AAOS public service announcements such as the one pictured above deliver the message that patients and doctors should communicate.


Published 9/1/2008

Communication is key to ease worry about orthopaedic surgery

Study finds that older patients’ concerns often go unspoken and unaddressed

When discussing surgery with their orthopaedic surgeons, older patients frequently do not raise all of their concerns about proposed procedures. A study published in the July 2008 issue of The Journal of Bone and Joint Surgery found that patients age 60 or older have many concerns and questions that they do not mention to their orthopaedic surgeons, which, in turn, can become a barrier to obtaining optimal care.

Using audiotapes of visits between patients and their orthopaedic surgeons, as well as postvisit telephone interviews, researchers found the following:

  • Patients raised only 53 percent of their concerns about surgery during office visits.
  • Patients rarely raised concerns about their ability to meet the demands of surgery or about the orthopaedic surgeon’s communication and surgical experience.
  • Patients did receive answers about the timing of surgery and about the care facility where the procedure would be performed.

“Unexpressed concerns can keep patients from accepting recommended surgeries that may be very beneficial for them,” said Pamela L. Hudak, BScPT, PhD, primary author of the study and a research scientist at The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto. “If patients don’t bring up concerns with their orthopaedic surgeon, then the opportunity to help is missed. For example, if a patient’s unexpressed concern is based on incorrect information, a surgeon will be hard pressed to help.

“Our study also found that many patients do not mention worries about their capacity to meet the demands of surgery, especially in the postoperative period, likely thinking that the surgeon cannot help. But orthopaedic surgeons may be able to direct patients to social workers and other professional staff who can,” Dr. Hudak said.

Orthopaedic surgeons and other physicians must be aware that patients will often have unexpressed concerns, and they must take steps to help bring those issues to the surface. To assist with that process, the AAOS has developed the Communication Skills Mentoring Program (CSMP). This expanding program, now in its eighth year, uses more than 40 trained Academy fellows, who help facilitate highly rated interactive workshops with video vignettes. Participants learn specific techniques designed to help improve their communication with patients.

“Patients are individuals, not ‘the left shoulder in room 2,’ but sometimes, orthopaedic surgeons become so technically focused that we forget to develop that necessary personal relationship,” said John R. Tongue, MD, chair of the AAOS CSMP Project Team. “About 20 percent to 30 percent of patients who undergo a knee or hip replacement end up having someone else do the surgery because they didn’t feel a personal connection was established in that first meeting with the orthopaedic surgeon.

“Improved communication skills can be learned, and even small changes can make a big difference,” Dr. Tongue said. “This research strongly supports our program’s emphasis on specific techniques that allow us to be more empathetic with our patients. Because the average orthopaedic surgeon sees 160,000 patients during his or her career, AAOS Communication Skills Workshops can have a significant impact on patient care.”

Researchers suggest that, when soliciting questions from patients, surgeons should be aware of and pay particular attention to the following aspects of good communication:

  • Their body language—Orthopaedic surgeons should stop competing activities (like writing in a medical chart) and always direct their body and gaze toward the patient.
  • The particular wording of their inquiries about concerns—Orthopaedic surgeons should ask “Is there something else you want to talk about today?” or “What questions do you have?”

The study also notes that it can be valuable for surgeons to be aware of all patient concerns, even those that they cannot help or change. “There are potential therapeutic benefits associated with simply allowing for the expression of these concerns” said Dr. Hudak. “Listening to our patients demonstrates a willingness on the part of the surgeon to engage in a dialogue with patients that supports their decision making. Simply offering some empathy and reassurance can go a long way in easing a patient’s concerns about surgery.”

Co-authors of the study are Wendy Levinson, MD, and Pamela L. Hudak, PhD, of St. Michael’s Hospital and the University of Toronto; Kristy Armstrong, MSc, of the University of Ottawa; and Clarence Braddock III, MD, MPH, of Stanford University. The study was funded in part by grants from the National Institute on Aging.