To head off a demonstration of how his phone also could play his recent vacation movies, I changed subjects and asked him what he thought about clinical practice guidelines in orthopaedics. As I suspected, he knew little about them.


Published 3/1/2003

You can “guide” a horse to water, but you can’t make him …

The other night I was at a local orthopaedic society gathering, and I ran into a fellow orthopaedist, Joseph Robert Roberts IV, known to all as Joe Bob. Joe Bob lives down here with me and Elvis and is a good, solid orthopaedist, but probably hasn’t been to a postgraduate continuing medical education course in 10 years. He showed me his new iPhone and how he can even work Sudoku puzzles on it—I was impressed!

“Aren’t those the latest version of consensus statements by experts? Remember those old algorithms that disappeared more than 10 years ago because they were confusing, with little consensus, and were litigation prone?” he said.

I responded, “No, no, Joe Bob. These guidelines are completely different from those of the past. These are simple guidelines about orthopaedic treatment. If you follow them, they will enable you to give your patients the very best treatment and clinical care according to the most recent and highest level research available.”

“What do you mean, if I follow them?” asked Joe Bob. “I’ve got a successful practice, and my patients—at least, most of them—are pleased with the outcomes of their treatment. Are these just more rules that I’ve got to follow? Don’t the government, insurance companies, and hospitals make us jump through enough hoops? Why does our own Academy have to add more?”

“Joe Bob, these guidelines are not rules,” I assured him. “There are no hoops to jump through. There is no paperwork. And the AAOS has gone through a lot of time, trouble, and expense to develop these guidelines.

“Currently, four guidelines have been prepared by the AAOS: one on the prevention of pulmonary embolism after total hip or knee replacement, two on the diagnosis and treatment of carpal tunnel syndrome, and one on treatment of osteoarthritis of the knee. All you have to do is bring up the one you want on the Internet on your phone. For example, the guideline on treating osteoarthritis of the knee has 22 simple recommendations. You should try it out. You’ll be surprised at how down to earth, unbiased, transparent, and practical they are.”

Joe Bob wasn’t convinced. “What if I don’t follow the guidelines? Am I more vulnerable to being sued? The malpractice situation is already so contentious.”

“Why not look at it this way? If you follow the guidelines, because they are evidence-based and have the AAOS approval, you are much less likely to be involved in litigation,” I responded.

He countered with, “I guess if I do something not according to the guidelines, I won’t be reimbursed. Insurance reimbursement is already incredibly decreased, onerous, and difficult.”

“I don’t think so,” said I. “As physicians, we have to put the patient’s best interest first. If there’s no clear recommendation for or against a treatment, it’s a matter of informed consent and an agreed-upon plan. If you follow the guidelines, you are more likely to be reimbursed by insurance companies and the Centers for Medicare and Medicaid Services. You may even be able to challenge and appeal payors’ decisions on payment because the guidelines have the approval of a national organization—the AAOS.”

Joe Bob was still not willing to “drink the water,” even though I had “guided” him to the trough. So I kept probing.

“Joe Bob, what do you know about the evidence-based practice of orthopaedics?”

“Not much,” he admitted, “I just do it like the old professors taught me! It worked for them, so I guess it works me. When something new comes out, I just look and see what the experts in the field recommend.”

“Where do you think they get their recommendations?” I asked. “From their old professors? If that’s how we all practiced medicine, how would the science progress?”

I tried another tack. “Joe Bob, have you ever tried to review the literature on some orthopaedic subject or operation, sort of like you had to do back in your residency days?”

At his emphatic “No!” I assured him, “Well, that’s another good thing about these guidelines. The AAOS knows that the practicing orthopaedic surgeon doesn’t really have time to do comprehensive literature searches. So the guidelines workgroup has done the work for us. They’ve searched the literature and amassed the relevant research. They’ve met with representatives of the specialty societies and vetted the information with outside stakeholders, so there is both peer review and expert commentary. They’ve determined how substantial, pertinent, and relevant the research is and formulated the guidelines. They’ve even assigned both a level of evidence (I-V) and a grade of confidence (A-C) to each consensus statement.

“Joe Bob, how about a drink of water?”

“Well, maybe just a sip or two,” he answered. Then he asked, “What do these guidelines look like?”

I replied, “Each guideline has a series of statements. The strength of each recommendation is determined by the level of evidence, which is noted next to the statement. Supporting documents—ranging from 200 pages to 600 pages—outline the methodology, inclusion and exclusion criteria, and evidence tables.”

“No, no,” he interjected with a touch of panic. “I just want to see the short form. Can you show me one?”

“I just happen to have a copy of the February 2009 AAOS Now with me. Here is one of the 22 guidelines on osteoarthritis of the knee:

‘We recommend against performing arthroscopy and débridement or lavage in patients with a primary diagnosis of symptomatic osteoarthritis of the knee—Level of Evidence I and II, Grade of Recommendation A.’”

“OK. That’s not so bad,” he answered. “Where do I find these guidelines?”

“Well, they’re on the AAOS Web site (, which you can bring up on your fancy phone; each one has been printed in AAOS Now; and a summary is being published in JAAOS,” I told him. “We’ve published 10 articles on evidence-based orthopaedic guidelines in AAOS Now in the past 2 years.” A new thought occurred to me.

“Joe Bob, do you ever read AAOS Now?”

With a puzzled look, he asked, “What’s AAOS Now?”

You can “guide” Joe Bob to water, but you can’t make him drink!

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