General practice

Variations in medical attitudes to postoperative recovery period

^a Department of Surgery, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, ^b Department of General Practice, University of Sheffield, Sheffield S10 2JF

Correspondence to: Mr Majeed.

Advice currently given to patients by both surgeons and general practitioners on return to work after commonly performed surgical operations may be empirical and seems to depend more on popular belief than hard evidence.¹ Although day case and short stay surgery have allowed considerable savings for hospitals, early discharge from hospital may not necessarily be translated into a reduced overall convalescence time. The responsibility for this may partly lie with doctors on whose advice and certification the patient remains off work.²

We conducted a survey to establish current opinions among surgeons and general practitioners about the time a patient should remain off work after uncomplicated common elective procedures, with the aim of establishing an index against which future improvements may be studied.

Subjects, methods, and results

We selected 100 consultant general surgeons in the Trent health region and 90 general practitioners affiliated to the department of general practice, Sheffield University, who taught medical students. They were all sent identical questionnaires asking how long they would recommend patients to stay off work after five common elective uncomplicated surgical operations according to the patients' age (25 or 55 years) and strenuousness of their work (sedentary, light manual, or heavy manual). Respondents were asked to assume that there were no physical, psychological, or social factors influencing recovery apart from those mentioned above.

Time off work recommended by surgeons and general practitioners for common surgical procedures. Values
are median numbers of weeks (ranges) unless stated otherwise
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                  Patients' age                           General practitioners'
Type of work         (years)        Surgeons' opinion           opinion             P value*
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                                    Varicose veins
Sedentary             25                 2 (1-4)                 2 (1-6)            0.01
Light manual          25                 2 (1-5)               2.5 (1-6)            0.0001
Heavy manual          25                 3 (1-6)                 4 (2-8)           <0.0001
Sedentary             55                 2 (1-6)                 3 (1-8)            0.0001
Light manual          55                 2 (1-6)                 3 (1-8)           <0.0001
Heavy manual          55                 3 (1-10)                4 (2-10)          <0.0001

                                Unilateral inguinal hernia
Sedentary             25                 2 (1-6)               2.5 (1-8)            0.1
Light manual          25                 3 (1-8)                 4 (2-12)           0.006
Heavy manual          25                 4 (1-12)                6 (2-13)           0.0001
Sedentary             55                 2 (1-6)                 3 (1-8)            0.008
Light manual          55                 3 (2-8)                 4 (2-12)           0.004
Heavy manual          55                 6 (2-12)              6.5 (3-16)          <0.0001

                                  Haemorrhoidectomy
Sedentary             25                 3 (1-8)                 2 (1-12)           0.001
Light manual          25                 3 (1-8)                 2 (1-12)           0.08
Heavy manual          25                 4 (1-10)                3 (1-12)           0.46
Sedentary             55                 3 (1-8)                 2 (1-12)           0.07
Light manual          55                 3 (1-8)                 3 (1-12)           0.53
Heavy manual          55                 4 (1-10)                4 (1-16)           0.85

                                  Open cholecystectomy
Sedentary             25                 4 (2-10)                6 (2-12)           0.001
Light manual          25                 4 (2-12)                8 (2-12)           0.0001
Heavy manual          25                 6 (3-12)                8 (3-20)           0.0001
Sedentary             55                 4 (2-10)                6 (2-12)           0.002
Light manual          55               5.5 (2-10)                8 (3-20)          <0.0001
Heavy manual          55                 6 (4-12)               11 (3-20)          <0.0001

                                Laparoscopic cholecystectomy
Sedentary             25                 2 (0-7)                 2 (1-8)            0.001
Light manual          25                 2 (1-10)                4 (1-10)          <0.0001
Heavy manual          25                 3 (1-14)                4 (2-12)          <0.0001
Sedentary             55                 2 (1-7)                 2 (1-8)           <0.0001
Light manual          55                 2 (1-10)                4 (1-12)          <0.0001
Heavy manual          55                 3 (1-14)                5 (2-12)          <0.0001
-------------------------------------------------------------------------------------------------------
*Surgeons v general practitioners; Mann-Whitney U test.

Replies were received from 59 (66%) general practitioners and 61 (61%) surgeons. The table shows how long the two groups of doctors recommended patients should stay off work. The most striking finding was the enormous variation in opinion between different doctors. For example, a 55 year old heavy manual worker having a haemorrhoidectomy could be given one or 16 weeks off work depending on which doctor he or she consulted.

Comment

This study shows the wide differences in opinion about time off work held by different doctors for identical sets of patients even when psychosocial factors have been excluded. The determinants of these opinions may be multifactorial, relating to patients, surgeons, and general practitioners.

For patients the immediate consequence of any common surgical operation is most likely to be acute pain, which gradually resolves over time. The metabolic consequences of anaesthesia and surgery may result in a feeling of fatigue, which is more common after major surgery.³ An important determinant of early return to work seems to be how patients are paid. Patients who are self employed return to work much sooner than those in salaried jobs.⁴ The amount of physical effort required in the job also determines the time taken to return to work. Patients' expectation of convalescence time before an operation strongly influences the time taken to return to full activity and in many cases depends on the advice of their doctors.

Restriction of activity on the advice of surgeons may be based on their concern for tissue healing and strength. Numerous studies have shown no increase in the recurrence of inguinal hernias after early return to work.⁵ These studies negate much of the folklore on tissue healing that may have arisen when absorbable sutures such as catgut were used.

Factors that determine general practitioners' attitudes to time off work are harder to analyse and are reflected in the wide variation in their opinions. Their attitude is of paramount importance because they have to issue the certification necessary to ensure financial compensation for the patient. A good understanding and trust between the patient and his or her general practitioner is therefore vital.

Hospitals in the United Kingdom have recently received large investments to establish minimal access surgical techniques and day case surgery, with a claimed reduction in the period of postoperative recovery. Unless attitudes to recovery from surgical operations change fundamentally the proposed benefits from these new techniques may never be seen.

This paper was read at the Association of Surgeons of Great Britain and Ireland annual meeting in Harrogate in April 1994.

Funding: None.

Conflict of interest: None.

1. Shulman AG, Amid PK, Lichenstein IL. Returning to work after herniorrhaphy. BMJ 1994;309:216-7. [Free Full Text]
2. Cannon SR, Ralphs DNL, Bolton JP, Wood JJ, Allan A. Early discharge following hernia repair in unselected patients. Br J Surg 1982;69:112-3. [Medline]
3. Christensen T, Hougard F, Kehlet H. Influence of pre- and intra-operative factors on the occurrence of postoperative fatigue. Br J Surg 1985;72:63-5. [Medline]
4. Ross APJ. Incidence of inguinal hernia recurrence: effect of time off work after repair. Ann R Coll Surg Engl 1975;57:326-8. [Medline]
5. Bourke JB, Lear PA, Taylor M. Effect of early return to work after elective hernia repair of inguinal hernia: clinical and financial consequences at one year and three years. Lancet 1981;2:623-5. [Medline]

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