Shared Decision Making – 2nd Opinions

HOWARD LUKS

Brian’s Note: Howard Luks MD produces short explanatory videos that are designed to clarify patient issues. We’re delighted to add his work to the patient- and clinician-centric resources here at C&C.

Not all findings on MRIs or X-rays require surgery. Quite the contrary, many do not. How do you decide? This video should help point you in the right direction to obtaining meaningful opinions, etc. If not, let me know why…

Good morning. Forgive the little bit of haze you may find in my presentation, that’s a residue of some Benadryl I took. It ripped myself of these Northeastern virus that’s been on misery especially in my family in the last week. And I have something to do with 30 inches of snow that we’ve dumped on us that everyone enjoyed yesterday. Anyway, that’s not what we’re here to talk to you about today. What I wanted to talk to you was about a short week of second opinions. Typically I see a number of people each week where I tend to see them as a second opinion —simply because I’m situated in a tertiary care or advanced level care institution and we are an academic center, so which means we train, that we train the next generation of surgeons and we tend to be a referral base for a very large catchment area.

Anyway there were some second opinions this week regarding the treatment of people with a history of Osteoarthritis of the knees. Some of these people were here to discuss whether or not I would do their replacement or whether or not they should go back to their previous surgeon and have them perform a knee replacement.

But I was surprised how very few of the discussions that the patients initiated began with the idea of do I need a knee replacement? It seems that they were simply shopping around for where their knee replacement should be done.

Now, let’s say there were 10 of these patients. In the end only five patients decided to have the surgery done, why? Realistic expectations. We went through a relatively crude but useful shared decision-making process. We went through the facts that this truly is a quality of life decision and it’s not the doctor who makes the decision when you’re thinking about a procedure that’s here strictly to improve your quality of life and alleviate pain. So, when the question was posed to the patient, do you feel that it’s time to have a knee replacement? Do you feel that the pain that you are experiencing is significantly interfering in your quality of life and you feel that you are willing to assume the risks of knee replacement in order to obtain that relief?

When that question was posed to those 10 theoretical patients— and they weren’t theoretical— the patients are real— the number is theoretical, half of them said NO, half of them said, I’m fine, you know, I’ll take my time or I’ll use my cane and I’ll come back when my symptoms are very severe.

That’s the power of shared decision-making and it has very broad implications for healthcare as a whole. A lot of these patients were told they’ll be up and around in a week or that there are really aren’t any significant complications associated with the knee replacement.

And, you know, I’m not going to critique other physicians work. However, it’s all in the presentation, you know, it really is incumbent upon us as physicians to let people know exactly what it is they are in for, as best as we can. We need to describe reasonably foreseeable risks. If there is a risk that occurs, one in one million or risks that we cannot, yet even conceive of, we are not held responsible for that. But things like infections and blood clots and the fact that it can take 6 weeks to drive in some situations or that 5 percent get stiff or one percent become infected. Those are very important things to discuss with patients.

I saw a number of patients this week with ACL deficient knees, that means that the ACL of the Anterior cruciate ligament was torn.

They were coming again to see whether I would do the surgery or to see whether or not they should go back and have the surgery with their previous surgeon. The same questions were proposed to all of them. Do you feel that the surgery is necessary? Sometimes it was met with a blank face (and some of you people out there have certainly shouted out at me and said it’s your decision, you are the doctor). No, it’s not necessarily true, I’m here to provide you with the facts. If your knee is buckling, unstable or you’re suffering from instability at the knee is giving away, you can’t go up and down the stairs, you can’t turn pivot or twist. And braces and therapy and everything else did not improve your symptoms, then you can consider yourself a good candidate for an ACL reconstruction. If you work on the roofs, or if you are a tree climber, if you’re a mountain climber or a rock climber, then in those situations I would suggest an immediate reconstruction simply because the first time your knee buckles it may in fact cause significant injuries, harm or even death. However, for the vast majority of you, you have an ACL tear yet you do not have any issues with your quality of life, you do not have any buckling instability or giving away, the knee may feel a little unusual but yet it doesn’t give out.

Do you need an ACL reconstruction? I don’t think so. But really, that is up to you. The indication for an ACL reconstruction is simply not its absence. It is the fact that it is causing an issue with your quality of life, with your ability to participate in activities that you would otherwise enjoy. There were other second opinions that I did this week are the lesser procedures such as meniscus tears etcetera, but it was the same story. These patients were being indicated for surgery by the presence of a finding on an X-Ray or the presence of a finding on an MRI. Not necessarily a custom-designed treatment plan based on how that injury was behaving in them.

I put a blog post up on this a while ago. I call it the personality of an injury. It’s simply because the same injury will not show itself or behave in the same way in many individuals. Some will be symptomatic, some will not be symptomatic, some will have problems, some will not. I have also talked about shared decision-making before. This is a process where we sit, we go through your quality of life. There are a number of scores that we can utilize, we go through a list of the reasonably foreseeable risks, your expected goals, your outcomes, and the time that you can expect to be in rehabilitation before you will be “normal,” if that in fact, it ever occurs.

And once we go through all this processes, you know, then people start to understand why I’m not as aggressive as others in recommending surgery only because it doesn’t seem to suit your injury properly. So, take home message, pay attention to shared decision-making principles. It’s going to be a very prominent area in medicine soon. Seek out a second opinion, they are worthwhile, if necessary seek out a third opinion, they are very worthwhile. And just because something shows up on an X-Ray or an MRI doesn’t mean it always needs to be treated surgically. You do have options, find someone who is willing to explain those options to you and respond accordingly. Hope you have a wonderful day. Bye.

Howard Luks MD is an orthopedic surgeon and sports medicine physician. He writes at The Orthopedic Posterus.

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