David Shewring: End compliance mindset to assist recovery

The British Society for Surgery of the Hand was founded by specialists from multiple disciplines collaborating to help people with injured and hands visibly affected by the condition receive the best possible care. Orthopaedic and plastic surgeons work alongside rheumatologists, neurologists, psychologists, and specialist hand therapists, in specialist teams. Yet regardless of all this expertise, outcomes will be limited if the patient is not actively involved in the process.

The hand is incredibly complicated, with 27 bones, 24 muscle groups, and three motor and sensory nerve pathways that lead us to conduct innumerable patterns of activity and function including feeling, gripping, manipulation, stability, and communication. As it may be the only part of us on display at all times, the hand also has a high cosmetic importance. Assuming early, accurate diagnosis and a high quality intervention take place, it is the six weeks following surgery or injury that is critical for optimising the outcome. A tailored programme of rehabilitation must be established for each patient with a combination of rest and protection through splintage and judicious exercises to mobilise the painful joint in order to minimise stiffness.

While the Montgomery Ruling has made it mandatory to ensure that patients are aware of all options available for treatment, as well as the potential consequences of declining a particular option, it must be recognised as different from helping patients to become active participants in the decision making process.  As medical professionals, we use the word “compliance” to indicate that a patient is doing what we have asked them to do to aid recovery; this terminology does not recognise the patient as a genuine partner in the process.

This is particularly pertinent in trauma cases, when patients are dealing with an unexpected adverse event and injury. Whereas patients undergoing elective procedures will have been warned about and planned for the consequences of surgery, people coping with an accident have to deal with both the disruption of the incident and concerns about their ability to look after themselves and their families.

Twenty percent of visits to A&E departments in England are for hand trauma, predominantly affecting young working men. [1] Whether as the result of a sporting or leisure injury, or a workplace accident, individuals will be anxious to get back to work as quickly as possible. Unless we recognise this from the outset—and involve patients closely in the decision making process—we can’t expect patients to fully engage with the rehabilitation process during that critical six weeks after injury.

There are usually several options for treatment and selection should be informed by each patient’s needs and priorities. It must be remembered that the ideal outcome as perceived by the surgeon may not necessarily match that of the patient, if the sacrifices incurred in obtaining that goal are too great.

Occasionally this may not be possible. Modification of a given treatment may result in such unacceptable compromise to the outcome that it cannot be justified. In such cases, honest conversations about the reasons and importance of the recovery regime are critical. Patients need to know that we are doing everything possible, not just for their hand, but because we understand the role their hand plays in enabling them to live their life. We are on the same side and part of their team.

By focusing on consent and compliance we are limiting our ability to help. Instead, hand surgeons and hand therapists need to include two addition Cs in their decision making processes; conversation and—where appropriate—choice. Getting this right, especially in the pressured trauma situation, will ultimately help improve “compliance” and lead to a better outcome for all.

David Shewring, President of the British Society for Surgery of the Hand

Competing interests: None declared.

1] BSSH: Hand Surgery in the UK report 2007