The concept of asking and accounting for patient preferences in non-emergent treatment decisions has been discussed in the medical literature for nearly two decades. Michael J. Barry, MD and others have quite fully developed this notion of “shared decision making” (SDM). In the context of patient desires, SDM includes a presentation of the treatment options and the data regarding those treatment options, and a discussion of potential complications involved in each option.
The earliest work on SDM centered around patient choices for managing prostate disease, degenerative disc disease of the lumbar spine, and urinary incontinence. Only recently have orthopaedic surgeons embraced this concept, as more of us get training in and practice the necessary communication skills and cultural competency needed to engage our patients in SDM. But we still have a long way to go when it comes to facility with SDM, and this seems to be especially true in the orthopaedic communities of some non-US countries.
In the May 1, 2019 issue of The Journal, Martinez-Siekavizza et al. report results of a survey on the use of SDM among orthopaedic surgeons in Guatemala. Survey recipients were questioned about their SDM techniques in the clinical scenario of intertrochanteric hip fracture, although hip fracture may not have been the ideal condition to focus on, given the worldwide acceptance that this condition is almost always best managed surgically. Nevertheless, the survey showed that 25% of the surgeon respondents ”never” or “hardly ever” allowed their patients to participate in the treatment decision-making process. While the authors cite many systemic reasons for such lack of patient participation (such as surgical consent not being required in Guatemala and the limited resources in many rural areas of the country that often leave no choices available), 75% non-engagement with patients/families strikes me as very high.
The key facet of shared decision making is discussing all the potential treatment options with the patient. This aspect of SDM seems especially important for nontrauma elective cases in which the “best” treatment option may be less clear than in trauma cases. Even so, Martinez-Siekavizza et al. found that surgeons who discussed the different treatment options with patients had an almost 3-fold greater likelihood of allowing patients to participate in decision making than those who did not. This makes intuitive sense, as it would be difficult for patients to take part in treatment decisions if they are not informed about the options that exist.
As surgeons, we need to do our best to ensure that patients understand all their treatment options, and we should sharpen our focus on shared decision making during our patient interactions. JBJS looks forward to receiving more manuscripts from all over the world that explore the techniques and value of SDM in orthopaedic patient management.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
I agree completely. But one other problem is educating the patients as well to understand that that they can become involved. With my experience on the mission field over long visits over 16 years, I found it very difficult to get the pts to listen to explanations about the surgery, its risks and alternatives. They just wanted to know if they needed surgery or not. The last 2 years, I did find a few more patients, esp. younger ones willing to listen to some extent. It was difficult with large and probable malignant tumors because they just wanted to have the lump cut out and did not wish to listen to other approaches. I guess the more we in the western world involve the pts, the more we will hope it spreads elsewhere.