Editorial: The Goal is Health, Not Surgery

Orthopaedic surgeons operate. We also clarify, commiserate, empathize, soothe, ground, guide, and accompany. So when patients see us as “fixers” and nothing more, we can experience moral distress that makes practicing our profession less enjoyable [16]. It’s easy to see how this happens. Every day we navigate conversations, advertisements, journal articles, and incentives in our practice settings that promote and perpetuate a surgery-centric view of our work. It’s too easy to lose track of what our patients seek from their visits with us: good health, not surgery. People visiting orthopaedic surgeons—like all people—would prefer to avoid surgery if possible. And while some orthopaedic procedures are necessary to preserve life or limb, most of what we do in the operating room is optional (elective or discretionary). We should keep this front of mind as we discuss surgical and nonoperative treatments with our patients. We should take every reasonable opportunity to give our patients what they really want. We wanted to offer a few thoughts about how to center our practices on the goal of improving health rather than on performing surgery. Our hope is that in doing so, we might stay focused on what really matters most to patients, which will, in turn, enhance the enjoyment of our work. In previous editorials [12, 18], we highlighted some of the ways in which our words and actions may increase the moral distress most patients feel when too much of a conversation focuses on discretionary surgery. For instance, terms like “failed nonoperative treatment” promote an inappropriate confidence among patients that the other form of treatment—surgery—is a winner [18]. This phrasing might make a person wonder, “Why don’t we skip a few steps and move straight to surgical success?” We have also reflected on the importance of remaining mindful that, among the many health options a person may consider, surgery always starts in deficit [17]. Surgery is done with a knife, and so it necessarily involves strategic harm. The trust that people place in us when they allow us to impose this strategic harm is sacred. The evidence [7, 19] that comfort and capability are as much about a patient’s thoughts and feelings as they are about the pathophysiological severity of that patient’s condition opens up important treatment avenues. Many patients find that guidance toward a healthier mindset regarding their bodies is all they need to live well with their symptoms. For instance, there is evidence that people are willing to continue with a cherished, painful activity even if the activity causes more rapid deterioration of a body part [2]. Fortunately, it’s a common misconception that one needs to make such a choice: There is evidence that moderate levels of painful activity do not accelerate conditions of musculoskeletal senescence such as osteoarthritis [8]. Given that patients are generally willing to accommodate symptoms—provided that we emphasize the health benefits of that choice—it seems plausible, if not likely, that many people being treated with surgery could manage without it, perhaps as effectively or more so [9, 11]. There is evidence that people choose the least invasive, least uncomfortable, least risky, and least costly treatments that can achieve their health goals, and they want these treatments to outperform accommodation [3], both in terms of efficacy and safety. At a minimum, we need to make sure the operations we offer satisfy those requirements. This is not always the case, even for many common orthopaedic procedures [5, 10]. We are as enthusiastic as anyone else about the many good operations orthopaedic surgeons perform that improve patients’ lives. Our point here is simply this: It’s important not to miss the chance to improve health by bolstering patients’ abilities to accommodate the changes to their bodies, in particular those that come with age, and when reasonable, to do so without offering surgery. We are closer to the ends of our careers than to their beginnings. As time has passed and experience been accrued, we've come to appreciate that the number of patients who can shift—with a surgeon's compassionate guidance—from the degree of despair that prompted the visit to a confident accommodation of a condition is much greater than we believed it would be when we were young surgeons. Since we are orthopaedic surgeons, the fact that much of the research we do focuses on helping people experience greater benefit from surgery makes sense. But since surgery is only a part of what we are supposed to do as physicians, an inordinate research focus on improving the results of discretionary surgery rather than on improving health may perpetuate the false sense that discretionary surgery is necessary. And even worse, when an experiment compares two surgical procedures or nonoperative treatments to one another, yet neither is clearly better than a placebo, the results of that experiment may normalize, legitimize, and promote both treatments, neither of which may be effective [1]. By contrast, a focus on health would emphasize accommodation as the preferred strategy when there are no disease-modifying treatments and encourage experiments to determine whether a specific intervention offers sufficient potential for benefit to balance the potential for iatrogenic, psychological, or financial harm. Too much musculoskeletal research addresses small bits of “pathophysiology,” like a little loss of water content (intervertebral disc changes as we age), a bit of thinning (normal senescence of the rotator cuff), a small fissure (as are so common in our menisci over time), or minor technical variations in treatments. None of these foci seem to have much chance of delivering meaningful measurable improvements in health given the impressive strength of placebo and nocebo effects [6] and the notable association of healthy mindsets and circumstances with greater comfort and capability [4, 13, 15, 20]. Here are a few ways we can try to keep the focus on health rather than surgery: Remember that most orthopaedic procedures are optional, and all surgery is strategic harm [17]. Consider the likely reasons that a person might find surgery appealing: Is it based on a thoughtful analysis of potential harms and benefits [14]? Or is it based on desperation and despair? An incidental finding on an imaging test? Misconceptions and insecurity? False hope? Make a habit of focusing clinic conversations on each patient’s health rather than on which surgical procedures might be used to treat his or her conditions. Placing the focus on health rather than surgery in everyday practice has the potential to rehumanize our work and make it more enjoyable. The less we focus on procedures that sometimes are unnecessary and always carry risk, the more our actions will align with our values—and those of our patients.