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Successful surgical outcomes are influenced by factors other than the surgeon
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After following many patients for more than 30 years, I have become more aware of factors other than surgical skill that, at times, contributed to some of my patients’ good outcomes. This became apparent in patients who elected to defer their surgical interventions and took a wait-and-see approach.
Many of the patients who did better than expected had chronic conditions with some or all of their symptoms related to underlying degenerative articular cartilage or a damaged or torn semi-lunar cartilage. Many of these conditions do not have a good natural history for the spectrum of involvement seen in a given patient.
Many conditions in orthopedics certainly benefit directly from surgery. I do not want to detract in any way from the skills, judgement and care my colleagues give every day. The point of this Commentary is to note that other factors also can affect outcomes when surgery tends to get all the credit.
Chronic conditions
Throughout my career, I have treated many patients with ACL tears without surgery. I followed some patients for more than 20 years, and these included at least 25 physicians. The patients have continued to work. Many patients stayed fit, with some continuing to ski, but most limited their fitness activities to straight-ahead sports after the ACL rupture. I have done partial meniscectomies on some of these patients after a number of years, and even did a few late ACL reconstructions in this group as well.
Douglas W. Jackson
A large number of patients with disabling extensor mechanism syndromes, usually with significant chondromalacia, were among the patients who often did surprisingly well after 3 years to 5 years. In time, some patients even returned to all of their activities, including running and jumping. If I had operated at the height of their restrictions, then I would have believed the outcomes were good and totally influenced by the surgery.
Personally, I experienced an episode of persistent radicular leg pain and could not run for more than a year. I was able to cycle but it took me a while to stand up straight after completing a long ride. I did not have epidurals and declined surgery, although I considered it at times. During the most uncomfortable times, I used of over-the-counter anti-inflammatory medications that helped take the edge off when standing in surgery, clinic and before cycling and other exercise.
This conservative wait-and-see approach I preferred was used when I was in the military. I had the opportunity to follow many officers and enlisted personnel with back involvement, neurological changes and even a few with foot drop that completely recovered within 6 months to 1 year. Most patients treated without surgery returned to full activity with no restrictions. The exceptions to this nonoperative care were patients with severe disabling pain or progressing neurologic changes.
Directed program
Many patients seek our opinion and an explanation for their pain. They want someone to spend some time with them, understand how their condition impacts their lives, explain the cause of their pain and assure them that it is not serious or progressively crippling. They want to know if they need to do something immediately and often want to be reassured that you will follow them and intervene if things change or get worse.
During this time, patients are usually willing to follow a directed program that may include patient education, weight loss, strengthening and conditioning within the limits of non-aggravating activities. It always amazes me how patients who undergo surgery will do a similar program and seem more motivated and serious if they have surgery.
Placebo vs nocebo effects
Many physicians regard true placebos to involve inert and ineffective treatments that often involve patient deception. However, I do not underestimate the “white coat effect,” as well as the surgeon’s reputation and other subliminal and induced biologic responses to produce a positive effect. Many patients want to please their surgeons with a good result and are positive individuals who are committed to a good result from surgery. After all, the Latin origin for placebo is, “I shall please.”
A wise surgeon also must be on the outlook for the “nocebo effect.” The term “nocebo” is derived from Latin meaning “I will harm,” which raises the possibility that a surgery may have negative consequences independent of the surgeon’s skills. The nocebo effect has been measured in the same way as the placebo effect. I learned to try and spot patients with strong secondary gains or significant depression, which can contribute to bad outcomes and worsening of symptoms.
Orthopedic literature
Orthopedic literature is filled with published papers arguing both sides of outcomes from surgical intervention and non-surgical approaches, especially for chronic conditions. Withstanding their limitations, two articles published in The Journal of the American Medical Association in 2006 reported results of the Spine Patient Outcomes Research Trial project. These papers were widely discussed, and critics raised some shortcomings in the application of the data and selection factors to the national standard of care. The multicenter trials involved patients with persistent disc-related pain and neurologic symptoms. There were difficulties in the randomization of patients undergoing disc surgery and patients who received other aspects of care, including patient education, anti-inflammatory medication and physical therapy. These studies, a well as other similar studies, have suggested that there are no major differences in the nonoperative and operative care of disc-related pain when patients are followed for 2 years.
Orthopedists treat large numbers of patients with osteoarthritis (OA) and its varied manifestations. A large number of studies have looked at the placebo effects of medications and treatments for patients with OA. In a study published in Annals of the Rheumatic Diseases in 2008, researchers reported on a meta-analysis of purported randomized controlled trials. The authors’ conclusions were that placebos are effective in the treatment of OA, especially for pain, stiffness and self-reported function. The size of the effect is influenced by many factors, such as the effectiveness of the active treatments available, baseline severity of the disease and other issues, such as the treatment delivery method and sample size. This paper identified 198 trials with 193 placebo groups with a total of 16,364 patients and a range of therapies, including non-pharmacological, pharmacological and surgical treatments.
Potential benefits
Many physicians have come to accept that approximately 30% of patients respond in some degree to placebo effects. The problem is that one does not know in advance whether a placebo effect will work for a given patient. Prescribing placebos should involve informed patient choice, but government claims do not reimburse for placebo treatments. Using placebos as a primary treatment raises ethical issues and affects the physician-patient relationship. I do not recommend prescribing placebos. However, even though the placebo effect is often unreliable and unpredictable, it can be good if physicians and patients benefit in some way.
As surgeons, we can benefit from the placebo effects in our elective surgeries. Likewise, we need to recognize patients with significant negative attitudes toward the effectiveness of the recommended surgery. A patient’s mentality and outlook influences his or her ability to get well and can enhance outcomes. A good surgeon learns definite factors that can enhance success and, at times, even make it more difficult.
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Douglas W. Jackson, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.