To the Editor: The concept of the surgeon as someone who considers that "the less the patient knows, the better for all concerned" dates from a time sometimes called "the era of the surgeons," when it was the surgeon who dominated the patient/doctor relation ship, and this situation was generally accepted by patients and family members as well as by society in general. That era came to a close, however, and was replaced by "the era of the patient," a period during which it was the patients' opinions that predominated and were respected, principally with the view of avoiding malpractice claims. This gave rise to the practice of "doctor shopping,"2 and turned the surgeon into the provider of services requested by patients or their family members. Likewise, with the growth of the influence of health care managers, the era of the patient has become "the era of the payers," in which the opinions and explanations of the people in charge of financing the health expense have assumed first place,5,6 making the patient a "user" of a network of services, and the surgeon a "provider" of the services initially proposed by the health care intermediaries, departments and organizations.

This change in the surgeon-patient relationship has not led to any improvement in communication between the two parties,4 since the expectations and desires of the patients do not in general coincide with those of the surgeon, in spite of the fact that the physician is seeking the best solution for the patient. Society, family members and the patients themselves have unrealistic expectations, almost always exaggerated, concerning the real benefits of surgery,5 and what often happens is that the patient does not altogether share the surgeon's satisfaction with the outcome of the surgery.

The evidence indicates that the quality of treatment, as measured by satisfaction indices, improves when the desires and expectations of the physician are attuned to those of the patient.6 When patients are dissatisfied, differences of opinion arise between surgeons and their patients with respect to diagnosis, treatment and prognosis. In order to ensure patient satisfaction, the surgeon must spend time listening to the patient and explaining all the aspects of the disease in their particular case.

More able surgeons tend to suspect that the solution to the problem at hand lies in anticipating the wishes of the patient, but some of these may not be foreseen.

They can be summarized as follows:

1. Patients' wishes during the diagnostic process:

--When their medical history is being recorded, patients want to feel as important as possible, so surgeons must convey the impression that they have the time necessary to listen to their patients and should avoid cutting short their explanations and interrupting them for details unrelated to their narration. It is preferable to move the interview on to the description of symptoms by asking direct questions, such as: Can you explain what is happening to you? Do you also notice...? Is all of this due to...? Did your doctor tell you that...? What is most important to you in regard to...? Patients perceive this approach as a sign of greater consideration of themselves and their problems.

--When a physical examination and complementary tests are performed, patients generally prefer a complete examination rather than a summary one or none at all. The surgeon must, however, take care that the first area investigated coincides with the patient's wishes or clinical situation, and should not insist on investigations the patient is reluctant to accept, particularly if the patient indicates "Not that!" Before an exploration is performed, the physician should ascertain whether the patient is willing, and explain the aim of the procedure and what is involved. When a patient rejects a necessary test or procedure, the surgeon's task is to explain all the reasons why it should be done and insist on the need to perform it for the good of the patient, without, however, concealing any drawbacks the procedure may have. If the patient still refuses, the physician should not go against their wishes, or reproach them for their conduct since this would automatically lead to a loss of confidence in the relationship. It is a good idea to explicitly accept the patient's criterion and to offer other, alternative tests. This approach will tend to build mutual confidence and reinforce the patient's faith in the doctor's opinion.

--While the physician is working towards a diagnosis and evaluating the prognosis, everything should be explained to the patient in plain language. Informed consent is not merely a question of signed acceptance of the diagnosis, surgical procedures, and postoperative complications. It also comprehends a concise and accessible explanation of the differential diagnosis, the benefits and disadvantages of different surgical techniques, the complications that might occur and their possible solutions, and the foreseeable long-term effects. But above all, what patients most require is complete information about their quality of life during the time they will not be able to live normally, and about any loss of functions or organic disorders after surgery. Doctors should not explain one thing to the patient and another to the family. It is preferable to talk to all concerned while avoiding words that might cause alarm.

2. What patients want when they are undergoing surgery and during the postoperative period.

Some surgeons are surprised by what their patients want, probably because they have never realized that the ill person is going through a delicate and conflictive period in their life. More and more surgeons, however, are taking into account the psychological aspects of treatment, aspects that only a few years ago were not even considered or were relegated to other personnel. One example of this was the absence of any explanations complementary to those given in the informed consent document. One of the most common desires of people who have had surgery is that the surgeon should explain to them how the operation went and why they have drains or drips or other postoperative aids. This dialogue is, however, often cut short because the patients are being monitored by other doctors, who have not operated on them. The situation becomes more difficult if the surgeon on call, a doctor whom the patient has just met, decides that a second intervention is necessary. The operating surgeon should explain these circumstances to the patient in preoperative sessions. Moreover, it is very important that the patient be introduced to the surgical team and understand their different roles in relation to his or her case. Such communication serves the quest for excellence.