When To Say When On Post-Op Follow-Up

I have a patient who recently moved to my area from out of state. He has diabetes and his primary care doctor referred him to me for diabetic foot care. He told me he had already seen a local foot and ankle orthopedic surgeon and he needs to have a triple arthrodesis for his flatfoot condition. I did not make a big deal of it and did not want to undermine the relationship between the patient and his orthopedist. The patient did not know I did any surgery but that was okay. He had his surgery and I was able to “monitor from afar” his progress with his frequent return visits for routine foot care.

Currently, he is walking in a shoe and has completed his physical therapy, but he continues to have pain. I asked him what his orthopedic surgeon said when he complained of foot pain five months after surgery. The surgeon told him it takes a year to recover. The patient said he would wait it out and see what happens.

I hear stories like that all of the time. A patient has surgery and then sees a physician assistant two weeks after surgery for suture removal. Further follow-up is typically a surgeon’s examination at six weeks and it is typically “adios” after that.

It makes me wonder if we, as a profession, see our patients too frequently. We know that most of the serious complications occur early in the postoperative period so it seems reasonable to see a patient regularly in the first few weeks postoperatively. After that, it is sort of a gray area.

I am sure you have had the same experiences I have had over the years. The longer I am in practice, the more common an “old surgery” patient resurfaces on my schedule after years of absence from the practice. When I see the patient’s name on the schedule, knowing that patient had a tumultuous recovery with “slow to get better” progress, it can be a source of anxiety. The irony is that more often than not, these patients had a new problem, their surgically treated pain/dysfunction condition resolved and they “forgot” how difficult things were. I routinely hear from these patients that it took a year or 18 months to get completely better. So I guess time does heal all wounds.  

We all have our routine postoperative management protocols. Personally, for major reconstruction-related procedures, I see patients at weeks one, three, six and 10. After the 10-week follow-up visit, I usually have the conversation to remind the patient it takes six months to a year to fully recover from surgery. While there may be elements of pain, swelling and joint stiffness, there should be gradual improvement over time. I also explain that if there seems to be gradual improvement over a period of time, it is likely that resolution of symptoms will occur. However, if the patient has no pain improvement or worsening pain, that is worrisome and one needs to address it.

I never want patients to feel like I am abandoning them when I tell them another appointment is not necessary. I will generally tell my patients they should mark their calendar for three months and if there are any problems or concerns, then making another appointment is in order. Otherwise, I tell my patients that I will assume no news is good news. I find that patients do need encouragement and reassurance that their progress is normal. However, I feel that frequent follow-up after 10 weeks is really not necessary. It may be counterproductive having too much follow-up, whether it is the psychology of patients dwelling on the “slow” recovery by coming back to the office over and over again, or the feeling that something is wrong so they feel the need to keep coming back (and pay for office visits and X-rays).

In conclusion, I do feel it is important to keep a close eye on our surgery patients, especially in the early recovery process. However, learning when to “cut the cord” and not micromanage the case is important too.