Dr. Anthony Romeo,
Shoulder,Elbow, Sports Medicine Surgeon
Executive Vice President, Musculoskeletal Institute

'The only way to avoid a surgical complication is to not have surgery.'  Yet, when they do happen, how do you navigate that conversation with your patients especially when you are not the surgeon that did the surgery.  

Dr. Anthony Romeo, is a shoulder, elbow and sports medicine orthopedic surgeon at Duly Health and Care, Chief Medical Editor for Orthopedics Today at Healio, and the Executive Vice President of the Musculoskeletal Institute.  His experience and reputation have made him a renowned surgeon for treating revisions and supporting secondary (or more) surgeries when there are original complications.    

In this podcast, he talks live about how to talk with patients when things DON'T go right in their surgery, and how to talk with a patient about complications.  Not only when you are the surgeon that completed the work, but also when you are the revisionist surgeon.  

Transcription of Podcast

Julie Soukup Take 1: Patient Podcast  0:01  
Hi, I'm Julie Sukup. I with our next episode of take one patient, I'm incredibly excited that I'm talking to Dr. Anthony Romeo. He is an orthopedic surgeon at Dooley health and care as over 90 providers that are doing surgery for patients there. And a few articles that he's written and his expertise about patients complications, really intrigued me. And so I asked him to to guest on our podcast, and we're gonna talk a little bit more about that today. So thank you for being here. I'd love if you kind of took a minute to introduce more in the of the depth and breadth of of your experience before we get started.

Dr. Anthony Romeo  0:40  
Sure, thank you, Julie, for the opportunity to speak with you today. I'm the Executive Vice President for the musculoskeletal Institute at Julie health and care. Julie health and care is now currently over 1000 providers or physicians. And in within that group, 90 of the physicians are related to the management of musculoskeletal problems such as orthopedics, spine, rheumatology and neurology. And my particular interest is in the field of orthopedics. With a special expertise in shoulder and elbow surgery, I've been President of the shoulder and elbow society, in the United States, and I've had a big role in much of the teaching and education related to shoulder and elbow over the last 25 years. And that's really where my patient population comes from, in terms of the care that I provide on a daily basis for for those patients.

Julie Soukup Take 1: Patient Podcast  1:39  
Fantastic. Well, I think one of the things that really interests me in our conversation that we were having previously, and in a lot of the articles that I've read, that you have written, really dealt around patient complications, and, and not only how to handle communication with your patients and their families after the fact, but also has to really ensure that you're kind of setting expectations and setting things up from the very, very beginning. So tell me a little bit kind of where where that is, especially in as far as that beginning piece of setting expectation of where some of these articles and some of the the need to kind of get that information out to other providers stem from with your experience.

Dr. Anthony Romeo  2:23  
As you go through your career, you take on more and more advanced and more complicated issues, not only with patient care, but also with patient management. And I think it's really important to pay forward, but also to pay back. And that is that, and so on in my position with the experience I have, I can share with my peers, and also the younger physicians, some of the challenging experiences I've had with patients, which are opportunities to try to do a better job and caring for those patients. And probably one of those areas that really affects all of us in the healthcare delivery system is when a patient has a complication. And a complication really can be defined as when the outcome of the treatment was not what you and the patient expected. And typically, it's it affects them in a way that's a negative result. And so the ability to speak with your patients about that is really important. And it begins from before the treatment actually starts. And so like with any relationship, one of the most common reasons why relationships fail, is the failure to meet expectations. So the important thing is to start from the very beginning to set the expectations. And we kind of have this idea that we we want to under promise and over deliver, we don't want to tell patients that oh, this is your 100% of the time you're going to do great and nobody ever has a problem because that's just not like, the only way to avoid complications is if you don't operate in terms of surgery. And so we have to have that discussion upfront.

Julie Soukup Take 1: Patient Podcast  4:04  
Well, and it's interesting that you're even talking about that, and using that word as the discussion is, you know, we had a previous guest, who was a doctor and the lawyer and he was really talking about how informed consent, which is where you're supposed to go with risks, benefits and alternatives have really needs to be a very thorough dialogue about okay, this is this is what this is. But these are some of the things that you're looking at kind of walking into and really setting that expectation setting. That's one from the beginning.

Dr. Anthony Romeo  4:33  
But I can tell you that when you speak to anyone that has a legal background, they're going to give you this perspective that you have to have this laundry list of things that you have to do to protect yourself if some thing happens, and that's one approach. But I The other approach is to develop a relationship with the patient where they know that you are doing everything you can to help them get better and they trust you And if they trust you, you're not going to have to worry about whether you hit every single thing on that laundry list every time. Because you are working with that patient in a relationship where they know you're going to do everything you can to make it right. And I think that's the best place to start from the perspective of Ryder. And then he's saying it's helpful to have experts in the legal field tell us? Well, this is the checklist of things that you really also want to keep in mind.

Julie Soukup Take 1: Patient Podcast  5:29  
Yeah, absolutely. Well, it's interesting even that you are saying that because one of medical memories biggest clients, is Barrow, Britain spine, which is also like scheduled surgeries. And so they have created a bunch of videos that are the like informed consent videos that go over risk, benefits, alternatives, everything under the sun, in a very simple way that they could send to patients very simply attractive, patients had that. But that's what they're saying has been in allows me to know, okay, I have given them all that information than they need to. Now I can focus on our communication and our trust, because I know kind of that piece has been covered, you know, with medical memory. So it's interesting, because they had kind of a very much a line that we have to cover both, but I want my I need to invest that time. And as we invest that extra time, I have to making sure that we're connected and making sure they trust me, and making sure that we're building that kind of relationship from the beginning, just as much as the legal part.

Dr. Anthony Romeo  6:23  
Yeah, I think there's a lot of different approaches to it from the legal perspective, and I'm not an expert in the legal world. But I can tell you, there's some attorneys, who will tell you, you don't want to put every single thing you can think of because the one thing that's not on there, they'll say, Well, you didn't include this. And that was a problem. You really want to present the perspective that you inform the patient of the most common challenges and problems that can happen with this type of surgical intervention. And that there's ways around that or managing those things if they need to happen, but you should be aware that this can happen. And again, setting those expectations. But really more than anything else, you have to get the patient to trust you. And one of the really important viewpoints that a physician has to have. And remember every single time is that patients do not care how much you know, until they know how much you care. And I think it's really important you develop a relationship with your patient, where they say, this doctor cares about me, he's going to do a surgery. And then if something doesn't work, at the end, he's more likely than not to say, You know what, I know you did your best, these things can happen. And we'll work through it together. Certainly there's times where there's a liability, and we want to cover that. And I don't want to downplay the importance of that. But for someone who's been in practice for almost 30 years, and has not been in the courtroom, or related to these issues, I think that developing that relationship with your patients is your best approach to malpractice. And then let the attorneys advise you on the other paperwork and other things that can be helpful. Sure. Well, and that's

Julie Soukup Take 1: Patient Podcast  7:59  
so that being said is let's talk because of the other article that you've written. And I thought that you have so much great advice of is Okay, so now, we have gone through surgery, and now there is a complication. What advice and so whether that be the physician that actually had the complication, or even a physician that's being referred to which that was one of your specialties is a lot of times you're being referred, what are some of the things that that you really encourage physicians to think about, in terms of communication, when it there is a complication on their own case, let alone someone else's,

Dr. Anthony Romeo  8:34  
I really have a broad experience with this because not only do I have my own complications, occasionally, hopefully as minimal as possible. But as you mentioned, because of my position in this community, more than a third of my patients come to me have already had a surgery that did not result in the outcome that they expected. And many times they're upset or frustrated, or just clearly angry about the way things went. And so I have to manage that not only for myself, but also for the referring physician in terms of how to take care of that. And I think that the really the British Medical Society has a concept which they call the duty of candor. And I think that's an important concept too. And that is you've got to be honest, and be as honest as possible. And that is you try in my situation and terror of taking care of these patients. First of all, this is the problem that you have. This is what I believe is the best way that we can manage going forward. And this is what we expect the outcomes and immediately the patient's going to want to go back to a Why did this happen and who's at fault. This is typical human nature. And the real key to our care for these individuals is to say that our focus needs to be on how we can take care of your problem and get you out of the situation that you're in here and get you into a better place and and We'll work with you to try to get that outcome much closer to what you expected. But it's important again, to develop the trust, the patient knows that you care for them, that you're going to give them hope that there's going to be a better outcome. And you're going to do everything you can to try to make sure and execute going forward with a plan that's going to actually make that difference for them.

Julie Soukup Take 1: Patient Podcast  10:19  
Right? When I and I appreciate how much she talks about, you know, really saying focus on the future, you know, saying, you know, especially when you're the, you're the new physician, that's potentially revising something else, of being, you know, I don't know, I don't know, I'm not an expert, I wasn't in the surgery. But let's focus on today and our relationship and how we're going to move forward. And that I'm gonna, you know, providing hope and saying, let's just keep this future focus, let's keep this focus on what we're going to do about it now, which I think is which is profound. And also, you know, based probably on a lot of experiences in that situation,

Dr. Anthony Romeo  10:54  
I think patients oftentimes do have a natural tendency to want to place blame. For me, the important thing is to validate their concerns and say, you know, what, you do have a problem. It's a real problem. It is not what what was expected from your surgical procedure. And I'm sorry that this happened. And I know that it's created a lot of challenges for you in terms of pain, and an ability to use your limb or to have the font that you want. But let's think about what you initially presented with what happened and how we can get you closer to that expected outcome that was talked about before your surgery. And I think there's so some ways we can work on that to help you out with that. And I, I do appreciate that this is a really tough problem for you. And I know that you've had to deal with it for a lot longer than our visit together. But I would like to focus on, I've got this problem, how can I spend as much energy as possible and figuring out how to give you the best solution. And I think that really does help the patients have a sense of that, okay, the doctor is listening, he knows that I've had this real issue, he's not discounting it as being something that just can happen randomly, but actually really was a problem. And in addition, he's helping me figure out what's a better way to get to where we'd like to go. And that's really important for them,

Julie Soukup Take 1: Patient Podcast  12:20  
right? Now, when you do have a patient that has been referred to you. And they are continuously going negative or continuously mad or angry. I mean, how have you, how do you pull them kind of out of even that space? Or that just their emotions are really high? Like, how do you manage that?

Dr. Anthony Romeo  12:43  
It's a, I think, again, it comes back to developing that relationship of trust. I think one of the most important things is that the physician has to be willing to listen. And there's so much about being present, they be mindful in terms of relationships from general. And when you sense that this patient's really angry and very negative, and really wants to kind of dig in, the most important thing to do is just be quiet. And listen, let the patient have their moment, let them say what they need to say, even if it really is a real complication somewhere else. But give them a chance to express themselves. And it's sort of a cathartic event for them to get that out to the doctor, the doctor listened to me. And it takes another few minutes to do that. But it will be helpful. If they continue down this path of just negative all the time, sometimes you have to say to the patient, I can understand why you're so upset, I can't resolve your anger. But if everything is going to be about how disappointing and how angry you are, and how upset this is, we're going to have a really hard time focusing on how to get you to a better place. And so I appreciate that this is an important feeling and emotion that you have to have. But while we're here together, let's try to figure out where we need to go so that we can alleviate some of the problems that you're dealing with. Right. Well, I

Julie Soukup Take 1: Patient Podcast  14:17  
think that that was really is amazing. They say kind of like I'm gonna give you you know, Grace in this space and appreciate the fact that like you're not shying away from the emotions that they're truly having. Because, you know, yeah, they have a maybe a reason to be upset or they are in a lot of pain and they're definitely not living the life that they thought that they were pre surgery. And so allowing that that outlet or that grace to just allow them to have it allows them to move forward. It sounds like

Dr. Anthony Romeo  14:47  
well, it may sound a bit awkward, but in fact, when that happens, I try to find a closer personal space with that individual, and that means if I'm standing up, I'm sitting down, and I'm face to face with that person, and I'm right in front of them. And I want to have eye contact, and let them say what they need to say, right? Because I think that it's so valuable to allow them to share with you how they truly feel, even if it's very negative and angry, that if you give them that moment, if you give them that grace, that's going to make a big difference in the trust that they have for you. And your ability to get closer to the outcome that they were expecting, right.

Julie Soukup Take 1: Patient Podcast  15:39  
And so for even providers that don't have the experience that you have, or have done it kind of for as long as it sounds like sometimes even the best two things that you can do is just get quiet and pay attention to your body language. And you don't have to say it all or defend anything, it's almost just like, get quiet and get closer or pay attention to the kind of the nonverbals that you're having.

Dr. Anthony Romeo  16:03  
Yeah, I think it comes back again to the fact that and I think when you're younger, in your profession, there's a sense of that, why I need to prove to this patient that I know what I'm doing. And I can take care of this problem. I'm smart enough to figure this out. I've seen this problem, we'll figure it out. And again, just remember, they don't care how much you know, until they know how much you care, establish that sense that you really care for them. You're listening to them, you're understanding their problem. And when they're ready, then you say, Okay, now that we're in a better place, and you don't have to say that, but you want to sense that they're now listening to you. Here's your problem. This is why I think this happened. This is how we're going to try to solve that problem. And these are the steps going forward. And I think you can be very successful in helping manage that patient with that type of approach.

Julie Soukup Take 1: Patient Podcast  16:52  
Right? Well, and as you had said, in your article is, is one of the best thing, even if if you were the physician that had the complication is being honest, 100% Direct, this is what this wasn't what we expected, this is what's happened, but also is apologizing and that apologizing isn't necessarily meaning that you're admitting guilt or meaning that there's that foul or admitting? Well, I told you before any of that it's just more so kind of bringing you both to the same level of just saying, I'm sorry, I'm sorry that this is happening. Um, you know, and how it can combo people.

Dr. Anthony Romeo  17:30  
Yeah, you know that that was really an issue as a human being, when you see someone hurting or suffering. You want to say I'm sorry, yeah, I'm sorry, this is happening to you. And unfortunately, in the legal system, there were places where that was picked up as a Ha, he's that person is guilty. They said they were sorry, they must be guilty. Fortunately, the vast majority of states have passed laws that say, when you apologize, you're not admitting guilt. And that is the most appropriate thing. I think one of the things that really people don't understand unless you're in our position is that when a patient has a problem, when they have a complication, it hurts us, too. It's very difficult on us to most of us have been driven to try to be the best student, the best doctor, the best surgeon. And if we do something, and it results in a bad result, it's very, very challenging for us in terms of our own egos in terms of our own mental health to just accept that, that well, that's the way things go. It really bothers the vast majority of us in a way that I don't think all the patients really understand we think about it at night. We think about it when we're working on other things. We always talk about the fact that when you take an exam, the one question you remember is the one that you miss. And once you get one, it's the same here, you could do 100 shoulder replacements and one patient gets an infection, which can happen in 1% or less. And it will drive you crazy figuring out gosh, did we do we make sure that the antibiotics were in on time? Do we do the proper prep? Do we make sure that we watched the show out very carefully after the surgical implants were done? And and everything can be perfect, but I think patients should understand that for us. It is also a secondary injury for us. And so I do want to say when they have a complication in my piece, I'm sorry this has happened. But here's what this issue is. And here's how we're going to help you out. So I'm sorry, and I apologize. I do understand what the problem is. And we've dealt with this before. And I'm going to give you hope that we can get to a much better place than we are today. And That's my goal when I have to address a complication to one of my patients, right? Right.

Julie Soukup Take 1: Patient Podcast  20:05  
And that's one of the things in that same article that I thought was interesting is that even if it does have to get referred to another physician is really is making sure you're not at the entity, that patient and being almost lean into engaging more in their care versus, you know, okay, so your problem now, you know, but leaning more into ensuring that you're still part of, of, of that process, even as they go, and that it's almost an element of healing for both even with that, as they are being referred out.

Dr. Anthony Romeo  20:34  
Yeah, in my practice, I've reached a level where, you know, many of those cases are referred to me. And so I take care of that end stage. But there are occasionally the rare problem, like, for instance, a neurologic injury where a nerve may have been injured in a way that wasn't seen at the time of surgery wasn't necessarily cut, it just doesn't work anymore. And they need to have some of these unique modern procedures like a nerve transfer. And that's done by very specialized people that do microvascular surgery that I don't do tendon transfers and tendon grafts. So I've got to refer them out to that end, but I tell the patient, listen, this is your problem. This is the individual who specializes in this in a very high level. And I'll call them and tell them what happened and explain to them so you don't have to worry about that. And then give them my recommendation and work with them to come up with the best plan to treat you. It's really important, again, care for your patients, listen to your patients, and stay involved with their future care, even if it goes to another provider, so that you can make sure again, that the patient realizes this doctor really does care about me and is doing everything they count, to get the best result.

Julie Soukup Take 1: Patient Podcast  21:50  
Right. Now, um, for the one thing that you speak so much about is making sure that you're building that relationship and making sure you're taking that extra little bit of time and whatnot.

Unknown Speaker  22:02  
So one of the things that I thought for a lot of our

Julie Soukup Take 1: Patient Podcast  22:05  
providers, oh, my gosh, I'm just so busy, I'm overwhelmed. You know, sometimes I don't have that extra 10 minutes, or whatever that might be, you know, that's where a lot of physicians that we encounter, start using video with medical memory, or even recording these visits with medical memory so that patients still have more access to it. But that being said, is one of the things that I thought was really awesome that you were talking about was, it's not just you building that relationship and that communication and that that you had talked about, you know, if you're not having the time, it's really leverage your team and have a true team approach to making sure that that that patient has a great experience. So talk to me just a little bit more about about how you do that, and ensure that your team really has that same value that you have in patient communication.

Dr. Anthony Romeo  22:52  
You know, in 2022, everybody thinks that technology is going to solve all of the problems in healthcare, and including the relationships between the doctor and the patient. So more video more digital, more handouts. That is not the answer. That is the assist to what needs to be done. The answer is still the relationship between you and your patient. And so yes, if you want to put videos in Sure, you can do that. But really, the more personal it is, the more human it is, the more effective it is. So you have a physician assistant, you have a medical assistant, you have a receptionist, your surgical scheduler, maybe the radiology technician, all of these people are interacting with your patient. And your patient needs to feel like the team is focused on their care, and is trying to figure out how to do the best thing for them. And so what's important is that you and in this situation, if I'm have this group that I work with on a regular basis, and I'm sort of the captain of the ship, we need to find time, preferably once a week to sit down and go over things. What did we do well, this past week, what did we have some problems with? And let's look at our cases going forward next week, particularly with our surgeons schedule, we like to look ahead and do that. And we meet together as a team. And we talk about these things. And they'll say, you know, Mrs. Smith had a really tough time and she was not happy at the front desk. And I said, Well, how did you manage that. And I want them to be concerning and and concerned and listening and helping them out. And I want my physician assistant and I want to have the whole group working towards that patient feeling like we're here for them. And the real insight to healthcare in the future that work. The way it's going to work is whatever we do, we put the patient at the center. And if we do that, no matter what the technology is, we keep putting them at the center. We'll come up with a better answer. There's no doubt that technology is going to help us but the but it's never going to substitute never in my lifetime for the relationship between people that interact with them and that pain.

Julie Soukup Take 1: Patient Podcast  25:07  
Sure, sure. And it's so interesting you say that because with a lot of the, or, you know, orthopedic or even neurosurgeons that we work with, it also goes to, you only have so much time. And so we only have an hour and there is a certain amount of time with a patient is how do you want to utilize that. And I think that that's what becomes really profound. When you are using resources, like video or reusing, you know, recording the conversation so that a patient can review this awesome experience that you're having together and review like the connection and seeing that that trust being built later, it allows the provider like I know, that educational piece was covered, I know my PC is not going to call back, because they have a recording of our dialogue. So now I can just truly just have this extra five minutes, less worried about all the education or all the other pieces, and being able to focus it more. And so just as I think you said it really beautifully, is it's not, it's never going to replace that human interaction. But I think technology, especially as it relates to patient, education, patient video, take some of that, that burden that still evolves for some providers on I have to cover everything, and I gotta make sure that educate, and I got to make sure that I don't have the risk that, okay, there's these tools that are in place. So now that you have that five minutes, you can focus more on on that trust and on building that and have these resources that you know, exists that will help support patient education, and that process. And so for a lot of our physicians, when they're recording, you know, telling a patient for the first time, you have neurosurgery of spine surgery, and they're able to be in that moment with them. When family members are watching it later. They're like, gosh, that provider really cares about you. And it's building that trust equity for everybody. So because the providers like I know that they have these other pieces now I get this extra time, you know they are and so I think that's where technology really can can support more as it it provides more time, you know, some spaces so

Unknown Speaker  27:03  

Dr. Anthony Romeo  27:07  
I think all your comments are entirely appropriate. And so for me again, you know, not everybody has the ability to have all of the technology that you mentioned, but if they do, it's wonderful. And there's no doubt that the patient satisfaction, patient experience is improved. And we should all work towards that. Yeah. But for me, again, it begins with putting the patient in the center, developing a trusting relationship with them. And then bringing all this together with the people that you work with the technology you have available. So certainly recording it is very valuable. But if you had no personal relationship with that patient, if you didn't develop a trusting relationship with that patient, if you didn't have the ability to be have candor and honesty, if you didn't have the ability to care show that you cared for them, that videos actually detrimental. And so again, we start with that centerpiece. And there's, I think it's a wonderful time for our profession and health care, but also the patience, to use technology to really expand the experience beyond what people have had in the past. But start with the core principles, and then add some of these wonderful technological advances that we have, like you've mentioned, videotaping the experience. And I think it'd be wonderful, you know, you videotape the experience, the patient has access now through a number of different mechanisms to their own medical records to their own radiological studies. And it's also a nice thing that you can do for your patients. And I've done this, I have a very intelligent patient that wants to know what's going on and on the MRI shows that I say, hear it, take your phone out for a minute, and just stand over here. And I'm going to say in the next 30 to 60 seconds, I'll show you on this MRI, here's what it is, is this, this and this and explain it to you. And then you have a record of that. And you can show that to your family members. So these are wonderful advances that we have to have. But the reason why I have the opportunity to share that with my patients is because they trust me, and they know that I care for them. And they know I'm going to try to do a really good job if I don't do that first. They don't care what I say on that video. So everything you said is absolutely correct. And really just makes it incredibly more fulfilling patient experience if you can put all of that together.

Julie Soukup Take 1: Patient Podcast  29:38  
Right. And that's why I think it's amazing hearing a lot of your experiences when things are a little hard and are a little stressful. So for some of the people that are wanting to use these things, but they're not as comfortable because they haven't kind of learned some of these things or had a complication. Oh my gosh, what if what if this happens and and a lot of you're experienced in your expert expertise Send your true like values, I think really shines and a lot of these articles that that you're writing. And then as far as a lot of this as far as, you know, building that trust equity, sharing that candor, and really leaning in there first, because 100% If that's not there, it doesn't matter anything else, all of its noise. If you don't have that, that piece first, and it's it with all your experience, that you're still coming back to that problem, which is why you got into medicine is is pretty, pretty amazing. So I so appreciate your intellect, and and your and your experience. And and I think it's a lot of the things that you have mentioned, are incredibly valuable for a lot of people that are wanting to really take their communication skills to the next level to implement some of these things. So I so appreciate you so much for joining, is there anything last minute that you kind of want to add? Yeah,

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