Goal Setting: A case note in a professional setting

“We learn wisdom from failure much more than
from success. We often discover what will do by
finding out what will not do; and probably he who
never made a mistake never made a discovery.”1d
Samuel Smiles (1816-1904)

Gynaecologic, urologic, and colorectal surgeons use a wide variety of operative interventions to treat certain disorders of the pelvic floor. However, nearly one third of women undergo repeat surgery to treat urinary incontinence, pelvic organ prolapse, and/or faecal incontinence.[1]

Until relatively recently there has been a paucity of data regarding patient expectations following treatment. Patient’s expectations regarding outcome may be shaped by previous personal experiences, those of friends and relatives and also by the attitude and experience of the clinician. Consequently the concept of ‘cure’ is relative. Achieving anatomical restoration of the urogenital tract may not be regarded as a cure if new symptoms related to urinary, sexual and bowel dysfunction are experienced following surgery. An alternative way of examining patient expectations of treatment is that of patient orientated goals[2]

Women’s goals for reconstructive pelvic surgery are personal and highly subjective. Lifestyle factors seem to play a large role, with many women focusing on return to missed activities (‘‘I want to be able to play with my grandchildren’’ or ‘‘I want to go back to an exercise routine’’), whereas others focused on resolution of the particular problem (‘‘I want the bulge gone’’ or ‘‘I don’t want to leak when I cough’’). For each woman, achievement of patient-selected goals is the primary reason for undergoing surgery. In fact, women’s expectations of goal achievement are so strong that even extensive presurgical counseling does not eliminate unrealistic hopes.

Women ‘‘hear’’ primarily what interests them. Selective attention may explain why women who are unhappy because of side effects or complications, often state that no one ever told them that this could happen and they were not well prepared for surgery. These women feel that the side effects of surgery were worse than the pre-existing problem. Achievement scores for sexual function, activity, and lifestyle goals highly correlate with satisfaction, whereas concrete goals such as prolapse resolution may not predict satisfaction. This contradict the traditional physician belief that objective cure without serious complications is the best measure of surgical success. In treating a disorder that affects quality of life, the patient’s perception of her quality of life and goal achievement appears to affect overall satisfaction more than traditional measures of surgical success. Possibly, aspects of postoperative care such as pain control, management of side effects, and greater preparation for expected events require more careful and timely attention to alleviate patient dissatisfaction.

Patient expectations regarding their treatment and the development of a patient and physicians ‘contract’ to establish treatment goals prior to surgery or medical therapy, may lead to greater patient satisfaction and provide a more meaningful measure of outcome and consequently offer a definition for ‘cure’.

[1] Olsen AL, Smith VJ, Berstrom VO, Colling JC, Clark AL(1997) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol;89:501-6

[2] Hullfish KL, Bovbjerg VE, Gibson J, Steers WD. Patient centered goals for pelvic floor dysfunction surgery: what is success and is it achieved? Am J Obstet Gynaecol 2002; 187: 88-92.