By Martti Vastamäki, MD

I have worked 50 years as a surgeon now. I received my orthopedic specialty in 1978 and graduated as a hand surgeon in 1980. My first two scientific publications were published in 1968. One dealt with the structure of mollusc collagen (Finland was that time one of the leading countries in collagen research in the world) and the other with radioactive isotope examination of the rheumatoid wrist. Both were last cited last year. I’ve handled about 100,000 patients and will continue my clinical and operational as well as scientific work, with about 70% efficiency.

My health has been moderate. One carotis interna artery 80% occlusion, operated, hip arthroplasty, spinal stenosis, once operated, recurred, walking distance 200 m, coronary stenosis, medication, prostate hyperplacia, medication, etc. Never glasses!

Building trust is an important instrument in a career as a hand surgeon. “Patients trust us. We can’t take that trust for granted.”

For this post, I have borrowed some points of Axelrod and Goold’s excellent article from the beginning of this millennium (Axelrod DA, Goold SD. Maintaining Trust in the Surgeon-Patient Relationship. Arch Surg. 2000; 135 (1): 55-61. DOI: 10.1001/archsurg.135.1.55). The things they were saying then still hold true today, and also with us, hand surgeons.

 “Changes in the technology and infrastructure of health care have resulted in new, challenging ethical dilemmas for surgeons and their patients. Surgical therapy has been radically expanded by technological advancements and novel diagnostic imaging technologies.” Also, hand surgeons are now better equipped to care for older, sicker patients than ever before. “The rapid expansion of an aging population together with this technology has contributed to dramatically higher health care expenditures. While improved anaesthetic techniques and minimally invasive procedures have allowed many more operations to be performed with shorter inpatient stays or even on an outpatient basis, the overall economic cost of surgical care is increasing.” In connection with this fact, our hand surgeons should always bear in mind that we strive for good treatment results with a reasonable financial effort. Although our own merits could be somewhat diminished.

“Interpersonal trust relationships are typically found where there are conditions of risk and uncertainty—certainly present also in hand surgery. The trusting patient is placed in a position of vulnerability to the surgeon. The patient grants discretionary power to the surgeon to achieve something the patient desires, usually better health or even the preservation of life.” This also applies to hand surgeons, even though our patients are relatively rarely at risk in our care.

“Excellent communication skills, strong clinical and technical abilities, and sound ethical judgment are the crucial elements in facilitating the transfer of trust from patient to surgeon.” Here in Finland, patients often complain that doctors “talk” to their computer rather than look at their patient. Unfortunately, this is often close to the truth. I have always used to make essential notes in a hand-written booklet and only after careful examination of the patient to write a coherent text on patient visit. The patient feels that the doctor has listened and examined the patient without the computer’s interference.

Sound ethical judgment is the cornerstone of trust. A patient of a hand surgeon must also be able to trust that the doctor does not think more dollars than the best for the patient. Money has sometimes been a problem, also in Finland. It is known that on the private side the threshold for operative treatment is often much lower than on the municipal side. I have been in a position where I have been able to decide my indications for surgery independently as a chief physician for over 40 years. It has always been my guiding principle that I will operate on the patient only if I myself would like to have surgery as a patient in the same situation or if the patient was a close relative or friend of mine. This principle has helped to avoid “attractive treatments” that would have yielded ten times more than conservative treatments. This principle does not apply to cancer treatments.

“To enhance patient trust, surgeons need to critically evaluate the outcome of surgical therapy, particularly through patient-reported outcomes research. By embracing this type of research, surgeons demonstrate to their patients a commitment to improving their life and health rather than merely to achieving technical successes.” This is a very important part of the patient’s care. In fact, clinical scientific rigorous examination and documentation of patient care outcomes are the basis of good care. It is known that many private clinics, including hand surgeries, all over the world do not invest enough in the scientific follow-up studies. Without it, good care in its best sense cannot be talked about. As an example, e.g. in the field of hand surgery, the Mayo Clinic can be considered, where special attention has been paid to clinical follow-up studies for decades. In fact, I’m almost 50 years and made this clinical follow-up evaluation and tried to develop instruments to improve it. An example of this is the recently released TOS patient quality of life questionnaire, TOSI, which I hope will be in use worldwide in the next few years. Validity and internal consistency of the thoracic outlet syndrome index for patients with thoracic outlet syndrome (Vastamäki M, Ruopsa N, Vastamäki H, Laimi K, Ristolainen L, Saltychev M. J Shoulder Elbow Surg. 2019 Aug 29. pii: S1058-2746(19)30397-0. doi: 10.1016/j.jse.2019.05.034. [Epub ahead of print]).

For me, of course, the patient’s trust and confidence in their hand surgeon has also been boosted by the doctor’s diplomas on the wall of his office. An example of this is my Pioneer of Hand Surgery diploma, which I was awarded at the IFSSH Congress in Buenos Aires 2016, and the Pioneer of Shoulder and Elbow Surgery I received at the ICSES Congress 2019, at the same location in Buenos Aires.

I wish all ASSH members a very successful decade and a good relationship of confidentiality between you and your patients.

Martti Vastamäki, M.D. Professor