Editor's Spotlight/Take 5: Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?

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When I was a resident, Dempsey Springfield MD—the Harvard University musculoskeletal oncologist, then at the height of his powers—visited our program and asked this provocative question: “What do patients want when they go to the doctor?” He waved away our responses; he wasn't looking for the obvious. It wasn't pain relief, return of function, or even to get a diagnosis. “Patients want you to see the future for them,” he pronounced.
I assume that there was some overstatement for didactic impact in his answer, but it had impact; it's still in my ears almost 25 years later.
The problem is, we may not be all that great at this sort of prognostication. We can forgive ourselves for not being experts at picking stocks or ponies. Perhaps we can even allow that we won't always get it right for our patients with cancer, though it surely would be better if we could. But is it possible that experienced surgeons have a no-better-than-chance likelihood of anticipating whether a patient undergoing one of the most-common operations orthopaedic surgeons perform—total knee arthroplasty—will improve enough to say that the procedure was worthwhile?
In this month's Clinical Orthopaedics and Related Research®, a provocative study by Hassan M. K. Ghomrawi PhD, MPH at Northwestern University (in collaboration with colleagues from the Hospital for Special Surgery and Weill Cornell Medical College), concludes exactly that [2]. The surgeons involved in this study are experienced, high-volume joint-replacement specialists from a leading international arthroplasty center. If a coin toss is as likely to give the right answer as a surgical recommendation from someone this experienced, we need to stop and ask why. (I note that they did much better when anticipating the results of THA, particularly for patients who were men, who had a BMI under 30, and who were older than 65 years of age).
The fact that the experienced, expert surgeons in this study were unable to anticipate whether a patient would benefit from TKA should be important—and concerning—to orthopaedic surgeons whether or not they perform knee replacements, since it gets to the heart of what patients look for when they come to us. How sure are we, really, when we shake hands and suggest an intervention to our patients that we are making a good decision? Perhaps the answer is “much less sure than we thought.”
This study was robust. It was prospective, the large majority of patients involved were accounted for, they were given ample time to recover from surgery (at least 2 years), and the outcomes tools employed were validated. They didn't hang the results on statistical differences, but rather on clinically important changes in patients’ pain and function using the WOMAC scale. This is not a study we can wave away, as much as we might like to. Patients need us to see the future more accurately than this.
Join me as I go behind the discovery in the Take-5 interview that follows with the Senior Author of this fascinating article, Dr. Hassan Ghomrawi.
Take-5 interview with Hassan M. K. Ghomrawi PhD, MPH, senior author of “Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?”
Seth S. Leopold MD:Congratulations on this important and well-conducted study. Let's jump right into the hard stuff: Imagine you're a patient considering TKA, but you're not sure. Your surgeon says he thinks it's likely to provide you with a substantial improvement in your pain and function. What does this recommendation mean to you, now that you've done this research?
Hassan M.K.
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