April 2001 Bulletin

How to discuss surgery with your patient

Shared decisions on treatment lead to better outcomes

By Carolyn Rogers

What’s the best way to approach an interview with a patient who may need surgery? There are nearly as many ways to approach a patient as there are patients, but many communication experts suggest viewing the encounter as an opportunity for you and the patient to share information. This two-way dialogue leads to a shared decision on treatment, which ideally leads to better outcomes.

Robert K. Snider, MD, an orthopaedic surgeon with a special interest in this topic, says determining the "patient’s preference" is a critical part of the dialogue. Dr. Snider says, "You want to try to determine, if possible, what the patient’s preferences are in terms of dealing with their orthopaedic problems. Before you can ‘share’ a decision you have to know what the other person has to share. And that’s relatively simple to do, just ask ‘how do you feel about this problem?’ This will give you an idea of where the patient sees this problem in his or her life—how it affects their comfort, function, work life and relationships. Once you have some idea of how the patient feels, then you need to share your thoughts about the problem as it might affect their orthopaedic health."

This sharing process then leads to some sort of a decision, which can include a myriad number of possibilities. Options typically range from doing nothing to implementing some form of surgical or nonsurgical treatment. "So that’s pretty much what happens in the shared decision making process from an outside perspective," says Dr. Snider.

One of the most important things to keep in mind during the process, Dr. Snider says, is to identify for the patient what you think the orthopaedic problem is, but be sure to not bias them towards some form of treatment.

"Give them the opportunity to share first without your thoughts on the options. If a person says ‘I really don’t know what to do—that’s why I came here,’ you can still keep them on the hook. Ask: ‘Is this a big enough problem in your life that you feel you need to do something?’

"It’s important not to duck out of that process too quickly. Otherwise, you’re not going to have a clear understanding. Patients may be very interested in trying some sort of nonsurgical treatment program because they don’t feel their problem is sufficient to warrant surgery, or because things going on in their life won’t allow for surgery."

If for some reason the physician believes the problem is best solved with surgery now, the two have to negotiate some sort of compromise.

"But that doesn’t happen very often in orthopaedics," Dr. Snider says. "Time is not so crucial with most of the problems we deal with. So the compromise may be to try nonsurgical treatment for six weeks, then perform an orthopaedic evaluation on a repeat visit, and see whether or not both parties still feel the same as they did before."

Another aspect of the patient interview that may affect the outcome is whether the patient comes to the office alone or with another person.

"They’re slightly different ballgames," Dr. Snider says. "If the patient is accompanied by a friend or family member, you have two people hearing things and between the two of them they’ll probably have a higher retention for what is said in the course of your conversation. But when the patient is alone, and one of the possibilities discussed is surgery—which is fairly threatening—a lot of subsequent information that comes out is lost.

"So it’s important to have the patient express their thoughts and concerns before hearing the word ‘surgery.’ You should also be sure that they leave with information that they can refer to later—either by making notes and passing that to them, or giving them a handout."

A benefit of the shared decision-making process is that the doctor and patient together identify the definition of a "good" outcome.

"The doctor may identify a ‘good’ outcome as the swelling going down and the knee being straight," Dr. Snider says. "For the patient, a ‘good’ outcome may be going to back to playing city league basketball as a point guard. Those two may or may not be able to be reconciled. So I think that’s part of what you get out of the sharing process. The dialogue attaches a much more realistic picture for the patient. And the more realistic the picture, the more likely a successful outcome. The doctor feels good that the patient met his or her goal, and the patient feels good that he or she reached a realistic goal, perhaps not an ideal goal, but a realistic one."

(Editor’s note. Robert K. Snider, MD, died March 12, 2001.)

Communicate welcomes suggestions about future topics for the column on patient-physician communications. Send your suggestions to the Bulletin at AAOS, 6300 N. River Rd., Rosemont, Ill. 60018.

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