Rethinking the postop patient-surgeon visit

Key clinical point: Scripted telephone follow-up by a midlevel provider after laparoscopic inguinal hernia repair is a safe, effective, and resource-sparing alternative to the traditional face-to-face surgeon-patient follow-up visit.

Major finding: Fifty of 55 patients who underwent laparoscopic inguinal hernia repair were safely able to be spared a follow-up clinic visit as a result of telephone follow-up by a physician assistant several weeks after surgery.

Data source: This was a prospective observational study in which patients who had laparoscopic repair of an inguinal hernia agreed to a scripted telephone follow-up by a physician assistant instead of returning to the clinic for the traditional surgeon-patient face-to-face encounter.

Disclosures: The presenter reported having no financial conflicts with regard to the study, which was funded by the Department of Veterans Affairs.




LAS VEGAS– Telephone follow-up by a midlevel provider after laparoscopic inguinal hernia repair is a possible alternative to the traditional surgeon-patient clinic visit, a pilot study indicates.

“It is feasible and seems effective. It is well received by patients, and it’s especially attractive for patients traveling long distances to receive their medical care. It may well prove to be the most efficient method for follow-up after laparoscopic inguinal hernia repair. It frees up clinic time: More than 80% of patients in our study were spared a clinic visit, and this allowed us to increase the number of our outpatient encounters,” Dr. Dan Eisenberg said at the annual Minimally Invasive Surgery Week.

Dr. Dan Eisenberg
Dr. Dan Eisenberg

He presented a prospective study of 62 consecutive patients who underwent laparoscopic inguinal hernia repair at the Veterans Affairs Palo Alto (Calif.) Health Care System and agreed to follow-up by a physician assistant 2-3 weeks after surgery in lieu of the traditional face-to-face clinic visit with the surgeon. The phone interview involved a predetermined nine-question script. A single “yes” answer prompted an appointment for a clinic visit.

Of the 62 patients, 3 were lost to follow-up. Because of a scheduling error, another four showed up at the VA clinic for a follow-up visit before the planned phone call. Of the remaining 55 patients, 50 (91%) were satisfied with their telephone follow-up experience.

Five patients were seen face to face at the clinic as a result of their telephone follow-up. Three did so because of self-limited groin discomfort, one for a large seroma, and one for early hernia recurrence treated by the total extraperitoneal approach, reported Dr. Eisenberg, a general surgeon at the Palo Alto VA.

Session chair Vincenzo Neri voiced a misgiving about the study.

“The only problem I see is that it contributes to the dehumanization of surgery,” commented Dr. Neri, professor and director of the division of general surgery at the University of Foggia (Italy). “The follow-up contact that you have in the clinic when you actually see the patient can be important because so many things can happen to the patient that he has no awareness of. Your way, the follow-up is basically gone.”

Dr. Eisenberg was quick to concur that the patient-surgeon relationship is basic to clinical medicine, and that the postop clinic visit is a fundamental part of this relationship.

“It is unfortunate to see that in the U.S., external constraints are changing the way we practice medicine,” he added, “but these external pressures are demanding more time efficiency and more resource efficiency, ultimately culminating, hopefully, in cost efficiency. The VA system is single payer. At the Palo Alto VA, we’ve noticed an increase in resource constraint limiting clinic access, and financial constraints going along with it.”

The Palo Alto VA Health Care System serves an enormous geographic area running north to the Oregon border and east into Nevada. The average roundtrip distance to the VA hospital for the study participants was 122 miles, and they were happy to forgo the journey.

“In Bay Area traffic, that corresponds to 3 to 3 1/2 hours on the road,” Dr. Eisenberg noted at the meeting presented by the Society of Laparoscopic Surgeons and affiliated societies.

His future research plans include randomizing patients to telephone follow-up or a face-to-face clinic visit after laparoscopic inguinal hernia repair in order to quantify the impact of the novel alternative on clinic flow and patient satisfaction. He also plans to extend the practice of telephone follow-up by a midlevel provider to other surgical procedures. He and his coworkers have already applied it to patients after laparoscopic cholecystectomy, where it also appears to be safe and efficient.

“It raises the question of how much further we can push this. Maybe it doesn’t have to be just for outpatient surgery,” according to Dr. Eisenberg.

Dr. Eisenberg reported having no financial conflicts with regard to the study, which was funded by the Department of Veterans Affairs.

The nine yes/no telephone follow-up questions

Do you feel unwell?
Are you requiring frequent analgesics?
Are you having trouble returning to your normal activities?
Do you have fever or chills?
Is there increasing redness or swelling at the incision site?
Do you have testicular swelling or pain?
Are you having trouble tolerating a regular diet?
Do you have any concerns?
Would you like a face-to-face clinic visit?

A “yes” answer to any of the above triggers a clinic visit.

Source: Dr. Eisenberg

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