A recent study of 458 patients found that prognostic counseling, which uses patient-reported outcomes and online tools to show models of survival and surgical success rates, helped patients feel more confident about surgery when faced with head and neck squamous cell carcinoma, as compared to typical presurgical counseling (JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2025.4838). The non-randomized trial took place at the Erasmus MC Cancer Institute at Erasmus University Medical Center in Rotterdam, the Netherlands.
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May 2026Whether or not surgeons use such online tools, which can help predict surgical outcomes based on specific diagnosis, tumor size, site, and other variables particular to a patient, it is important that patients feel they are collaborating with their surgeon about how to proceed with treatment decisions, rather than as if they are simply following doctor’s orders.
As professionals, surgeons understand the concept of explaining informed consent and procedural risk, “but trying to do this in an effective manner is not something that we as surgeons often discuss or think about a lot,” said Nithin D. Adappa, MD, professor and vice chair of clinical operations, surgical director, Penn AERD Center, and fellowship director, rhinology and skull base surgery, in the department of otorhinolaryngology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “But I think this is a critically important topic for the comfort of your patients.”
Giving patients enough time to truly consider all the nuances of what their options are, whether a team approach is necessary, and how options are presented, while fully conveying the elements of risk, side effects, complications—some of them permanent—and how much pain to expect, are all different aspects of effective presurgical discussions.
Work to Build Trust First
What are the best practices for presurgical discussions? As surgeons, it can be difficult to translate general outcomes to a patient’s specific case, said Samantha Tam, MD, MPH, vice chair of research and academics at Henry Ford Health in Detroit. “A lot of these things we know at a population level: what the percentage of shoulder dysfunction might be, or difficulty swallowing, or if someone will need a permanent G-tube, but there isn’t any good way for us to say, ‘Hey, you’re likely to fall into this percentage versus this other percentage,’” she said. “There are guesses that we make based on how the patient presents, but it’s very hard for us to predict that accurately.”
To help patients feel more comfortable about what is being said, Dr. Tam said building trust is crucial. “I think it’s really important to build up that relationship early on, before surgery, because there can be things that are uncertain and things that are unpredictable,” she said. Transparency in the relationship can help build patient confidence so that “if there are any disappointments afterwards, they will have trust in you to work with them through it.”
Building the relationship can start by telling patients how much you know and understand what is going on with their symptoms, diagnosis, and possible treatments. “I give patients some context of myself as a surgeon,” Dr. Adappa said. “How long have I been doing these types of surgeries—15 years. I typically tell them a rough idea of how many similar types of surgeries I’ve done, and we’re going to discuss the complications in the context of my total number. So, for sinus surgery, I will talk about the rate of post-operative bleeds or the rate of post-operative infections, in the context of the total number. It gives them a better idea of what to expect and the chances of a complication. I think that honestly helps quite a bit for patients to understand what they’re getting into.”
Building Strong Conversations
For Adam Zanation, MD, MBA, a head and neck tumor surgeon at Carolina Ear Nose & Throat Sinus and Allergy Center in Hickory, N.C., presurgical discussions start with identifying what is known and what is unknown.
“In general, when I’ve got a tumor patient, we know generally where the tumor is through imaging. We usually know the pathology through a type of biopsy, like a pineal aspiration,” he said. “What we don’t know is how this tumor is truly behaving as far as how the tissue planes interact. We don’t know how the tumor is going to behave during the dissection. We don’t know whether the tumor or the cancer has metastasized to other spots, such as lymph nodes around the area. So, we talk about what the purpose of treatment is. How do we eliminate as many unknowns as possible so that we can personalize and optimize their treatment? In general, that builds an informed data point for patients, so the patient is hopefully understanding.”
Dr. Zanation cited a patient with cancer on the right side of the tongue. While it’s most likely related to smoking and drinking, it might not be, he said. Some lymph nodes may be affected, and the cancer may have spread elsewhere in the body. If the patient’s goal is to be cured of cancer for the next 10 years, Dr. Zanation said he discusses the situation with the patient’s goal first. “Because if you jump right into treatment, and you’re like, ‘Well, you know, generally the standard of care for a stage 4 cancer would be tri-modality therapy, with surgery, chemotherapy, and radiation therapy,’” the patient would immediately ask if they have stage 4 cancer, and Dr. Zanation said, upon a first meeting, it’s too early to know exactly what it is. “If you don’t set that unknown aspect of things out there, then the process for the options becomes very muddy,” he said. “I like to just start and go through the treatment options—if our chance, if our optimal treatment for a cure is surgery, followed by adjuvant therapy, which can be radiation therapy, chemo and radiation therapy, or immunotherapy.”
If a patient asks what that looks like, Dr. Zanation says that surgery is the standard of care for tongue cancer and discusses the risks and benefits of surgery. He also asks if a patient wants to hear secondary and tertiary options, where the cure rate is lower but maybe won’t require the loss of as much of the tongue as surgery would entail. “If they say yes, I would like to hear about options, or if they say no, it sets the expectation that the patient understands what other options are, even if they have less of a cure.
Dr. Zanation said he tries to establish what he calls an information pyramid. It covers “where are we right now, what our goals are, and what are our options to achieve those goals optimally, and then what are other options if the patient decides they don’t want to go down the path of standard of care,” he said.
At the same time, Dr. Zanation said it’s important to try to minimize bias when the patient needs to decide how to proceed. “It’s really difficult because I’m a surgeon and I like doing surgery,” he admitted.
Dr. Zanation also discussed the differences when a team of specialists sees a patient in one day of visits, versus spreading out the initial interactions over time.
In some medical settings, a patient will meet with a multi-disciplinary team where they will see a surgeon, radiation oncologist, and a medical oncologist to discuss chemotherapy and/or immunotherapy. “The patient gets input from everybody, but the problem I have with that paradigm is that the patient sees three people, and it may be the first time they’re really discussing the severity of their cancer,” he said. “They get all this information, and they leave, and the only thing they remember is, ‘I just got a diagnosis of stage 4 cancer,’ and ‘I’ve got to do all this stuff, and I may die.’ And they don’t get any of the intricacies of the discussion.”
In his current practice, Dr. Zanation prefers to meet with the patient first, present what is known and build upon that, and then discuss options and treatment goals. Then, the patient will return to the office for a second visit to meet with the radiation oncologist and medical oncologist. Dr. Zanation remains available for a phone call with the patient in between the first and second visits to answer any questions or further discuss anything the patient didn’t understand at the first visit. “That way, when they go into those next visits, hopefully they can really start refining their personalized treatment decision process and not just the shock of, ‘I’ve got throat cancer,’” he said.
Regardless of how many specialists a patient will initially see after diagnosis, slowing down is critical, said Dr. Adappa.
“The biggest, best practice for me is really taking your time with this, and I think that can be challenging,” he said. Many practitioners are busy with a high patient volume, so it can be difficult to make the time to really sit down and stop to have a presurgical discussion with a patient. “But this is such critical decision making for my patients; I really want to slow down.”
Dr. Adappa noted that he has had this presurgical conversation many times, while his patients likely have not. A slow approach helps them better understand their options and goals. He also uses any available imaging, such as a patient’s CT scan or MRI, to review the patient’s diagnosis in real time.
Dr. Zanation also uses visual imaging, as well as anatomic models in his office, to explain to patients what is happening clinically. “It makes it organic and provides something that is like, ‘Oh, I can see this. I understand the location and why this is complex,’” he said. A patient may see a lump on their skin in the mirror, but imaging and models help them understand, “OK, here’s part of the facial nerve, and I may have to move the nerve because the tumor is right there,” he said. Such one-on-one consultations are generally more effective with patients than using videos of surgeries to help understanding, he said, though he has also offered videos and websites to help patients comprehend what they might undergo.
“In general, it’s the one-on-one contact with you in the room, discussing a patient’s particular case, with easy-to-understand illustrations, that I’ve gotten the best feedback on,” Dr. Zanation said.
Multiple Conversations, If Necessary
Dr. Adappa said for those patients who haven’t yet decided on surgery, or who are still not completely comfortable with the surgery, he sends them home with the surgical consent form so they can read that through in a non-rushed fashion, and often provides post-operative instructions so they can get a sense of what is happening in that immediate post-op period. He will also speak with patients over the phone after the first visit or schedule another in-person visit to answer any questions or concerns, often including the patient’s family or friends, so everyone’s questions and concerns can be addressed.
Even if the patient is told their diagnosis is time-sensitive, such as a cancer diagnosis, there is still time for them to get other medical opinions about how to proceed or time to discuss their situation with family or other loved ones before making a potentially life-altering decision, he said.
“I just want to make sure that they completely understand because, honestly, you get the best outcomes when the patients understand exactly what’s going on and the expectations for them and for us are understood,” Dr. Adappa said. “I think this is a critical enough decision space for the patient that you really want to give them as much time to have that informed decision making as possible.” Patient compliance post-surgery can play a large role in recovery.
Another tactic that can be helpful is introducing patients to others who have gone through the same procedure, Dr. Tam said. “If patients are open to it, I think speaking to other patients that may have gone through something similar can be a useful tool,” she said. Other allied health professionals on the surgeon’s team can help make that happen, though protocols can vary from medical center to medical center.
Having more information about patient-reported outcomes following procedures is also helpful when counseling patients about future procedures, Dr. Tam added. “If we have a better understanding of what patients’ functions, quality of life, and symptoms are not only in the short term, but in the long term after our treatments, it will allow us to improve our understanding of what these patients are going through. It’s an important aspect for us to incorporate more into our pre-operative assessment. We need to understand what our patients are going through now, so we can better tell them what they’re going to go through later. It will certainly give us more data to understand what patients might be going through as they recover from treatment.”
Discussing Complications, Side Effects, and Pain
With patient recovery, it’s important to convey both uncertainty about complications and how they may arise and about the length of the recovery period, Dr. Tam said. Symptoms and functional changes after surgery, such as pain, swallowing issues, arm function, and potential long-term medication use, are possible and may be minimized before surgery in favor of talks about what the procedure will entail and what to expect during the surgery. At the same time, patients need to understand that “where they are immediately after surgery is not where they’re going to be in a year or two years after surgery,” she said. “There is lots of recovery that can happen, and sometimes they have to be patient for that.” At the same time, surgery comes with risks, and sometimes complications occur. “Even if we have all the numbers in terms of what percentage of patients have X, Y, or Z complication or outcome, it’s important for them to also know that there is uncertainty all around this. Unfortunately, even if everybody does the best that they can, there can be complications and bad outcomes,” she said.
Dr. Adappa said a common concern he hears from patients facing sinus surgery is how much pain they will be in post-operatively. His group published a study answering that question in 2019 that illustrated the average number of opioids used after such procedures (Otolaryngol Head Neck Surg. doi:10.1177/0194599818803343). Most patients took fewer than 15 oxycodone and acetaminophen tablets in the first four days after surgery, and a quarter of the 219 subjects in the study took no pain medication at all. “You can actually cite literature, and I think that’s always helpful,” he said. Ultimately, “our goal as surgeons is to try to explain the surgery, and the potential pitfalls that include not being satisfied with the results,” Dr. Adappa said. “That’s going to be a risk for any surgeon in any field. It is our duty to try to explain to patients that this is part of the risks that they are undergoing.”
What Not to Do
Surgeons should avoid presenting information that might cause a patient to have the wrong outlook or perspective on what they will experience or what will occur during or after the procedure.
Avoid absolutes. For surgeons, “if you haven’t ever had a particular complication, it’s more than likely because you haven’t done enough of that particular surgery,” Dr. Zanation said. Dr. Tam agreed. “If you are too certain about outcomes and something ends up happening that you didn’t expect, that would be something you’d want to avoid,” she said.
Don’t dismiss patient concerns. “Even if it seems like a question is coming out completely from left field or is something a patient shouldn’t really be worried about, it’s important to take those concerns seriously,” Dr. Tam said.
Be there for your patient post-surgery. “Have them understand that you’re going to be a resource,” Dr. Tam said. “You are not going to abandon them if something bad happens after surgery. You’re going to be somebody that’s going to guide them through whatever happens afterward.”
Partner with your patient. “My main goal is not to have a patient feel forced or coerced into surgery,” Dr. Adappa said. “I really want a patient to feel this is a partnership, and that they are very comfortable with that decision making.”
Don’t badmouth prior providers. If a patient comes to you seeking an additional opinion, focus on the now, Dr. Zanation said. “I see a lot of people who have had prior therapy from other people, and they’ve either had a recurrence or persistent disease. Now they are seeing me for the first time. They will ask things like, ‘Should something have been done differently?’ I will try very quickly to redirect them into the present and say, ‘We can’t go back. I don’t know the specifics of your discussion with your other doctors, but they were trying to do the best they could. Now, we need to move forward to getting things fixed.’ I try to always redirect with, ‘We’re going to be pragmatic and thoughtful, and these things can happen. You’re in my hands now.’”
Ultimately, when surgeons effectively connect and communicate with their patients before procedures, it strengthens their relationship. That strong connection can help prevent dissatisfaction, maintain a neutral if not a positive patient attitude, and ultimately help both the surgeon and the patient collaborate to handle post-operative challenges, Dr. Adappa said. “I appreciate when patients say, ‘Yes, you discussed this. I remember us talking about this,’” he said. “That allows us to kind of work together and get through whatever concerns or issues we’ve had surgically.”
Cheryl Alkon is a freelance medical writer based in Massachusetts.
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