We want our patients involved in shared decision-making. But do patients feel they are? A report by Alokozai et al. in the May 4, 2022 issue of JBJS indicates we have work to do. And it highlights opportunities for improvement. 

As an orthopaedic community, we have been well informed regarding the critical importance of shared decision-making, particularly for discretionary treatment interventions. Several decades ago, the seminal work of Dr. Jack Wennberg and his team from Dartmouth enlightened us as to the huge regional variations in rates of procedures like knee arthroplasty and spinal fusion across the U.S. In subsequent years, medicine moved toward evidence-based treatment recommendations. We at JBJS instituted a Level of Evidence rating for all of our clinical articles nearly 20 years ago.  

At the same time, the surgical community also began to recognize that patients have their own perceptions of pain and its influence on quality of life. And that a patient’s perceptions about the risks of various treatment options, or about their ability to follow a recommended rehabilitation plan, can help inform the treatment conversation. Shared decision-making allows for mutual discussion between surgeon and patient about the evidence for a recommended treatment—and how treatment options align with the patient’s personal and cultural beliefs, their values, and preferences.   

Patient and Surgeon Perceptions Not Aligned 

Alokozai and colleagues invited patients seeking care at a musculoskeletal specialty office to rate their preferred level of involvement in decision-making before their visit, and their perceived level of involvement after the visit. Following the visit, surgeons rated their perception of the patient’s involvement in decision-making. A total of 136 patients were included. 

The investigators found poor agreement between patients and surgeons regarding the extent of patient participation in decision-making. Access the report here. 

One notable observation was that surgeons rated patients who did not have a high school diploma as having less involvement in decision-making. This finding may be multifactorial. Nonetheless, it reminds the orthopaedic community that we must work harder to discount the notion that educational level or perceived socioeconomic status has anything to do with the importance of a patient’s involvement in the process of shared decision-making.  

The authors describe their results as “humbling.” And as they suggest, the study highlights opportunities for more research into effective strategies for improvement. One example: condition-specific question prompts to direct conversations toward issues that matter most to the patient. In addition, establishing trust by prioritizing the patient relationship.   

Shared decision-making has been taught fairly well throughout our educational programs in recent years. Now is the time for all of us to continue to develop essential skills in connecting with our patients. Through such commitment, patients can be more assured that their values are highly prioritized in the decision-making process. 

Marc Swiontkowski, MD 

JBJS Editor-in-Chief 

View the JBJS Video Summary of this study.

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