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Scientific Articles   |    
Older Patients' Unexpressed Concerns About Orthopaedic Surgery
Pamela L. Hudak, BScPT, PhD1; Kristy Armstrong, MSc2; Clarence BraddockIII, MD, MPH3; Richard M. Frankel, PhD4; Wendy Levinson, MD, FRCPC5
1 The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada. E-mail address: hudakp@smh.toronto.on.ca
2 Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5, Canada
3 Department of Medicine, Stanford University School of Medicine, 251 Campus Drive, MS0B X333, 5404, Stanford, CA 94305-5404
4 Center for Implementing Evidence Based Practice, Richard L. Roudebush Veterans Administration Medical Center, Indiana University School of Medicine, 410 West 10th Street, Suite 2000, Indianapolis, IN 46202
5 Department of Medicine, University of Toronto, Suite 3-805, R. Fraser Elliott Building, 190 Elizabeth Street, Toronto, ON M5G 2C4, Canada
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institute on Aging (RO1 AGO18781). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at St. Michael's Hospital, Toronto, Ontario, Canada

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jul 01;90(7):1427-1435. doi: 10.2106/JBJS.G.01077
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Abstract

Background: As the U.S. population ages, orthopaedic surgeons will increasingly be required to counsel older patients about major surgical procedures. Understanding patient concerns or worries about surgery could help orthopaedic surgeons to assist their patients in making these decisions. The objectives of this study were to explore the nature of patient concerns regarding orthopaedic surgery and to describe how patients raise concerns during visits with orthopaedic surgeons and how orthopaedic surgeons respond.

Methods: As part of a study involving audiotaping of 886 visits between patients and orthopaedic surgeons, fifty-nine patients sixty years of age or older who were considering surgery were recruited to participate in semistructured telephone interviews at five to seven days and one month after the visit. Patients were asked about their perceptions of the visit and how they made their decision about surgery. These interviews were analyzed to identify patients' concerns with the use of qualitative content analysis and then compared with the audiotaped visits to determine whether these concerns were actually raised during the visit and, if so, how well the orthopaedic surgeons responded. Analyses based on patient race (black or white) were also performed.

Results: One hundred and sixty-four concerns pertaining to (1) the surgery (anticipated quality of life after the surgery, the care facility, the timing of the operation, and the patient's capacity to meet the demands of the surgery) and (2) the surgeons (their competency, communication, and professional practices) were identified. Patients raised only 53% of their concerns with the orthopaedic surgeons and were selective in what they disclosed; concerns about the timing of the operation and about the care facility were frequently raised, but concerns about their capacity to meet the demands of the surgery and about the orthopaedic surgeons were not. Orthopaedic surgeons responded positively to 66% of the concerns raised by the patients. Only two concerns were raised in response to direct surgeon inquiry.

Conclusions: Patients raised only half their concerns regarding surgery with orthopaedic surgeons. Orthopaedic surgeons are encouraged to fully address how patients' capacity to meet the demands of the surgery, defined by their resources (such as social support, transportation, and finances) and obligations (to family members, employers, and religion), may impinge on their willingness to accept recommended surgery.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Dorothea Z. Lack
    Posted on July 23, 2008
    Addressing the Unexpressed Needs of Older Patients: Making it Multidisciplinary
    Independent Practice

    To the Editor:

    As the demands for services increase with a growing population (1), it seems less and less efficient and/or effective to ask the orthopaedic surgeon to address yet another demand for communication. I find it interesting that patients were willing to disclose their concerns to a stranger in a telephone interview and not to the surgeon.

    I am proposing a whole new approach to the necessary communication surrounding proposed surgery--add a communications expert, such as a psychologist to the orthopaedic team. I think it will still be necessary for an orthopaedic surgeon to discuss the procedure, risks and possible outcomes, but the psychosocial concerns can best be left to a separate expert in communication, one who is not directly involved the patient's care.

    The concerns which lead to this suggestion are consideration for the surgeon's time and the demand characteristics of the situation, which may make it difficult for the patient to be fully open for fear of appearing to be a difficult patient, or fear of losing the respect of the surgeon.

    The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.

    1. Richard Iorio, William J. Robb, William L. Healy, Daniel J. Berry, William J. Hozack, Richard F. Kyle, David G. Lewallen, Robert T. Trousdale, William A. Jiranek, Van P. Stamos, and Brian S. Parsley; Orthopaedic Surgeon Workforce and Volume Assessment for Total Hip and Knee Replacement in the United States: Preparing for an Epidemic J Bone Joint Surg Am. 2008;90:1598-1605.

    Ziad Harb
    Posted on July 15, 2008
    Unexpressed concerns: time constraints, informed consent and surgeon grade
    St George's Hospital, London

    To the Editor:

    We read with interest the article by Hudak et al.(1). In our experience it is difficult to fully address patients' concerns because of time constraints,particularly during busy fracture clinics and business ward rounds.

    In a recent study that assessed the ability of orthopaedic surgeons to counsel patients and obtain informed consent, orthopaedic residents were found to be better than consultants in performing this task; presumably because of their immediate need to focus on decision making, preoperative planning, and the planning for post-operative care(2).

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1.Pamela L. Hudak, Kristy Armstrong, Clarence Braddock, III, Richard M. Frankel, and Wendy Levinson Older Patients' Unexpressed Concerns About Orthopaedic Surgery J Bone Joint Surg Am 2008; 90: 1427-1435

    2. Hamilton P, Bismil Q, Ricketts DM. Knowledge of the laws of consent in surgical trainees. Ann R Coll Surg Engl. 2007 Jan;89(1):86;

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