for surgery can be more predictive of patient satisfaction than the surgeon’s perceived level of success.

While not essential for every case, in complex hand deformities and in patients with comorbidities, close communication of the team including the surgeon, hand therapist, and physician and psychologist is often necessary. As part of the consent process, there should be ample opportunity to freely ask questions, identify any barriers to recovery, and identify solutions to mitigate these concerns. Strategies for managing daily activities while immobilized after surgery, such as driving, eating, and showering, must be in place prior to surgery, especially for the person living alone. Table 26‑1 provides a list of potential presurgery discussion topics for the surgeon and patient. These include, though should not be limited to, conservative treatment options, timeframes for recovery following surgery, rehabilitation stages and expectations, financial costs and time burden to the patient, expected return to work or other gainful employment, and potential complications from surgery.

Table 26.1 Surgeon and patient presurgery discussion topics

26.2 Importance of Patient Expectations with Relationship to Outcome and Unhappiness/Litigation

Patients present to a surgeon primarily for problems with pain, loss of function, or correction of deformity—patients are often reluctant to discuss the fact that they are also concerned by the appearance of the hand or finger and their ability to resume their hobbies. The primary problem, for example, pain, remains the focus of discussion and treatment, and issues like surgical scars, persistence of bony enlargement, and loss of motion are not adequately discussed. In a study of patients seeking litigation after maxillofacial surgery, medical errors were the least common cause of the discontent. The majority of complaints related to poor explanation of the proposed procedure or unrealistically high patient expectations.³

A lot of importance is paid to likely complications of surgery, but it is equally important that the preoperative discussion should include and must document: surgical scars, patient verbalization that they understand the procedure, pain management, and postoperative rehabilitation and recovery time. When treating patients with fractures and injuries, while keeping an optimistic attitude, the surgeon must be realistic about the scarring, number of operations that may be needed, expected motion, and if they would be able to return to their preoperative level of activity.

26.3 Role of the Therapist in Preoperative Counseling

Patient communication is the extent to which important information is delivered from health professional to patient, and vice versa.^4,5 In addition, the time spent with the therapist will far exceed the time spent with the surgeon, enabling more opportunity to explore rehabilitation elements using depth and detail, with time for patients to think of and ask probing questions. The therapists’ answers must be accurate, while also taking into consideration their individual role within the treatment team, and future interaction with the surgeon and other team members. The therapist is often asked to clarify surgical or rehabilitation information provided by the surgeon or other treatment team member by the patient. This is an opportunity for the therapist to demonstrate their injury, surgery, or anatomy knowledge, while reinforcing the treatment plan laid out by the surgeon. Pictorial, written, and verbal information should be utilized to ensure the patient better understands what was previously unclear. Rehabilitation goals should be discussed clearly using days or weeks as milestones for recovery.

As cost-effective patient care continues to integrate a multidisciplinary team approach, regular and meaningful surgeon-patient and therapist-patient communication interaction opportunities will increase.6

The surgeon-patient communication relationship is usually limited by time and occurs semiregularly, with increasing duration common between appointments. The surgeon possesses the injury knowledge and surgical information required to guide patient recovery and make patient-centered and injury-specific rehabilitation decisions. The information provided by the surgeon must be comprehended by the patient in a relatively short time, with some patients feeling unable to question or ask the surgeon for clarification during their scheduled review appointments. This can leave the patient feeling unsatisfied with their level of care, potentially causing conflict later in recovery. Answering patient questions is a core therapist skill, which can reassure and calm an anxious patient. Anecdotally, some patients have reported feeling more comfortable asking questions to their therapist, rather than the treating surgeon. The therapist-patient interaction occurs more regularly and is not usually limited by the same time restriction as the surgeon. The therapist can discuss the injury, rehabilitation plan, some general aspects of the surgery, using the time and detail required to ensure patient comprehension is achieved.

26.4 Factitious Disorders: Definition and Classification

Surgeons are accustomed to seeing patients for a defined problem and generally expect an “organic” disorder—where the condition has a known pathology, is supported by imaging and other investigations, and generally responds well to appropriate medical or surgical intervention. However, every surgeon will occasionally encounter a patient with a “nonorganic” disorder, with symptoms or signs that cannot be explained or supported by investigations, with emotional response of the patient varying from a lack of distress or extreme exaggeration.

Nonorganic disorders often relate to an underlying psychological disorder such as depression, personality disorder, or may have a psychiatric problem such as schizophrenia. The various types of nonorganic disorders include somatization disorder, where the patient focuses on a physical illness; conversion disorder, presenting as unexplainable paralysis or weakness; pain disorder simulating fibromyalgia or hypochondriasis, with phobia that a lump is cancerous.

Factitious disorders (FD) are a specific subset of nonorganic disorders where the patient feigns a physical illness or willingly creates a physical problem for the purpose of assuming the sick role and seeking medical attention. Unlike conversion disorder or hypochondriasis where the condition is not voluntarily produced, patients with FD knowingly feign symptoms, may actively create physical problems, such as wounds or swelling to deceive the medical team. Patients with FD are generally not seeking financial gain, merely seeking sympathy or attention from being unwell, and will often readily undergo a surgical procedure. They are not aware of any self-motivating factors and lack insight into their condition. This contrasts with a malingerer who will willingly exaggerate symptoms or signs following an injury to seek compensation for financial or nonfinancial gain such as access to drugs, delay return to work, or to avoid criminal prosecution.

Factitious disorders are included in the 2020 ICD-10-CM with diagnosis Code F68.10 as “Factitious disorder imposed on self, unspecified.” The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies factitious disorders into factitious disorder imposed on self and factitious disorder imposed on another, in order to replace Munchausen’s syndrome and Munchausen by proxy, respectively.7

The diagnosis of FD is by exclusion after every possible organic cause for the presenting symptoms is ruled out. For example, a patient with hand paresthesias with a nonanatomical pattern and inconsistent signs on clinical examination will need repeated clinical assessment, neurophysiological testing, magnetic resonance imaging (MRI), and possibly even a neurologist work-up. Cost of additional investigations, multiple specialist consultations, and hospital visits can amount to high costs in excess of 50,000 US dollars.⁸ Although every patient is unique and requires individualized treatment, the following discussion includes the four types of FD presentations to the hand clinic.

26.4.1 Self-Mutilation

Self-mutilators create physical signs by covertly injuring themselves with blunt trauma or by injecting various substances under the skin, varying from air, liquids or physical objects such as needles. The term “Munchausen syndrome” applies to a patient with additional features of peregrination (wandering from hospital to hospital) and pseudologia fantastica (exaggerated irrelevant stories of self-importance).⁹ Patients with Munchausen syndrome are twice as likely to be male and generally have more severe disease and worse prognosis. A variation of this disorder is Munchausen by proxy, where the illness is created in a dependent such as a child, with repeated hospital presentations requesting surgical intervention on the child for minimal symptoms.

A common type of presentation to the hand clinic is a nonhealing ulcer created by the patient (Fig. 26‑1). The patients typically have a lack of concern about the problem that often has been going on for several months and after treatment at multiple hospitals. Clinical examination, cultures, and biopsy are necessary to exclude a malignant ulcer before making the diagnosis. An X-ray may reveal inexplicable foreign bodies lodged in the deeper tissues inserted through the ulcer. These patients will typically manipulate the wound to prevent it from healing and will resist casting or other occlusive dressing that will preclude wound interference.

Related posts:

Complications: What They Do to the Patient Debunking Complex Regional Pain Syndrome/Sudeck/Reflex Sympathetic Dystrophy Flexor Tendon Repair in Zone 2: Prevention and Management of Complications by Hand Therapy Management of Complications Following Open Reduction and Plate Fixation of Distal Radius Fractures Treatment of Complications after Scapholunate Ligament Repair Management of Complications of Extensor Tendon Surgery

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