Many factors are involved in providing appropriate diagnoses, tests, and treatments.
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Published 5/1/2017

Issues of Appropriateness in Patient Safety

AAOS Now article triggers discussion during recent committee meeting
A "Safety Now" article by Robert J. MacArthur, MD, in the January 2017 issue of AAOS Now ("Wrong-Side Procedure in the Modern Era") provided members of the Patient Safety Committee with considerable food for thought. At a recent meeting of the committee, chair David Ring, MD, PhD, facilitated a discussion among committee members Dwight Burney, MD; Michael Pinzur, MD; Alan Reznik, MD; Andrew Grose, MD; Chris Gaunder, MD; Ramon Jimenez, MD; Michael R. Marks, MD, MBA; and Michael Archdeacon, MD, on factors that can affect a physician's judgment and interactions with patients as well as strategies that can be employed to help improve quality and patient safety.

Dr. Ring: Appropriateness of diagnoses, tests, and treatments is an important priority in quality and safety. With Dr. MacArthur's permission, let's start our conversation with the patient he described in his AAOS Now article. Bob is becoming a true quality champion, bravely sharing his journey so that we can all learn from it. He related that this patient was treated at a time when his practice was drifting toward surgery of questionable benefit.

You may recall that the patient was a 21-year-old professional boxer with knee pain that limited his running. The exam was nonspecific and radiographs were normal. Even the MRI that was obtained was normal. That's remarkable—it's difficult to have a normal MRI. But the decision to obtain an MRI raises the following questions:

Is an MRI appropriate in this setting? Does sophisticated imaging have more potential for good than for harm in this setting? What would you do next?

Is a corticosteroid injection appropriate for a nonspecific diagnosis? Are intra-articular corticosteroids appropriate given the fact that they harm articular cartilage?

Three steroid injections were given. It can be argued that these are desperate measures when an MRI is ordered for a normal knee or when corticosteroids are injected into a normal knee.

Dr. Reznik: Many times we are faced with patients who have unrealistic expectations of both their bodies and their physicians. Our own search for an answer merges with a willing participant in almost any solution. This is a formula for unsuccessful treatments of increasing complexity.

Dr. Ring: It's also worth stating that there is a notable potential for harm to self-image, increased symptoms and limitations related to stress and distress, reinforcement of maladaptive coping strategies, and iatrogenic harm from treatments.

In this setting, the diagnosis of "plica" was made and the patient was scheduled for surgery. Again, we can ask questions about appropriateness:

Is this an appropriate diagnosis? Can it be supported by objective evidence? Does this diagnosis do more harm than good? Is knee arthroscopy appropriate for a nonspecific or debatable diagnosis? What level of risk, discomfort, and inconvenience is merited for a largely diagnostic intervention? What if the wrong knee now was scoped, and the "plica" was identified? Are any of us immune to this?

These are the shortcomings of human intelligence and perception. Magicians use pattern formation and human rationalization to create such illusions for our entertainment. How do human intelligence, perception, and natural rationalization affect our daily practice? How do we avoid tricking ourselves into doing what patients have placed their hope on rather than what is more prudent?

Dr. Pinzur: I can understand how these types of appropriateness issues arise. In some practices, national data regarding the percentage of new patients undergoing surgery are used to benchmark surgery rates by specialty. The message can be, "You're not operating on enough people, because we have national standards on what people in your specialty are doing."

Dr. Ring: It's best if data can be used in a positive way. Surgeons who realize they operate much more frequently than their peers should awaken to the possibility that they might be doing more harm than good. For instance, it's compelling to find out that you are 10 times more likely than other surgeons to operate on a patient with a benign, self-limited problem such as tennis elbow. Or that you frequently diagnose radial tunnel syndrome when most of your peers rarely or never make that diagnosis. Would data as feedback improve appropriateness?

Dr. Reznik: At the same time, the risk is that benchmarking data could marginalize effective, but culturally less popular surgeries. For example, European surgeons perform osteotomies for knee alignment much more often than American surgeons. Because osteotomies are not the community standard, when something goes wrong, it may be more difficult to defend them in an American court. In the case of osteotomies, the true indications may be somewhere in the middle. Here, "group think" may cause a rationalization to not use the indicated procedure.

Dr. Ring: I would argue that malpractice depends less on how common a surgery is than on how well it's done.

Dr. Reznik: If few others are performing the surgery, it looks much worse when something goes wrong. If your peers don't agree with your interpretation of the value of that surgery, it may be more difficult to defend.

Dr. Grose: Let's consider the diagnostic dilemma in the scenario presented. If a patient has a puzzling problem, it's better to have a colleague give a second opinion than to order an MRI or give a steroid injection.

Dr. Ring: We also need to get comfortable with nonspecific diagnoses like "nonspecific wrist pain" or "nonspecific knee pain." It's estimated that about 50 percent of symptoms are never linked to discrete pathology.

Dr. Pinzur: I'm concerned that some surgeons may walk into the exam room thinking, "What operation can I perform on this patient?" If there isn't a diagnosis that leads to a surgery, they may say "I've done all I can" rather than helping that patient with palliative treatments and resilience.

Another aspect of appropriateness is optimization of the patient. There is some evidence that a person with a body mass index higher than 40 would benefit from learning and practicing healthier eating and exercise habits prior to total knee or hip arthroplasty for osteoarthritis. But it's difficult to communicate this without disappointing and potentially offending the patient. The patient might get frustrated and go to another surgeon who would not prioritize healthy habits.

Dr. Ring: Surgeons may find themselves giving three steroid injections in the absence of identifiable pathology, applying debatable diagnoses, and offering questionable surgeries because they don't know what else to do. The patient is passive and places all hopes on the surgeon. Many of us accept this role: "I'm their only hope..." Our language also reflects it; we say the patient "failed" nonsurgical treatment, or "required surgery." The formula in our mind is "I've done everything else, so now I must scope the knee." When altruism combines with stress contagion, we may take on the patient's sense of hopelessness and need to act. This might lead to more inappropriate surgery than a seemingly less altruistic simple profit motive.

Yet the foundation of good health is resiliency. Given that diagnostic and therapeutic limitations are common, bolstering resiliency is often a leading option for improving health. The appeal of resiliency is enhanced by expertly scripted and well-practiced communication strategies that most of us lack.

Dr. Marks: I agree. Part of it is that we don't know how to say, "I don't know," or "I can't figure this out."

Dr. Ring: Experts can help us script and practice ways to convey uncertainty and limited options while bolstering hope. For example, instead of saying "I don't know," try "This is puzzling." When you're thinking, "I don't have anything to offer," consider saying, "I wish we had an answer for this." We should tap into the science behind effective communication strategies.

Dr. Jimenez: Surgeons hate to admit that they can't help. They don't want to say a form of "no" to the patient. They don't like saying, "No, we can't help you" or "No, you've come to see the wrong doctor" or "Everything we've tried is wrong" or "This treatment isn't working with you."

Dr. Ring: If we say "yes," we get better reviews, compete better in the market, avoid difficult conversations, and get paid to do the work.

Dr. Archdeacon: There is a component of realigning expectations, both ours and the person we are caring for. It's important that people know we can't fix all their problems.

Dr. Ring: Which is a more appropriate way to conceptualize this: "setting expectations" or "accurate diagnosis of mindset and circumstances?" When a surgery is a technical success and the patient is disappointed, I consider that a misdiagnosis; we didn't diagnose and treat the mindset and circumstances that led to disappointment.

To get back to Dr. MacArthur's patient, he's probably worried his dream is going away. That's often the case with baseball pitchers who want Tommy John surgery when they have little or no valgus instability. They just want to throw 10 miles per hour faster and they imagine the surgery can give them that. Sometimes it's easier to say "My knee hurts" than it is to say "I'm depressed" or "I'm scared."

Or perhaps when his knee hurts, he's limited by the sense that he's causing damage that will end his boxing career. Psychologists refer to this as catastrophic thinking.

It's natural to try to reduce every illness to a measurable or unmeasurable pathophysiology (such as plica or meniscal tear). But it may help to take a broader view and consider that the person may be depressed, scared, or frustrated. We can be vigilant for the verbal and nonverbal signs of stress, distress, and less effective coping strategies.

For instance, the word "unbearable" may mean "I'm overwhelmed." And the phrase, "I have a high tolerance for pain" may mean "This is a crisis." Symptoms of depression and less effective coping strategies are responsive to treatment with cognitive behavioral therapy. This is an opportunity we should not overlook.

Dr. Grose: It seems like the longer you are in practice, the greater your tendency to delay an offer of surgery until it is likely to make a meaningful difference. We hear about people needing a knee or a hip replacement. Nobody has ever needed a hip replacement. Some people benefit from joint replacement enough in potential improvement of quality of life to justify the inconveniences, discomforts, and risks of replacing a joint that is no longer working well.

Dr. Reznik: It's been said that the pathology is usually less than half the reason why a person sees a doctor. More often than not, an event unrelated to the pathophysiology motivates them to seek care.

Dr. Ring: Good point. For instance, everyone who lives long enough gets base of thumb arthritis. Not everyone sees a doctor. Some people are unaware they have thumb arthritis. Among people with thumb arthritis, the subset that sees a specialist and the even smaller subset that has surgery differ in important ways from the average person with thumb arthritis.

Everyone stands to benefit from growing their resiliency. Among people considering surgery for thumb arthritis, a little boost in resiliency might tip the scales against surgery. And if they do have surgery, they will have an easier recovery and are less likely to be disappointed.

Given that most musculoskeletal surgeries are discretionary, we have plenty of breathing room. Efforts to optimize resiliency prior to surgery are likely to reap substantial rewards.