Secondary Logo

Journal Logo

Editorial

The Sacredness of Surgery

Ring, David, MD, PhD; Leopold, Seth S., MD

Clinical Orthopaedics and Related Research®: June 2019 - Volume 477 - Issue 6 - p 1257–1261
doi: 10.1097/CORR.0000000000000783
REGULAR FEATURES
Free
SDC

D. Ring, Associate Dean for Comprehensive Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA

Seth S. Leopold, Editor-in-Chief, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA

S. S. Leopold MD, Clinical Orthopaedics and Related Research®, 1600 Spruce St., Philadelphia, PA 19103 USA, Email: sleopold@clinorthop.org

The authors certify that neither they, nor any members of their immediate families, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or the Association of Bone and Joint Surgeons®.

Received March 22, 2019

Accepted April 02, 2019

The fact that many patients seem to prefer surgery over nonsurgical approaches [15] strikes both of us as strange. It may be simply a function of which patients—among all of those who have symptoms—decide to come see a specialist, or who are referred to one. The “preference” for surgery that some attribute to patients may instead be driven by how surgeons (and even family doctors, before the surgical visit) present the options [14], which may itself be influenced by factors other than which option is healthiest [20]. But we believe something deeper is at work. When a person encounters a physical limitation or experiences pain, the urge to find a fast fix can be nearly irresistible. Based on this drive, patients will make (and physicians will endorse) surgical decisions that sometimes look like magical thinking.

And without getting overly mystical, we think the way to avoid making these bad decisions is to recall the sacredness of the surgeon-patient covenant. But before we come to that, let’s first explore how the bad choices get made.

Back to Top | Article Outline

Why People Make Surgical Decisions that Might not Benefit Them

Healthy people take good health for granted. In times of good health, we just “are,” and we feel like we always will be. It seems as though our bodies (and our minds) will always work like they should. The belief that when we get sick we will get well carries into illness (at least initially), but at some point this must change, because life is terminal. And before each of us arrives at the irremediable condition that results in our undoing, most of us will experience some number of smaller infirmities that either cannot be addressed, or that should not be tackled because the risk of dealing with them exceeds any reasonable expectation of reward.

The idea that a condition cannot or should not be addressed can be hard for a patient to swallow, particularly if there is an operation that sounds perfectly suitable to the task. Something torn? Why not repair it? Something worn? Why not replace it? It takes an orthopaedic surgeon with deep empathy, insight, as well as patience and time, to help a patient understand that some musculoskeletal changes are a part of normal aging [3, 7, 22, 24], and that not all of our commonly used fixes for those “problems” even outperform placebo surgical interventions [23, 25, 32]. In fact, good estimates suggest that that less than half of the medical care given in the United States is supported by adequate evidence [10].

As importantly, many patients struggle to redefine themselves in the face of musculoskeletal diagnoses, whether those diagnoses are age-appropriate or not. This struggle is harder for patients who have psychological distress, and those more-vulnerable patients may be more likely to maintain a belief that surgery is likely to improve health, whether or not this is the case [1, 15]. Unfortunately, those patients also are at greater risk of this not proving true [12, 31]. In the absence of psychological distress, redefining our “selves” as our bodies change with age is an essential part of life, and one that surgeons might spend more time helping patients to adjust to.

But what about the more-acute orthopaedic diagnoses? Patients can’t redefine themselves around acute injuries, can they? Very often they can, and should. Imagine a patient with a displaced clavicle fracture. She can see the deformity, feel the fracture moving and crackling, and be mortified by radiograph showing half of the bone in the wrong zip code. It’s easy to conclude that surgery is necessary. But she might not consider the prominent scar that may be associated with tenderness, the possibility of bothersome numbness over the chest wall or even persistent supraclavicular nerve pain, the fact that she might feel or even see the plate and screws under the skin, and of course, the drill the surgeon will aim at some very-important structures. Unconsidered, and too-often unspoken: The things that can go wrong during or after surgery, while perhaps less common, often are much more severe and lasting than the things that can go wrong without surgery.

In light of all this, the first diagnosis a thoughtful orthopaedic surgeon needs to make is that of the patient’s values: What does the patient care most about? What does (s)he fear? If we misdiagnose a patient’s deeply held values, there is no hope that we’ll agree on a treatment consonant with those values. Helping the patient to share those values with us takes time, and so in the setting of a surgical practice, “costs” money. We believe this is time and money very well spent. The second step is to ensure that our patient doesn’t choose surgery based on misconceptions: Misconceptions about a procedure’s efficacy in general [4] (which often are overstated because of the kinds of bias so prevalent in retrospective surgical research [19]), or misconceptions about a musculoskeletal procedure’s ability to help somatic symptoms in a patient with psychological distress (even in the presence of “objective” musculoskeletal pathology, which may be nothing more than age-related tissue changes [3, 22]).

Back to Top | Article Outline

Why Good Surgeons Endorse Bad Choices

The dehumanizing of surgeons begins early. We enter medical school with a deep respect for surgery, but this may begin to change during anatomy training. We find ourselves in a room full of dead people with bags over their heads. Questions abound: Who is this person? Who loved him? What did he experience? What did he accomplish? Did he donate his body or was there no one to claim him when he died? But in that moment, these questions do not matter. We cut in, damaging the body. By the end, we have sawed and pulled and pushed and ripped and cut him in clumsy, untrained ways. We feel ashamed, as though we have violated him. Towards the end of the year, we remove the bag to dissect his face and head. Only then do we finally see, with no further possibility of denial, what we have done to another human being.

And downhill we go from there. As residents, we were so fatigued and wrought that our ability to care about the person whom we were “caring for” (and operating on) drops, sometimes to near-zero levels. We just wanted to be done. To go home. To rest. To sleep.

Then, once fully educated, we (and our patients) expect that a switch will flip, and our humanity somehow will return, fully nuanced and empathic. Of course, this is not realistic, and when this expectation goes unmet—as it so often does—other pressures can nudge surgeons’ decisions, usually in the direction of more surgery [20].

Journals and specialty societies spend a great deal of energy trying to categorize surgeons’ conflicts of interest; the American Academy of Orthopaedic Surgeons lists 11 different kinds of financial conflicts its members can report [2]. But perhaps the largest one, and the one most-seldom discussed, is that surgeons like surgery [20], and many of us get paid more as we do it more often. Research suggests that these incentives may influence the frequency with which surgery is performed for the same general indication [9, 21, 26, 27]. But as important as those incentives are, we do not believe they are even the strongest impetus driving surgeons to lean into surgery, even when its value is in doubt.

Despite the rough training we earlier discussed, we believe that at heart, most surgeons possess a larger-than-average dose of that natural human tendency to want to help another person who is uncomfortable. Unfortunately, in the setting where they most can do so, this beneficent urge is hindered by a mistrust of the evidence [30], negative perceptions about standardizing decision making among surgeons [33], an unawareness of what is known [16], fear that not operating will displease patients and adversely impact one’s online ratings [8, 29], or other factors such as preferentially using randomized-trial evidence only when it is advantageous to surgeons to do so [11]. Regardless, there is a sense that if we don’t do something—where “doing” is defined as some physical, intervention-based treatment—we have nothing to offer. This sense is so pervasive that it leads us to endorse treatments that don’t merely lack proof of efficacy, but rather that have substantial evidence showing that they don’t work, a sadly recurrent theme in this Journal’s editorial pages [17, 18].

We believe that surgeons are most dangerous when we do not identify a patient’s misplaced hope for what it is, and when we follow that misplaced hope to a nearby operating room. One of the strongest factors associated with a reconstructive procedure not providing the desired result is a history of prior surgical procedures on that same body part [5, 13, 28]. And so, we find it strange how often patients who have been disappointed by a series of revision attempts still seek more surgery. And we are impressed—not in a good way—by how much more willing surgeons are to offer it when they did not do any of the prior procedures. Perhaps this is an ego issue; six previous surgeons have not solved the problem, but I think I can. In this respect, surgeons may be unusually susceptible to the human tendency that poker players like Annie Duke describe as “resulting” [6]: We interpret good results as a function of our skill, and bad ones to luck, nature of disease, or bad behavior on the part of the patient. We seem happier to ride along with the heavy human biases than with science.

Regardless, it seems as though a patient who has a stiff, painful knee following an arthroplasty and five revisions, and who is in a healthy state of mind, would want to avoid a seventh operation like the plague. And evidence indeed suggests that patients who are not in a healthy state of mind are more likely to do the opposite [15]. Because of that, it’s the surgeon’s job in that situation to be more circumspect, and to spend at least as much time trying to get the patient into the right state of mind as (s)he spends considering that another operation will be the patient’s lucky number seven.

Back to Top | Article Outline

The Way Out: Connecting with the Sacredness of Surgery

We earlier mentioned the sacredness of our profession, and we should have hastened to indicate that by this we intend no religious meaning. Rather, when a patient accepts an anesthetic, and indicates a willingness to have us cause injury in the name of healing, that patient places in us an ultimate, existential trust.

We must return this trust of a life with a confidence that it will be well rewarded, not with a slight benefit, not an outside hope of a benefit, but with a substantial and likely one. The frequency with which we perform our interventions may have a tendency to dull the poignancy of this surgical covenant. Our comfort with the surgical act may breed an excessive level of complacency about its meaning in the life of the person undergoing it. What we do five times on a Monday is (one hopes) once in a lifetime for the five people we do it to.

When a loved one faces the prospect of surgery, or when one is asked to operate on a friend or close acquaintance, the sacredness of the endeavor comes unavoidably into focus. This person has chosen to submit to intentional injury. She trusts that this injury will produce more benefits than harms. But what happens if we err or misjudge? What if our loved one develops an infection or nerve palsy? We think more about things we might not otherwise; the length of the scar, the quality of the closure.

Losing the appreciation for these specifics—and more generally, for the awe and wonder of surgery—may be a function of the intensity and duration of the training we go through as we become surgeons. This loss dehumanizes us and dehumanizes our patients, and it may cause us to harm those who have placed the ultimate trust in us in situations where helping them remained a choice we could have made.

Though surgeons are fortunate to have the power to cure with our hands, we are at our best as healers when we first use our hearts, our empathic words, and our thoughtful suggestions about how a patient might adapt to an apparent problem with the body, and that we suggest repairing or remodeling it only when we have a well-founded confidence that doing so will keep the most-serious covenant one person can make to another.

Back to Top | Article Outline

Try This at Home (or at Work)

  • Find a way to affirm how a patient has adapted to his or her condition in clinic today.
  • Reconsider the idea that nonoperative treatments are something patients pass through en route to more-definitive treatment (like surgery). Imagine that a surgical solution didn’t exist; how would you play it? This is more than a thought experiment. Surgery may not be consistent with your patient’s core values.
  • What would happen if you emphasized getting to know each patient and putting him or her at ease as much as you emphasized identifying a problem and offering a solution? The time this takes might be associated with a slight loss of income, but perhaps greater job satisfaction for you, and certainly a better and more-connecting experience for your patients. Might this be worth it?
  • Consider the possibility that some of the interventions you perform are not making patients healthier; certainly, there is evidence that this is true for many common interventions we perform [17, 18, 32]. What if the things we “know” aren’t so? Consider the possibility that sometimes we do feel pressured into operating [20, 29]; the awareness of the pressure being exerted may help one just enough to resist it.

A lively appreciation of the sacredness of surgery may satisfy our curiosity and humility sufficiently to take a more-deliberative approach, to help us to catch the frequent errors of our automatic thoughts, and perhaps even to help us to cultivate a new set of principles that guide our patient interactions.

Back to Top | Article Outline

Acknowledgments

The authors would like to thank Lee M. Reichel MD for his edits and suggestions, which helped improve the editorial.

Back to Top | Article Outline

References

1. Alokozai A, Eppler SL, Lu LY, Sheikholeslami N, Kamal RN. Can patients Forecast Their postoperative disability and pain? Clin Orthop Relat Res. 2019;477:635–643.
2. American Academy of Orthopaedic Surgeons. AAOS disclosure program. Available at: http://www7.aaos.org/education/disclosure/options. Accessed February 18, 2019.
3. Becker SJE, Briet JP, Hageman MGJS, Ring D. Death, taxes, and trapeziometacarpal arthrosis. Clin Orthop Relat Res. 2013;471:3738–3744.
4. Bogduk N, Andersson G. Is spinal surgery effective for back pain? F1000 Med Rep. 2009;1:60.
5. Cheung EV, Sarkissian EJ, Sox-Harris A, Comer GC, Saleh JR, Diaz R, Costouros JG. Instability after reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2018;27:1946–1952.
6. Duke A. Annie Duke: How to make decisions like a poker player. Available at: https://constantrenewal.com/annie-duke-thinking-in-bets/. Accessed March 13, 2019.
7. Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, Felson DT. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359:1108–1115.
8. Epstein D. ProPublica. When evidence says no, but doctors say yes. The Atlantic. February 22, 2018. Available at: https://www.theatlantic.com/health/archive/2017/02/when-evidence-says-no-but-doctors-say-yes/517368/. Accessed March 19, 2019.
9. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, eds. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington DC: National Academies Press; 2010.
10. Institute of Medicine (US) Roundtable on Value & Science-Driven Health Care. Learning What Works: Infrastructure Required for Comparative Effectiveness Research: Workshop Summary. Washington DC: National Academies Press (US); 2011.
11. Jawa A, Pittman JL, Carducci MP, Koenig S, Bhandari M, Tornetta P 3rd. The effect of level I evidence on surgical decision making in the United States versus Canada. J Am Acad Orthop Surg Glob Res Rev. 2018;2:e056.
12. Judge A, Arden NK, Cooper C, Kassim Javaid M, Carr AJ, Field RE, Dieppe PA. Predictors of outcomes of total knee replacement surgery. Rheumatology (Oxford). 2012;51:1804–1813.
13. Kheir MM, Tan TL, George J, Higuera CA, Maltenfort MG, Parvizi J. Development and evaluation of a prognostic calculator for the surgical treatment of periprosthetic joint infection. J Arthroplasty. 2018;33:2986–2992.e1.
14. Knops AM, Legemate DA, Goossens A, Bossuyt PM, Ubbink DT. Decision aids for patients facing a surgical treatment decision: A systematic review and meta-analysis. Ann Surg. 2013;257:860–866.
15. Kortlever JTP, Ottenhoff JSE, Tran TTH, Ring DC, Vagner GA, Driscoll MD. Do patients unconsciously associate suggestions for more-invasive treatment with better care? Clin Orthop Relat Res. [Published online ahead of print]. DOI: 10.1097/CORR.0000000000000608.
16. Kumar S, Nash DB. Health care myth busters: Is there a high degree of scientific certainty in modern medicine? Available at: https://www.scientificamerican.com/article/demand-better-health-care-book/. Accessed March 18, 2019.
17. Leopold SS. Editorial: Appropriate use? Guidelines on arthroscopic surgery for degenerative meniscus tears need updating. Clin Orthop Relat Res. 2017;475:1283–1286.
18. Leopold SS. Editorial: Getting evidence into practice—or not: The case of viscosupplementation. Clin Orthop Relat Res. 2016;474:285–288.
19. Leopold SS. Editorial: Getting the most from what you read in orthopaedic journals. Clin Orthop Relat Res. 2017;475:1757–1761.
20. Leopold SS. Editorial: What makes young surgeons tick (or cut)? Clin Orthop Relat Res. 2015;473;1853–1855.
21. Leopold SS. Editor’s Spotlight/Take 5: Is there variation in procedural utilization for lumbar spine disorders between a fee-for-service and salaried healthcare system? Clin Orthop Relat Res. 2017;475:2833–2837.
22. Liu TC, Leung N, Edwards L, Ring D, Bernacki E, Tonn MD. Patients older than 40 years with unilateral occupational claims for new shoulder and knee symptoms have bilateral MRI changes. Clin Orthop Relat Res. 2017;475:2360–2365.
23. Louw A, Diener I, Fernández-de-las-Peñas C, Puentedura EJ. Sham surgery in orthopaedics: A systematic review of the literature. Pain Medicine. 2017;18:736–750.
24. Menendez ME, Chen NC, Mudgal CS, Jupiter JB, Ring D. Physician empathy as a driver of hand surgery patient satisfaction. J Hand Surg Am. 2015;40:1860–1865.
25. Paavola M, An Malmivaara, Taimela S, Kanto K, Inkinen J, Kalske J, Sinisaari I, Savolainen V, Ranstam J, Järvinen TL, for the Finnish Subacromial Impingement Arthroscopy Controlled Trial (FIMPACT) Investigators. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: Randomised, placebo surgery controlled clinical trial, The BMJ. 2018;362:k2860.
26. Schoenfeld AJ, Makanji H, Jiang W, Koehlmoos T, Bono CM, Haider AH. Is there variation in procedural utilization for lumbar spine disorders between a fee-for-service and salaried healthcare system? Clin Orthop Relat Res. 2017;475:2838–2844.
27. Shafrin J. Fee for service vs. capitation: How financial incentives affect medical service provision. Available at: https://www.healthcare-economist.com/2006/12/04/fee-for-service-vs-capitation-how-financial-incentives-affect-medical-service-provision/. Accessed March 22, 2019.
28. Song SY, Goodman SB, Suh G, Finlay AK, Huddleston JI 3rd, Amanatullah DF. Surgery before subspecialty referral for periprosthetic knee infection reduces the likelihood of infection control. Clin Orthop Relat Res. 2018;476:1995–2002.
29. Talbot SG, Dean W.Physicians aren’t ‘burning out.’ They’re suffering from moral injury. StatNews. July 26, 2018. Available at: https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed March 19, 2019.
30. Teunis T, Janssen S, Guitton TG, Ring D, Parisien R. Do orthopaedic surgeons acknowledge uncertainty? Clin Orthop Relat Res. 2016;474:1360–1369–1531. Erratum in: Clin Orthop Relat Res. 2016;474:1530–1531.
31. Thorpe AM, O’Sullivan PB, Mitchell T, Hurworth M, Spencer J, Booth G, Goebel S, Khoo P, Tay A, smith A. Are psychologic factors associated with shoulder scores after rotator cuff surgery? Clin Orthop Relat Res. 2018;476:2062–2073.
32. Wartolowska K, Judge A, Hopewell S, Collins GS, Dean BJF, Rombach I, Brindley D, Savulescu J, Beard DJ, Carr AJ. Use of placebo controls in the evaluation of surgery: Systematic review. The BMJ. 2014;348:g3253.
33. Youngerman BE, McKhann GM II. Innovation in surgery and evidence development: Can we have both at once? Virtual Mentor. 2015;17:41–48.
© 2019 Lippincott Williams & Wilkins LWW