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P a r t I
Preoperative
The First Encounter
Lee E. Smith and Anjali S. Kumar
1
Key Points
• Honesty, humility, and communication are the keys
to success in establishing a solid relationship with
your patient at the fi rst encounter.
• Advocating for the patient by providing extra support services will endear you to your patients.
• Patients have diffi cult yet predictable questions.
Know the answers beforehand in order to ease the
encounter.
• Making yourself available by phone and Internet,
and making time for face-to-face meetings, will
make you approachable and popular among referring providers.
• Approaching each situation as if you were the
patient is always the best practice.
• While it is important to educate and counsel your
patients, it is often much more important to be a
good listener.
L. E. Smith , MD, FACS, FASCRS (*)
A. S. Kumar , MD, MPH, FACS
Section of Colon and Rectal Surgery ,
MedStar Washington Hospital Center,
Georgetown University , 106 Irving St NW St 2100 N ,
Washington , DC 20010 , USA
e-mail: caroleandlee@rcn.com; askumarmd@gmail.com
Introduction
Key Concept : Draw upon your own personal experiences
and background to form a solid base for your patient interactions . While your goals may vary depending on the stage of
your career , each patient interaction is often unique , and
approaching things from the patient ’ s perspective is a good
rule of thumb .
This chapter may seem unusual for a textbook of surgery.
How does one create an atmosphere of trust with patients? As
with all human interactions, fi rst impressions are key, and this
chapter is a subjective look at the topic from the perspective
of two surgeons at opposite ends of their careers. The topic is
quite subjective, so we draw heavily from our experiences in
order to provide the perspective of both a senior surgeon with
40 years of experience in the fi eld of colon and rectal surgery
( LE Smith ) and that of a junior surgeon just starting her
colorectal surgery specialty practice ( AS Kumar ). We preface
our individual statements with our respective voices.
( LE Smith ) In writing this chapter, I refl ect on more than
40 years of seeing patients in military, academic, and nonprofi t private hospitals. The patients in each type of hospital
vary to some degree, but certain universal principles exist to
help enlist the patient as an ally in solving his or her problem.
One principle that has guided me throughout life is worth
sharing, because it applies to surgery as it does to life. As a
child in grammar school, I was given a cheap 12-in. ruler,
which had printed on the side: “Do unto others as you would
have them do unto you.” Even as a child during the depression
and the emotionally charged days of World War II, I recognized the wisdom of this succinct rule and permanently fi xed
it in my mind. It has served me well in my surgical career.
( AS Kumar ) In working with Dr. Smith to craft this chap-
ter, I refl ect on my fi rst 3 years building a practice and a
referral base within our region. I was hired to help Dr. Smith
retire, but soon found that his referral network consisted of
physicians of his generation who thought an older, more
experienced physician would be better suited to care for their
patients than someone who was just starting out of fellowship.
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_1, © Springer Science+Business Media New York 2014
3
4
L.E. Smith and A.S. Kumar
My success, therefore, relied more on my accessibility and
visibility for in-hospital consults, my presence on the
Internet, and my ability to connect with recent graduates of
other referring medical fellowships (such as interventional
gastroenterologists and medical oncologists with emphases
on gastrointestinal cancers). Once securing an appointment
with a new patient, it is essential that I give the best of care,
be well liked and well respected by my patients, no matter
what the circumstances. I quickly found that patients would
refer their friends and families to me if they saw me as a passionate advocate for their health.
Keep in mind that someday roles may reverse, and you
could be the patient. In the fi rst encounter and the succeeding
ones, imagine yourself on the receiving end of whatever it is
that you are dispensing—an unfavorable pathologic result,
the terminal sentence of a chronic disease, the news of a permanent, potentially disfi guring procedure that offers the best
chance for a cure, or even a lubricated fi nger.
Prior to the Encounter
Key concept : The patient ’ s fi rst encounter with you and your
team sets the stage for their entire work - up , management , and
follow - up . Make it as easy as possible ( within reason ) for
your patients and your referring physicians to gain access to
you , whether it is through the phone , e - mail , or in person .
The team—every member of it—must be competent and
convey this sense to the patient. The selection of your patientoriented team is, therefore, critical. Regardless of how
thoughtful, competent, well-trained, and skilled you are, the
patient will ultimately judge you and the hospital by the
qualities of your entire team.
The teamwork begins with the fi rst telephone call the
patient makes to schedule an appointment. In most practices,
the telephone is the main interface with patients and referring
physicians; therefore, this initial telephone conversation must
be answered promptly with a friendly and helpful attitude. The
receptionist must discreetly fi nd the reason for the requested
visit and make a decision about urgency. Generally, patients
with pain, an abscess, or a presumed cancer need early or
urgent appointments. The receptionist must have a medical
professional—a nurse or a doctor—whom they can call upon
if the course of action is uncertain. More importantly, they
should recognize when they should “bump up” the request to a
more authoritative, more experienced triaging assistant.
Sometimes, patients may be reluctant to discuss anorectal
problems on the phone. If hesitancy is recognized, it is often
wise not to question further, and instead turn the discussion
toward sending or bringing records from the referring physician. The patient’s needs for the fi rst visit should be explained
verbally and repeated back by the patient if there is any question of the ability to understand or hear. If there is time, the
confi rmation of the appointment and what is required should
be sent by mail. The patient needs to know that in order to
accomplish as much as possible during the fi rst visit, he or she
needs to provide pertinent records, such as color copies of
colonoscopy reports, operative reports, digital fi les of imaging
studies, laboratory reports, pathology reports, and sometimes
even pathology slides. If a mailing goes out, forms for demographics, insurance, and medical history could be included in
order to save time during the registration process. No patient
wants to get lost, so providing a map for travel, parking, and
public transportation is useful. Figure 1.1 provides an example
of what the radiology department at our hospital uses to
remind patients of the preparation they need to undertake
before coming for their appointment, and where on a map the
appointment is. Tangible and clear communications like these
convey to the patient the sense of a plan being formed.
Choosing a staff member for telephone scheduling and
counseling is no trivial matter. A person who is rude,
abrupt, or slow will have an outsized impact on your
patient’s experience. Consider splitting the task between
several people; the receptionist’s job is repetitive and tiring,
and it is helpful to fi nd ways to relieve stress and burnout.
Maintaining a caring and friendly attitude is in everyone’s
interest. Whatever attitude the patient is greeted with, or
whatever frustrations they harbor from the obstacles they
had to surmount to get to you, will be present when you
begin your evaluation.
Referring doctors handle their patients’ referrals in different ways. Some will have the patient call and make an
appointment without providing any information. Others will
give the patient background records and studies to pass on,
and some may even send a cover letter requesting the referral
with records and studies included. Sometimes, a referring
physician may be the fi rst person to call regarding the patient
and his problem. To aid the referring physician, the recording that usually greets him or her must be short and include
the option to go quickly to a “live person” who can put him
or her in contact with the surgeon. Listening to a long and
time-consuming recorded message can lead to a hang-up and
the loss of a referral. In recent years, we have maintained a
separate telephone line, the “back line”, for physicians. It is
provided to referring physicians who call frequently. The
referring doctors message needs to be conveyed to the surgeon whether he or she is in the offi ce or the operating room.
A good experience for referring physicians makes it more
likely they will call again. If the surgeon cannot be reached,
staff should arrange an appointment for the patient and
promise that the surgeon will be alerted so that a return call
can be made.
( AS Kumar ) I am in contact with many of my referring
physicians by e-mail. Through my hospital’s secure network,
they are able to send me the patient’s pertinent medical
records as PDF attachments, and I am able to ask them the
necessary questions to ascertain the urgency of the appointment.
Often, especially if I get a sense that the patient will need
1 The First Encounter
Fig. 1.1 An appointment
confi rmation notice with
a map can be extremely
helpful to patients
5
6
L.E. Smith and A.S. Kumar
minor surgery (e.g., a recent fi nding of anal dysplasia), I
appreciate having control over my clinical schedule to get
them triaged in time for an open, convenient slot in my operating room schedule. My referring providers appreciate how
rapidly I get the issue settled. They enjoy knowing that the
loop is closed. Often, the e-mail interaction with the referring physician is simply a quick reply that is forwarded to my
front desk staff to schedule the appointment. On occasion,
my front desk staff has been willing to e-mail the patient for
additional information. Some practices rely almost exclusively on new patient referral requests coming through the
Internet and hire staff specifi cally with this intent.
We look at the appointment schedule to review new
patients and their diagnoses. We grew accustomed to doing
so in residency when preparing for an upcoming clinic or a
case. If we see that a neoplasm or pain is involved and the
appointment seems to be too far in the future, we either alert
a nurse to get more information or telephone the patient ourselves to hear an abbreviated history. At that time, we can
reassert the need to bring the appropriate records and decide
if it is best to move the appointment up, or delay it for completion of studies that may have been ordered by the referring physician, or that we think to order. A simple call creates
an early bond that reassures the patient that you have their
interest at heart and that communication lines between
patient, the referring physician, and you are wide open. In
addition, word of this call may be transmitted to the referring
doctor, who will be appreciative of your efforts.
The Initial Encounter
Key concept : Oftentimes , the fi rst impression is your best
chance for a good impression — remember your appearance ,
demeanor , communication , and your organization have a
major impact on how you are judged by your patients .
The second chance to be judged by the patient is upon
arrival in the offi ce. Quick, amiable, competent service is
how you like your offi ce to be represented. At evaluations of
staff, these qualities need to be reinforced. Entry of data into
the electronic medical record must be as accurate as possible
so that you and others can easily access dependable records
in your practice and hospital. This electronic record is
impressive to patients and creates a sense that they are in a
technologically advanced setting.
Hopefully, the appointment schedule runs on time. Patients
often value their time as much as you do. There will be days
when surgery runs overtime, an outpatient shows up in the
emergency room, or a patient is found to be in trouble while
on rounds. Anticipate these delays as early as possible and
have a policy that gives patients the option to reschedule or
that estimates a realistic wait time. Generally, patients understand unexpected situations and delays in a hospital; they
imagine that if it were them that needed urgent attention, they
would appreciate the priority. Your desire to excel in the operating room is self-evident to your staff and patients. Apologize
to the long-waiting patient when you arrive late, but only the
briefest explanation of what detained you is necessary.
How you dress is a sign of respect for your patient. What
is in fashion has changed, and there has been a trend toward
informality. An exception is the military and uniform of the
day. Sometimes, you or the staff wear surgical scrubs in order
to save time when rushing to get to the offi ce. This should be
a rare occurrence because, with good planning, the offi ce
schedule should not be a reason to hurry an operation. We
encourage dressing with the respect that is warranted when
you tell a patient he has a chronic disease or a late- stage or
incurable cancer. As styles change, consider what you would
wear to church, a wedding, a job interview, or a funeral.
While a serious medical event is run-of-the-mill for you, the
patient sees it as a singular, personal, and even life- changing
medical problem. How you dress telegraphs respect or disrespect to the family of a patient and also lets your staff know
what is expected of them in the way of appearance.
After a short time in the waiting room, the patient usually
sees a nurse or nursing assistant who takes vital signs as part
of the physical examination. The basic forms for the review
of systems, past medical history, surgical history, and medications and administration times may be entered into the
record by the nurse as well. These records need to be
reviewed, updated, or corrected by the surgeon at a later
point during the evaluation. This record handling is another
opportunity to demonstrate professionalism and competency
and to reassure the patient. In a teaching setting, the student
or resident may start with the patient to gather a history.
A Formal Introduction
During the initial work-up by the nurse, student, or resident,
intercede to introduce yourself and explain your team’s roles.
The patient and family appreciate a formal introduction. It
will help them understand the roles that the nurse practitioner,
physician’s assistant, resident, or student plays in fi lling out
the history and physical in the record. To let the patient know
you have his or her facts committed to memory, you might
review the salient points of their story back to them, asking
for confi rmation. Alternatively, you can request that the pertinent history is repeated to you again to seal it in your mind.
The Physical Examination
The physical examination can be performed with the team
member (nurse, student, or resident) and surgeon together.
Usually, this will be the abdominal examination, digital rectal
1 The First Encounter
7
examination, anoscopy, and sigmoidoscopy. To explain why
so many people are involved, say “It’s good to have multiple
sets of eyes on this so we don’t miss anything” or “I’m going
to need a hand with some of the instruments so I have a few
helpers.” For male physicians, it is often good practice to have
a female member of the team present during the pelvic and
anorectal exams of women patients. A team- oriented physical
examination also helps to sell your team as a competent unit.
If a sink is in the examination room, wash your hands in
front of the patient both before and after the examination.
Patients appreciate this after so much publicity regarding the
safety promoted by hand washing. Patients do not like to
have their bare bottoms exposed, so try to position the table
so that the patient’s head faces the door. If you traditionally
examine the patient in the knee-chest position, consider installing a curtain to be drawn in front of the exam room door.
Patients feel vulnerable not being able to see what you are
about to do. Talk the patient through every part of the examination. Predict what the patient may experience and give a
warning that a fi nger is entering the anus or vagina, or estimate
and verbalize the size of an instrument relative to your fi nger.
Let them know that an urgency to defecate is normal and not
to move if a cramp occurs. We have found that a letter sent to
the patient prior to the appointment which explains that a rectal exam is a standard part of a colorectal fi rst encounter, helps
establish a sense of preparedness for this intimate and sometimes uncomfortable part of the exam. Also, suggest to patients
that they consider clearing their rectal vault of any contents by
self-administering an over-the- counter saline enema 2 h prior
to the visit. This is something that, when done in the privacy of
home, helps the patient mentally prepare for what may ensue
during your examination.
If pain is elicited, perform the painful examination only
once. If there is no perception of pain, the step may be
repeated by the other examiner, with the introduction “you
are going to feel another fi nger now.” Depending upon the
working diagnosis, pain may be predicted with some manipulations, while some exams should not be painful. In any
case, an effort to minimize pain will endear you to your
patient. For example, lubricate the fi nger or instrument liberally and be gentle. If you see an obvious fi ssure, do not feel
obligated to perform a digital rectal examination or anoscopy on the fi rst visit. Sometimes, asking the patient to push
out against your fi nger not only relaxes the muscles but gives
the patient an action to focus on so that he or she will not
immediately tense up when sensing your hand nearby.
steps. If the pathology is favorable, consider telephoning
the patient to relay the good news. This demonstrates to the
patient that you are thinking of him or her. Do not put off
the call. Often, the patient is anxious and waiting by the
phone. If a weekend is near, and the result is favorable, telephone them with the happy result, even if it is late on Friday
night. Waiting and not knowing a pathology result exacerbates patient anxiety. Hearing from you during the “offhours” especially impresses a patient. If the pathology is
foreboding, wait for the scheduled appointment or move
the appointment sooner.
( AS Kumar ) I employ e-mail to communicate with
many patients about their pathology. After taking a biopsy
and before leaving the patient’s side, I discuss the option
of receiving the results by e-mail. In an era of exorbinent
outpatient co-pays, I sympathize with the patient’s interest in avoiding another face-to-face encounter. If e-mail is
an option, we can spend a few extra minutes at the initial
encounter itself, talking through the potential next steps
based on the outcomes of the pathology report. The e-mail
that I ultimately send encloses a digital version of their
entire report and includes a summary of my impressions.
I ask the patient to reply with a phone number and a good
time for me to call to discuss it further. This step empowers the patient, since many like to keep shadow copies of
their medical records and also like the opportunity to
share the diagnoses with the primary care provider.
Sophisticated electronic personal health systems employ a
web portal where patients log in to see their personal
health record and interact with their physicians. This
allows them to access their laboratory and pathology
reports and correspond with their physicians via the
secure portal (Fig.
1.2 ) [ 1 ]. Nonetheless, I am careful to
get the patient’s permission before sending an e-mail,
since the Internet is not a fully private environment. Many
institutions’ e-mail servers provide a disclaimer statement
(Fig. 1.3 ) that underscores that your e-mail is a confi den-
tial communication to them. I take the extra step of committing e-mails to and from patients in the electronic
health record (EHR) under the “letter” or “correspondence” sections. Similar to a “phone note,” this step makes
your electronic conversation with the patient or providers
an integral part of the medical chart.
The Team and Teaching
Conveying Pathology Results
When biopsies are taken or a biopsy result is outstanding,
have the patient schedule an appointment within the week
to come back and learn the result and plan the ensuing
Key concept : Each member of the team plays a critical role —
ensure the patient understands who everyone is and what
that role encompasses . Have several different platforms (i.e.,
brochures , videos , online links , support groups ) of educa-
tional resources available for your patients .
8
L.E. Smith and A.S. Kumar
Fig. 1.2 Internet portals can allow patients to access their personal health records ( With permission from Kaiser Permanente [ 1 ] )
MedStar Health
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a
Chesapeake Potomac Regional Cancer Center
The PHI (Protected Health Information) contained
in this FAX/email is HIGHLY CONFIDENTIAL.
It is intended for the exclusive use of the addressee.
It is to be used only to aid in providing specific
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b
Fig. 1.3 Confi dentiality statements employed by institutions’ Internet transmissions at ( a ) MedStar Health ( b ) Memorial Sloan Kettering and ( c )
Chesapeake Potomac Regional Cancer Center
The Team’s Role
others who will be working with the patient and emphasize
that these same people may be present at the hospital or dur-
At a convenient break during the fi rst outpatient visit, explain
that the team consists of a nurse, nurse practitioner, physician’s assistant, residents, other surgeons, ostomy nurses, or
ing follow-up. For example, you may volunteer that they
might be speaking to the nurse by telephone to answer questions, to residents or partners for hospital rounds, or to nurse
c
1 The First Encounter
9
ba
Fig. 1.4 Brochure racks are a simple and affordable solution for patient education. ( a ) An example of what is displayed in a patient exam room;
( b ) in our nurses’ room, information about ostomies is also provided
practitioners or physician’s assistants during follow-up. This
never frees you as the surgeon from your ultimate responsi-
Educational and Informational Resources for Patients
bility—rounds and follow-up are a part of your primary obligation to your patients.
The patient may wonder why there are so many people
involved. You can assure them that each team member
plays a valuable role, that many minds are dedicated to
their problem, and that not a step will be missed. It also
serves to keep everyone educated. For a colon and rectal
surgery resident or a chief resident, you can add that they
are a trained (often board certifi ed) general surgeon or are
about to fi nish a rigorous general surgery-training program.
The residents provide an additional observer of progress or
problems and a level of continuity if surgery and hospitalization are contemplated.
Repetition is a form of teaching. Direct your patient to the
many resources for more information, such as pamphlets or
videos. Educational aids are readily available from several
sources. The American Society of Colon and Rectal Surgeons
(ASCRS) and the Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES) have brochures and videos
that address the various diseases and surgeries of the colon,
rectum, and anus. Such educational references can set up as
hyperlinks on your practice’s website. Putting up a brochure
rack (Fig.
1.4 ) is a small investment, but videos and custom-
ized websites may be costlier. As an alternative, provide the
patient with the links to websites you trust. Both ASCRS and
10
L.E. Smith and A.S. Kumar
a
Fig. 1.5 Specialty society websites provide patient information. ( a )
American Society of Colon and Rectal Surgeons (ASCRS) ( With per-
mission [
2 ]); ( b ) Society of Gastrointestinal and Endoscopic Surgeons
SAGES have patient-specifi c links (Fig. 1.5a–c ) [ 2 , 3 ], which
also include written and video testimonies from patients who
have had specifi c colorectal issues [ 4 ]. Take a few minutes to
browse the web for materials relevant to the patient’s situation. An endorsement from you will be more productive than
leaving your patient adrift on Internet search engines.
Support Groups and Personal Resources
We sometimes encounter patients who declare, “I will never
have an ostomy,” and this is always a tricky conversation.
What helps is to acknowledge their desires but also ask that he
or she investigate and get all the information. As necessary,
they can then revisit the issue with you, or if there is a misunderstanding, then schedule a revisit for a repeat discussion. It
is an overwhelming decision to choose a permanent ostomy on
the fi rst encounter with you, especially if their primary care
provider has not previously broached the subject. In cases like
these, it is best to introduce the possibility of an ostomy, and
b
(SAGES) ( With permission [
multiple languages ( With permission [
3 ]); ( c ) SAGES Patient information in
3 ] )
c
then give some time for the news to sink in. Then patients can
check in with their support systems, as well as others that you
may suggest. Many communities have support groups. Our
region has several ostomy help groups, which have trained
ostomates to share their situations and show that they are able
to go about their lives. It is reassuring for a potential ostomy
patient to see someone who is a match in disease, gender, and
age and who is living well. An educated patient is your ally
and will work with you to get the best outcome. Also, linking
an ostomy nurse to your practice is a valuable asset in instructing a patient about the practical use of an ostomy. A patient
will learn more readily before surgery than after when postoperative pain and anxiety may interfere with concentration.
Counseling and Consent
Key concept : An upfront , open , and honest discussion regarding
the risks , benefi ts , and alternatives to your planned management
is the key to successful counseling and managing expectations .
1 The First Encounter
11
After the history, physical, review of the available studies,
and a call to the referring physician (if necessary), a plan is
formulated. The patient should not leave the offi ce without
this plan fi rmly in mind. Missing pieces such as additional
studies or communication with other doctors must be fi lled
in. Release-of-information forms must be signed, studies
ordered and scheduled, and follow-up arranged. Accounting
for each step conveys to the patient a sense of effi ciency and
relief that a plan is in motion. Many term this concept “onestop shopping”. If information is complete enough, the management discussion can start. If the course is surgery, the
informed consent requires a discussion of risks, benefi ts, and
alternatives, the procedure(s) recommended, and the possible complications. In communicating potential risks and
complications, we counter the inevitable fears by offering
that permanent morbidity or mortality is statistically possible, but usually not a great probability. A cancer diagnosis
means that therapy needs to begin within a month, i.e., chemotherapy, radiation, or surgery. Document everything you
recommend.
Honesty is the key to successful counseling. Your training, postgraduate education, and experience reinforce the
standards of care that you live by. If your opinion differs
from that of another physician, explain the standard of care
for colon and rectal surgery as you honestly know it. Educate
the patient and family in clear, simple terms. This brings
them to the point where they can understand you and make
informed decisions. We do not routinely offer our volumes of
similar operations, outcomes, or experiences unless patients
ask. Seldom do we know these numbers unless a targeted
effort has been made to collect the data. As electronic data
collection becomes uniform (such as in the case of the
Surgeon Specifi c Registry [
comparisons to national standards, will be available (Fig. 1.6 )
[ 5 ]. In the days of an implicit trust in the healthcare system
and its practitioners, more patients just said, “do what you
need to do.” In recent years, patients are emboldened to ask
more questions. Patient’s rights need be honored. An
informed patient is an understanding patient. If your recommendations are not within the standard of care, the plan
could be deemed research or experimental, and a protocol
should be reviewed by the investigational review board (IRB)
of your hospital. If it is research, the elements of a research
informed consent need to be included as per the IRB.
Counseling is one thing, and critical instructions are
another. For example, with a patient who needs a colonoscopy, the surgeon must review possible complications and
stress the need for good colon preparation. Critical instructions are needed for other procedures or studies. The colonoscopy scheduler and the person who goes over the preparation
of the colon may not emphasize the importance of a perfectly
clean colon, so a word from you may be necessary. Explain
that a poorly prepared colon hinders your ability to see and
may force cancellation of the colonoscopy. Also keep in mind
5 ]), more of your case data, and
that patients often fl out the rules and overestimate their abilities after discharge, assuming that they can take a taxi alone
or fi nd their own way home on public transportation. Many
institutions require that if sedation is received, an escort is
required. Make it clear to the patient that the absence of an
escort may result in procedure cancellation, which is especially frustrating to a patient who has completed a bowel
preparation. We have found that we cannot always rely on our
schedulers to convey this critical piece of information, so we
take a few moments to go over it personally.
Diffi culties at the First Encounter
Key concept : Recognize potential barriers to your patient ’ s
overall care , be prepared for the diffi cult questions , and ,
again , rely upon an open and honest discussion in educating
and counseling your patients .
Physical, Psychological, or Language Barriers
Some patient diffi culties are apparent immediately, such as
obesity, diffi culty walking, shortness of breath, or pallor, but
others do not emerge until the patient starts to talk. Language
barriers, limits on mental capacity, anxieties, denial, and
inappropriate expectations are among the obstacles you will
encounter.
The patient may not be fl uent in English, so have an interpreter available. Since Spanish is frequently a fi rst language, a
Spanish-speaking employee can provide a valuable bridge
while arrangements are made for an interpreter. Often, the
patient recognizes the language problem and brings a friend or
relative who can interpret. The initial phone call usually alerts
your receptionist to the language situation, and arrangements
can be made in advance. Similar arrangements need to be
made if the patient is a minor, needs a guardian, is mentally
compromised, or needs consultation via a power of attorney.
The Internet: A Double-Edged Sword
Patients, friends, and relatives all go online to learn about the
disease. At the same time, they may use the Internet to read
about you. Being board certifi ed equates with “better” in many
patient’s minds. Since your education is usually listed, you
may need to be ready to discuss where you studied and why or
why you have stayed in the area or moved so many times.
( AS Kumar ) Many surgeons view free online profi les such
as healthgrades.com or vitals.com [
fact, this can be a tremendous marketing advantage if you take
some time to feed the sites correct information and a photo [
If your practice does not have or cannot afford a web presence,
these sites could help promote your practice and yourself. As
6 , 7 ] as a nuisance, but in
8 ].