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Sunday kicked off the Discovery Channel’s annual Shark Week on TV with a much hyped “Phelps vs. Shark” event, promising the world would see who is faster: Michael Phelps or a great white shark. Public outrage and backlash followed the event, when it turned out that Phelps was not actually racing a shark, but a computer-generated animation of a shark. This event and the public response shows the dangers of setting high expectations but failing to meet them.

In the world of elective orthopedic surgeries, the stakes are just as high. Studies have shown that up to 20% of patients are not satisfied with their outcome following total knee replacement, and that satisfaction was highly correlated with patient expectations. Another study found that “expectations not met” results in a 10.7x greater risk of dissatisfaction. Here are 5 areas where active management of patient expectations in joint replacement surgery is necessary:

  1. Expectation of return to function
    Care teams should take the time to ask patients about their recovery goals, and help reset expectations if those goals seem unreasonable. If a patient is severely arthritic and having problems walking, it may not be realistic to think they can take up a new sport after surgery. Also, weight loss after joint replacement has not been consistently proven through clinical evidence, so clinicians should avoid promises of this as a primary outcome.
  2. Expectation of pain level
    It’s a hard truth, but joint replacement surgery hurts. It’s a major surgery and there’s no way around it. The entire care team needs to be pushing the same message that they will keep pain at a manageable level, not that the surgery and recovery process will be pain-free.
  3. Expectation of mobility
    A patient’s expectation of a hospital stay is usually a few days in bed, watching TV and ordering room service. However, patients that get up and moving as early and often as possible, even within hours of surgery, have better outcomes. Ensure patients know that they will not be treated as invalids, but your goal is to return them to everyday activities quickly.
  4. Expectation of discharge
    The experience of joint replacement has changed. Patients who had a replacement years ago and spent four days in a hospital followed by three weeks in a skilled nursing facility may still have those same expectations for their next surgery. Don’t let it be a surprise when they get the orders to be sent straight home on post-op day 2. And make sure proper expectations are set for why a SNF stay is not appropriate for healthy patients.
  5. Expectation of home recovery
    Patients may not be ready to take on a to-do list when they get home from the hospital. Making sure they have a good support system in place is key, along with doing some prep work on their home environment before surgery. Reinforcing symptoms to watch for and wound care instructions before, during, and after the hospital stay will help prevent costly complications and readmissions.

Florence Nightingale has been quoted as saying, “Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.” The good news is that proper expectation setting can give patients confidence, lay their fears to rest, and ultimately deliver higher satisfaction scores. A study at HSS found that a pre-operative education class was successful in bringing discordantly high expectations back into closer alignment with those of the surgeon. This means that expectation setting needs to rely on more than just the initial surgeon’s consult. It needs to be something that is reinforced multiple times across the episode.