Koltai PJ. Editorial Footnote. Arch Otolaryngol Head Neck Surg. 2000;126(6):722. doi:10.1001/archotol.126.6.722
The article by Rosbe et al presents us with a novel and challenging concept: using a telephone interview instead of an office visit for the traditional postoperative follow-up for simple surgical procedures, such as adenotonsillectomy. There is a contemporary logic to this idea, yet I suspect that it will be troubling for many surgeons. The goal of this commentary is to explore the soundness of this proposal and to gain some insight as to why the surgical community may resist its implementation.
In their introduction, the authors state that "In recent years, the changing health-care environment has forced hospitals and third-party payers to cut costs and payments for these procedures." It is these cost-cutting measures that prompted their study. However, in most circumstances, there is no service charge for the initial postoperative visit, since the cost of the follow-up evaluation is included in the operative fee. In reality, eliminating the one-time postoperative visit actually provides cost savings not to hospitals or to third-party payers, but to the surgeons who did the procedure. The tradition of our training and the values of our medical culture do not predispose us to view the physician-patient relationship simply as an economic unit; hence, we accept the additional care necessary for routine postoperative visits without expecting any compensation. The study results suggest that a postoperative telephone interview effectively and efficiently brings closure to the follow-up care for routine, complication-free adenotonsillectomy. The question that we each have to answer for ourselves is whether this approach, which benefits us, is worth considering.
When these findings were presented at the 14th Annual Meeting of the American Society of Pediatric Otolaryngology in April 1999 at Palm Desert, Calif, the audience response, as reflected by the comments and questions, was generally negative. The primary concern expressed was that a postoperative complication may go unrecognized and cause later harm to the patient. While this was not a problem found among the patients in the study of Rosbe et al, the limited size of this group of patients does not exclude such a possibility, especially for procedures as commonly performed as tonsillectomy and adenoidectomy.
This was not the only objection, however. In trying to understand why our colleagues found this new cost-cutting measure disturbing, it is important to recognize the extent to which our patterns of practice are tradition-based and value-weighted. The resistance was in part a result of the simple fact that we have always seen our patients after surgery; this is how our mentors practiced medicine and taught us to practice medicine. Generally, the follow-up visit is an opportunity not just to check how well the surgery has gone, but also to formally complete the physician-patient relationship in a very human and personal way. The routine postoperative follow-up on a case that has gone smoothly provides us with a moment of pleasure that is spiritually uplifting and that gives us psychological ballast for the burden of responsibility, especially during times when we experience problems in the care of our patients.
It is only when we set our professional concerns aside and look at the issue from the perspective of patients and their families that the idea of a postoperative telephone follow-up begins to have some merit. Rosbe et al found that "with this pilot study . . . patients and their families were . . . actually happier not to have to come back for another visit." The authors warn us that this is only a pilot study and that the level of satisfaction with this method of follow-up may not remain as high with a larger sample of patients. Nevertheless, the observation may be valid and reflect more broadly held cultural values that are influenced by family schedules, the demands of school and work, and consumerism.
Without a compelling reason, most of us would resist taking a car back to our mechanic after a routine repair just to have him make sure that the repair is in good order. Surgery and auto repair are not entirely analogous, but I suspect that our patients and their families would be more willing to acknowledge the similarities than physicians. Many of those we care for welcome the reassurance that the postoperative visit can provide, and for them, this should be available. However, for others, the necessity of a routine postoperative follow-up visit, after there have been no problems or complications and the recovery has been smooth and uneventful, can appear to be more ritualistic than functional. This is not a frivolous point of view, and while we may disagree with the values it is based on, it should not be dismissed without contemplation.
The suggestion of Rosbe et al to do a telephone interview to follow up uncomplicated routine surgery is neither right nor wrong as an abstract concept; rather, it is a method that can succeed or fail. Depending on the type of surgery, the reliability and the expectations of the patients and their families, and our own level of professional experience, this form of follow-up may prove to be a practical option. However, implementing it safely will require us to practice sound clinical judgment with a strong emphasis on patient education, accessibility, and communication. It will be up to us as surgeons to accurately assess with which of our patients we are willing to share the responsibility of follow-up.