Patient perspectives on postoperative
visits after common general operative
G. Paul Wright, MD,a,bAndrea M. Wolf, MD,a,b,cGavin Ambrosi, MD,bMatthew B. Dull, MD,a,b
and Mathew H. Chung, MD, FACS,a,b,cGrand Rapids, MI
Background. Many postoperative concerns after common general operative procedures may be addressed
over the phone, thereby saving time and resources for both the patient and surgeon.
Methods. Over a 6-month time period, patients who underwent laparoscopic cholecystectomy,
appendectomy for uncomplicated appendicitis, and inguinal or umbilical hernia repair were mailed an
anonymous survey. The primary outcome measure was whether or not patients felt their concerns could
have been addressed adequately over the phone in place of an office visit.
Results. A total of 1,406 surveys were mailed with 339 responses (24%: 174 laparoscopic
cholecystectomy, 83 inguinal hernia, 41 appendectomy, and 41 umbilical hernia). One hundred twelve
(33%) felt their concerns could have been addressed adequately over the phone without an office visit.
Patients who spent less time with their doctor at the appointment favored telephone follow-up (P <.001).
Patients undergoing inguinal hernia were less interested in telephone follow-up compared with laparo-
scopic cholecystectomy (15% vs 41%; P < .001), appendectomy (15% vs 34%; P = .018), and
umbilical hernia (15% vs 37%; P = .010). Of 66 patients (20%) with self-reported complications,
44% sought care from a healthcare provider other than their primary surgeon.
Conclusion. These observations are important for healthcare organizations seeking to maximize surgeon
efficiency while improving patient satisfaction. (Surgery 2013;154:934-40.)
From the Grand Rapids Medical Education Partners/Michigan State University General Surgery Residency
Program,athe Michigan State University College of Human Medicine,band the Spectrum Health Medical
Group,cGrand Rapids, MI
THE TREATMENT OF COMMON general surgical prob-
lems, such as gallbladder disease and appendicitis,
has undergone a substantial evolution over the
past 25 years. With the advent of the laparoscopic
cholecystectomy in the late 1980s, duration of hos-
pital stay decreased dramatically, and care soon
shifted to an ambulatory model.1-3Similarly, outpa-
tient protocols have been developed and em-
ployed in the treatment of appendicitis and have
long been used for uncomplicated elective hernia
repair.4These protocols all center on the low
morbidity rates demonstrated after these proce-
Healthcare reform remains a hot topic, partic-
ularly in the face of the recent presidential election
and debates regarding the Affordable Care Act.10
With implementation of this new legislation
pending, access to care is likely to increase to pre-
viously unseen levels. When considering the
increasing elderly population and relatively static
continue to search for ways to maximize surgeon
efficiency while attempting to decrease burnout
and cost.11In a 2004 report, an expected increase
in the general surgery workload of 32% was antic-
ipated by 2020.12
Postoperative follow-up occurs typically 1–2
weeks after operation or hospital discharge. For
low morbidity procedures, however, in-office post-
operative follow-up may not be necessary.5Proto-
cols for phone call follow-up by nurses have been
described in the pediatric surgery literature with
successful outcomes and patient (parent) satisfac-
tion.13-16Favorable results have been published
from the United Kingdom and Australia for phone
call follow-up for common general surgery proce-
dures as well.17-19With no domestic data available,
we sought to evaluate patient perspectives on post-
operative follow-up visits with general surgeons in
Accepted for publication May 10, 2013.
Reprint requests: G. Paul Wright, MD, GRMEP/MSU General
Surgery Residency Program, 1000 Monroe NW, Grand Rapids,
MI 49503. E-mail: firstname.lastname@example.org.
0039-6060/$ - see front matter
? 2013 Mosby, Inc. All rights reserved.
the Institutional Review Boards of Spectrum Health
Systems and Saint Mary’s Health Care and was
granted exemption status. Compliance with HIPAA
standards was maintained at all times. General
surgeons at 3 university-affiliated, community hos-
pitals were recruited for participation. Contact
information was obtained for patients who under-
went designated operative procedures over a
6-month time frame. Procedures targeted were
outpatient or short-stay procedures, including lapa-
roscopic cholecystectomy, appendectomy for un-
complicated appendicitis, elective inguinal hernia
repair, and elective umbilical hernia repair. All
patients were given printed discharge instructions
after the procedure. Patients meeting these criteria
institution not affiliated directly with the surgeon’s
office. Responding to the survey served as informed
consent for participation in the study as outlined in
a letter attached to the survey. The survey questions
are listed in Table I with available responses in
The primary outcome measure was whether or
not patients felt their postoperative concerns
could be addressed over the phone in place of
an office visit. Patient responses were compiled
into an electronic database for analysis. Groups
were analyzed for the primary outcome measure
using either the 2-tailed Fisher’s exact test or Chi-
square test as indicated for univariate analysis.
Multivariate analysis was performed using a logistic
regression model that included all variables with
P < .20 on univariate analysis.
A total of 1,406 surveys were sent to the patients
of 22 participating general surgeons. Three hun-
dred thirty-nine (24%) completed surveys were
received (Table II). The median age of respon-
dents was 56 years (range, 18–91). Respondents
were divided relatively equally by gender and the
most common procedures were laparoscopic cho-
lecystectomy and inguinal hernia repair.
Survey responses are found in Table III. Most
patients were seen promptly by their surgeon and
spent <10 minutes with them. Few patients in
this mid-sized city traveled to their visit using pub-
lic transportation. The most common concerns ad-
dressed were pain at the incision site(s) and return
to work. Sixty-four respondents (19%) addressed
>1 concern at their postoperative visit. Common
‘‘other’’ concerns listed by respondents included
dietary modifications, healing of the incision,
and restrictions of activity. One third of respon-
dents felt a phone call would have been sufficient
to address their concerns in place of the office
visit; one quarter felt follow-up was not necessary
after operation. The overwhelming majority stated
they would contact their surgeon if they experi-
enced a postoperative complication. Despite this
response, almost half of the 66 patients with self-
reported complications sought care from a source
other than their primary surgeon.
Results for the primary outcome measure are
listed in Table IV. Patients who spent less time with
their surgeon; had greater total visit times;
received transportation from a spouse or friend;
underwent laparoscopic cholecystectomy, appen-
dectomy, or umbilical hernia repair; and those
who reported no postoperative complications
were more receptive to phone call follow-up. There
were no differences between groups in age or
gender, waiting times, or by the type of time off
from work needed to complete the follow-up visit.
Multivariate analysis demonstrated that the type
of operation, physician time spent with the patient,
and occurrence of self-reported complications had
the greatest influence on responses to phone call
follow-up (Table V). Age, total time spent on the
office visit, and method of travel were not different
Routine postoperative office visits after standard
general operative procedures are commonplace.
These visits allow the surgeon to examine the
patient for any signs of surgical site infection or
other postoperative complications in addition to
providing a forum for various patient concerns
including incisional pain, wound healing, and
return to work or activity. With large datasets
demonstrating low morbidity rates for many com-
mon operative procedures, routine follow-up in
the form of an office visit may not be necessary.5
the need for postoperative follow-up and the feasi-
bility of doing so via a phone call. Although 66% of
patients felt that some type of follow-up was neces-
sary, one third felt that a postoperative phone call
would be an adequate vehicle for addressing their
concerns. Patients undergoing laparoscopic chole-
appendicitis, and umbilical hernia repair were
more comfortable with phone call follow-up. For
laparoscopic cholecystectomy alone, a phone call
follow-up could save >400 office visits annually in
Volume 154, Number 4
Wright et al 935
our community. In contrast, only 15% of patients
who underwent inguinal hernia repair felt that a
phone call alone would be sufficient.
In our series, all appendectomies were treated
as 23-hour, short-stay procedures. The laparoscopic
cholecystectomies and hernia repairs were sched-
uled outpatient procedures, of which <5% stay
overnight historically at our institutions. For
short-stay procedures, all patients were seen by
a physician, either a surgery resident and/or
attending before discharge. All outpatients are
discharged by the postoperative recovery staff
based on predetermined criteria. Although pa-
tients may feel more comfortable with their post-
operative care if they are seen by a physician before
discharge, we did not see evidence of this in our
dataset, which would be an important distinction
in future studies on this topic.
Despite widespread use of all the procedures
investigated here in a short-stay or ambulatory
setting, inguinal hernia repair poses unique chal-
lenges in postoperative care. Substantial postoper-
ative swelling and pain are common, and many
this occurs. The palpable ‘‘healing ridge’’ after
standard open operative repair is another ordinary
source of concern. Inquiries regarding return to
work and other normal activities are addressed at
postoperative follow-up and serve to reassure pa-
tients about the recovery process. Although we did
not separate laparoscopic from open repairs, the
open technique remains more prominent in our
community. Purported claims of a more rapid
recovery process in laparoscopic inguinal hernia
repair are outside the scope of this study.20
In addition to differences based on operative
procedure, both the amount of time spent with the
surgeon and total time dedicated to the post-
operative visits impacted patient responses. Those
who spent <5 minutes with their surgeon were far
more approving of phone call follow-up compared
with other groups. Although this subgroup may be
biased for obvious reasons, this highlights that in
an uncomplicated postoperative course, there is
often little substance to the in-office visit. We also
found that all 10 patients who spent >2 hours’
time in aggregate for their visit felt that phone call
follow-up would be sufficient. For practitioners
Table I. Survey questions
What is your age?
Are you male or female?
What operation did you have performed (laparoscopic cholecystectomy, appendectomy, inguinal hernia repair,
umbilical hernia repair)?
How long did you spend waiting to see the doctor (<5, 5–10, 10–20, >20 min)?
How much time of your visit was spent with the doctor (<5, 5–10, 10–20, >20 min)?
Including travel time, how much total time was spent for your postoperative visit (<30 min, 30–60 min, 1–2 h, >2 h)?
How did you travel to your appointment (public transport, ride from friend/spouse, drove self)?
How would you classify your time off work for this appointment (paid time off, unpaid time off, no time off/
What concerns, if any, did you address with your doctor (pain at incision site, drainage from wound, fever, return
to work, other, did not have any concerns)?
Do you feel a phone call would have been adequate to address your concerns in place of an office visit (yes, no,
Did you feel a follow-up appointment was necessary (yes, no, not sure)?
If you had a complication after surgery, how would you be most likely to seek medical care (surgeon, primary care
physician, emergency room/urgent care, other)?
Did you experience any complications before your office visit (yes, no)?
If yes, who did you contact regarding your complication (surgeon, primary care physician, emergency room/urgent
Table II. Demographics
Inguinal hernia repair
Umbilical hernia repair
936 Wright et al
with a wide geographic referral base, phone call
follow-up may be advantageous and more conve-
nient for patients.
The final portion of our survey queried patients
regarding their method of follow-up if they expe-
rienced postoperative complications. Although
these were self-reported complications and not
necessarily true surgical morbidities, the results
are interesting. Only 56% of patients with compli-
cations sought care from their primary surgeon.
This phenomenon is difficult to explain based on
the limited information from our data, but follow-
up by someone other than their surgeon may
indicate that many patients are less comfortable
with their surgeonthan other healthcare
Table III. Survey responses
Waiting time (min)
Time spent with surgeon (min)
Total time (min)
Method of travel
Ride from spouse/friend
Time off work
Pain at incision site
Drainage from wound
Return to work
Did not have any concerns
Phone call sufficient
Care if complication
Call surgeon’s office
Call primary care physician
Visit emergency department or urgent care
Complications before visit
If yes, care received
Primary care physician
Emergency room/urgent care
Table IV. Is phone call follow-up sufficient?
Waiting time (min)
Time with surgeon
Total time (min)
Type of operation
71 (47.7) 78 (52.3)
12 (16.7)60 (83.3)
*Responses of ‘‘not sure’’ not included.
yPatients who spent >30 minutes not included (n = 2).
Volume 154, Number 4
Wright et al 937
providers. The reasons for this are unclear,
although decreasing accessibility
owing to more strenuous workloads may be
partially responsible. These other avenues of
care, however, may be equally appropriate for
some minor complications compared with surgeon
follow-up. This concept serves as a reminder of the
importance of establishing rapport on the initial
consultation and providing appropriate informa-
tion on how, when, and where patients should seek
care in the postoperative period.
Increasing demands on general surgeons are
multifactorial. An increase in the baby-boomer
expectancy have provided a large population of
patients with common complaints, such as gall-
bladder disease or hernias. Unparalleled accessi-
bility to care is expected as a byproduct of the
Affordable Care Act.11With changes in lifestyle
preferences among younger providers and in-
creases in hospital employment of physicians, a
surgeon shortage may exhaust the resources of
continue undoubtedly to search for ways to maxi-
mize surgeon efficiency while decreasing potential
burnout from these demands. The results from
our study should provide useful information that
could improve on office practice efficiency while
maintaining patient satisfaction.
phone call follow-up have been published previ-
ously in the UK and pediatric populations, there
are several potential downfalls from this strategy.
Office follow-up in the postoperative period pro-
vides a safety net to ensure complications are not
missed. Missed complications from phone call
morbidity, although this is purely a theoretic
with increased life-
concern. In an era of unprecedented numbers of
care transitions, the patient–physician relationship
has changed to a degree as well. Continuity of care
throughout the perioperative period can reinforce
patient trust in surgeons and lack of postoperative
follow-up has the potential to fracture that rela-
tionship. The medicolegal implications of a phone
call follow-up system are a reasonable concern
given the litigious nature of our society.
The major limitation of this study is its cross-
sectional design, as well as the relatively low
response rate of 24%. Patient bias based on
feelings toward their surgeon, both positive and
negative, and impression on the quality of care
received likely influenced responses. The findings,
however, substantiate the formation of a prospec-
tive protocol for phone call follow-up while still
leaving the option for an office visit. This targeted
approach could save time and resources for
surgeons and patients, with cost-efficiency serving
as a crucial outcome variable in any prospective
studies. In conclusion, many patients are receptive
to phone call follow-up after common general
operative procedures. Proactive pursuit of solu-
tions to the increasing demands on surgeon’s time
will remain vital in the face of a surgeon shortage.
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Table V. Multivariate analysis
Type of operation
Inguinal hernia repair
Umbilical hernia repair
Time with surgeon (min)
938 Wright et al
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Dr John Mellinger (Carbondale, IL): I want to
congratulate Dr Wright and colleagues from Michigan
State Grand Rapids for their effort to explore a key issue
that we will be facing, as you’ve outlined, in the surgical
workforce in the years ahead: What is the patient’s view
of our hallowed tradition of a routine postoperative visit?
Although your response rate of 24% with the survey
instrument certainly leaves openness to bias, based on
the limited reporting, this sample of >300 patients that
weighed in on this issue, along with the absence of any
data, as you point out in your manuscript, on this
subject, from a US-based population, make the paper
very worthy for our consideration.
Your take-home lesson, that it all depends, including
on the type of operation as well as the amount of time
the surgeon spends with the patient, are worthy points of
emphasis for all of us to consider as physicians. Your
manuscript is well written, and I commend it to the
I offer the following questions to you, Paul. First, can
you tell us what percentage of the patients were cared for
as overnight or 23-hour stay type patients, as opposed to
true outpatient surgery? You could hypothesize that,
even if brief, a certain amount of postoperative educa-
tion in the hospital, for those that stayed closer to 24
hours, might make a difference in their perceptions
regarding the need for postoperative follow-up.
Second, do you have any other information on
patients who sought input from other providers other
than their surgeon for self-reported postoperative com-
plications? We’ve long known as surgeons that certain
kinds of patient complications may not return to us. For
example, recurrences after we fix someone’s hernia.
And it’s interesting that even for early postoperative
follow-up for fairly simple operations, almost half the
patients, when they had a perceived need or complica-
tion, sought their help from someone other than their
surgeon. Does this suggest perhaps that we are forming
more casual professional relationships with our patients
and are being perceived more as interventionalists
rather than real physicians with this outpatient surgery
population? If so, how would you recommend we
address that in the future?
Dr G. Paul Wright (Grand Rapids, MI): To address
the first question, the brief answer is, no, we did not
relate any patient outcomes to the survey results received
from our respondents. I can tell you some historical data
from our institution. For appendectomy, 100% of the
cases involved were short-stay procedures or 23-hour
stay procedures. All of these patients were seen by, at
For the other 3, the hernia repairs and laparoscopic cho-
lecystectomies, approximately 90–95% are done as a
pure outpatient basis.
The second question is interesting, and something
that we didn’t expect to find based on our patient
responses. The impetus for including the question
originally was that there are no domestic data available
on this particular topic. And the data from Europe,
Australia, and New Zealand on this topic focuses on the
gatekeeper concept, because the general practitioner
sees these patients often postoperatively.
We asked the question in 2 ways. The first question
was whether or not the patients perceived experiencing
a complication. If they did, we asked who they sought
care from. And interestingly, only 56%, as you said,
sought care from their primary surgeon.
We also asked patients who did not experience a
complication, in a hypothetical scenario, if they did, who
would they seek care? And we found that 90% of those
said that they would seek care with their surgeon. I’m
not exactly sure where that discrepancy comes, but I
think it’s just probably a reflection of patients’ comfort
with their surgeon.
In terms of recommendations for how to address
these issues, I think the statement ‘‘You never get a
second chance to make a first impression,’’ probably
holds true here. The relationship between patient and
physician is established at that first preoperative consul-
tation and that’s likely going to color the patient’s
feelings regarding postoperative follow-up and other
issues in the postoperative period.
Dr Roland Vega (Madison, WI): You made me think
instead of letting it sit around. I just want to make some
comments about some experience we’ve had.
In 1999, we did an audit of our postoperative
documentation and discovered that---this was written
Volume 154, Number 4
Wright et al 939
charts---much of our documentation among a group of 6 Download full-text
general surgeons that practiced within the department
at the University of Wisconsin, but practiced at commu-
nity hospitals, that much of our postoperative documen-
tation was inadequate, that most of our patients who had
complications either came in before or after their actual
scheduled visit. And that we were missing patients who
just didn’t make appointments or didn’t show up.
So we actually instituted a call-back program, similar
to what you are talking about, that’s actually performed
by RNs, using a template of questions. And these are
usually the RNs that also saw the patient preop. So
there’s some continuity with that. And we’ve been doing
that since that time.
And it actually has saved us approximately 800–1,000
visits in a group of 6 general surgeons. We were
concerned about the legalities. And the compliance
folks said, ‘‘This is legal.’’ Because people in the
department said, ‘‘You can’t do that.’’ And we said,
‘‘Oh, we can do that.’’ And it actually worked out well.
There are a few caveats. And one you addressed. And
that is, the patient given the choice to have an
appointment, if they would like to, afterward, the nurse
having the discretion to schedule an appointment if she
thinks something is wrong. And the last thing we did was
anyone coming new into practice, for the first 6 months
to a year, needed to see all their patients postoperatively,
because we thought that was extremely important for
them to understand what was going on.
But I congratulate you on this. You are on the right
track. And I hope my comments help to jump start you
to the next level, because I think this is important. And it
certainly is a great patient satisfier.
Dr G. Paul Wright: We as well have had some anec-
dotal experience from our pediatric surgery group,
who have been employing this strategy for several years.
And they initially started with physician callback in the
early stages of that and found over time that proved to
be not necessary. They similarly use an RN for phone
call follow-up after common procedures, such as
inguinal hernia repairs. And they have had, really, great
anecdotal success with that model.
Dr Angash Gosain (Madison, WI): I have 1 comment
and then a question for you about your prospective study
that you’re designing.
You mentioned that your clinic wait time before the
patients see their surgeon was <10 minutes. I think
that’s phenomenal, and I think we could all learn from
that. We have experienced some challenges, and I think
maybe you can help to clarify this.
As you move toward designing your prospective study,
I think the 3 things that we all have to balance are that
we’re striving to increase patient and family satisfaction,
decrease complications, also decrease cost. So for the
patients that you’re going to offer a telephone follow-up
only to, those are patients that, when they need to be
seen, are going to need to be seen in an urgent fashion.
What sort of clinic setup do you have to swap them in
in an expeditious way, so that you don’t have just empty
clinics waiting to be filled, tying up the surgeon’s time? I
will tell you, from our experience, we experimented with
primarily nurse practitioner follow-up for our pediatric
surgery population. And our patient and family satisfac-
tion scores plummeted. The patients really want to be
seen by their surgeon when they need to be seen. Again,
Dr G. Paul Wright: With regard to the wait time, I
stress that this is the patients’ perception of the wait
time, so it may have been more extensive, as well as
the time spent with the surgeon.
With regard to the model for how to roll this out in a
prospective fashion, that has been an issue that we have
been facing. At our institution, we have undergone a
series of changes over the past 2 years, since the study
was initially rolled out. Three private practice groups
have now combined into 1 large, multispecialty group.
In addition to that, over that time period, we’ve also
rolled out an acute care surgery service.
Initially, we’re looking at targeting likely the acute
care surgery clinic, which is staffed on a rotating basis by
an available acute care or emergency general surgery
surgeon, and targeting appendectomies for uncompli-
I do think there are some kinks to work through.
And, certainly, getting all surgeons on the same page for
this is an issue.
Dr Carol E.H. Scott-Conner (Iowa City, IA): So work-
ing at an academic health center in a very rural state, our
patients come from long distances. And one thing that
we’re learning to---and you might think about this as
you move into the next stage and develop your proto-
col---is to make better use of our referring physicians.
Because if you call the referring physician, tell them
what you did, and tell them what you’re worried about,
then the patient has an additional safety net. They
have somebody right in the community who knows
what to look for, who knows the patient’s comorbidities,
somebody they can go to see who will get them back to
you if there’s a problem.
Dr G. Paul Wright: I agree. We also serve a very rural
encatchment area. And I think that that is a very note-
worthy statement, that we do need to take care of the pa-
tients as a team approach, as opposed to just solitary
940 Wright et al