Technical aspects of orthopedic surgery are only part of the equation
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After 30 years of practicing orthopexdic surgery, I faced one of my career’s most critical and challenging decisions – choosing a surgeon for my joint replacement.
With many talented friends and colleagues and the consistency of state-of-the-art joint replacement, the factors that went into my decision were evident — skill and competence, but also overall patient experience. I wanted a complication-free, outpatient experience with a surgeon and team who would provide the best possibility for an uneventful procedure and a multiple-decade outlook on the longevity of the implant. I immediately appreciated how difficult it is for patients without connections in medicine or orthopedics to make the same decision.
For years, I have managed arthritis in my left knee. The steadily increasing stiffness, inability to run, enlarging osteophytes, advancing varus deformity past 10°, decreasing response to an occasional cortisone injection and my fitness routine were sentinel events that were leading me to make the decision to have a knee replacement. Five prior surgeries for traumatic events, including ligament reconstruction and meniscal surgery, had finally taken its toll. The surgeries also significantly increased the complexity of the surgeon’s decision-making process: mechanical vs. kinematic axis; how much correction of varus; cemented vs. uncemented tibia due to less bone from prior surgeries and varus alignment; infection prevention; prosthetic stability; and impact of a patient who will return to high-level recreational activities. I have spoken to many orthopedic leaders during the years to better understand how they would approach my surgery, hoping it would help me choose the best surgeon.
My hip replacement
One day, I stood up from a deep-seated position and felt a “pop” in my hip in the limb opposite my arthritic knee. I could sense some crepitation and soreness throughout the day as I tried to stretch and reduce my weight-bearing. My initial thought was a torn labrum because I had no prior restrictions with work or recreational activities, including weight training. A standard series of radiographs were performed to show expected mild degenerative changes, but mostly to get approval for an MRI to confirm soft tissue injury. Unfortunately, the hip images were consistent with advanced osteoarthritis of my hip joint. Due to the sudden onset, I remained hopeful that rehabilitation, injection or arthroscopic hip surgery would return my hip to its preinjury level of comfort and function. The results of my hip MRI were definitive – arthritis was beyond the indications for an arthroscopic solution and a hip replacement was my only reasonable option. Unlike my knee, my hip symptoms did not respond to nonsurgical treatments.
As I had done for my knee, I thoroughly investigated surgeons who would perform my hip replacement. I was impressed by my local colleagues, surgeons I have worked with before and others who are recognized as regional and national experts. There was significantly more consensus on the type of implant, use of a ceramic head, cementless fixation and modern polyethylene liners. Postoperative rehabilitation was simple, including advancing weight-bearing as tolerated, returning to work in 4 weeks or less and return to the gym in 6 weeks or less. The major controversy was the surgical approach, with many surgeons strongly recommending the anterior approach. However, some surgeons cautioned that years of leg exercises may challenge the ability to get enough anterior exposure to insert the femoral component in its best alignment and avoid complications.
Selection of a surgeon
My experience provided me with better insight into a patient’s selection of a surgeon. The most important single factor is trust. Regardless of the level of understanding about joint replacement, patients should believe their surgeons will use their knowledge, skill, integrity and leadership of the surgical team to provide the best opportunity for a successful result. Patients will use various sources to develop the needed trust to consent to surgery, including referrals from primary care physicians, surgeon’s education and credentials, community reputation and, increasingly, the information and ratings available online.
The most powerful method of developing trust remains a direct one-on-one relationship with the surgeon. In the short time spent with a patient, the surgeon should intentionally make the effort to make the relationship personal. This can be facilitated by office staff, medical assistants and especially the advanced practice providers working as a team with the surgeon.
With active listening, understanding the patient’s concerns and questions, and appreciating the mental stress that underlies the decision, the surgeon can demonstrate empathy and provide clear and logical answers. Responses should reflect the surgeon’s competence and experience. Communication and empathy are directed to improve the patient’s understanding of the process and procedure by using language that matches their level of education, maturity, mental status and cultural background.
Achieving trust
Achieving a patient’s trust positively impacts the entire procedure, including compliance with postoperative instructions, final outcomes and community reputation. If a complication occurs, a patient’s trust in your abilities will encourage them to work with you to resolve the complication.
My hip replacement surgeon is a world-class expert. His peers and those who have trained with him frequently refer to his surgical skills as a differentiating factor. However, the most crucial factor was trust.
I met my surgeon as a classmate in college and we went to medical school together. Those eight formative years, combined with decisions and accomplishments during the next 3 decades, made it easy to trust that he would make decisions in my personal best interest. Other persuasive factors included having the surgery in a location distinctly separate from my previous and present work environment. The surgical team was well-organized, personable and comfortably answered questions with authority and experience. The operation was performed with spinal anesthesia and sedation. I went home the same day, walked unaided in a few days and resumed work in weeks. It is unlikely I will need any other surgery on my hip during my life, and I can return to all activities. I remain impressed with the entire experience.
My surgical journey
My decision-making process and surgical journey have significantly influenced how I approach my practice. I now place an even greater emphasis on the overall patient experience. I strive to build trust through open communication, empathy and personalized care.
My goal is to ensure my patients feel confident in their care and know we will provide a surgical expertise that leads to best possible outcomes. I have been reminded that technical aspects of surgery are only part of the equation. The human connection and trust built between the patient and surgeon are equally, if not more, important in determining the final result. This experience has made me a better surgeon and reinforced my commitment to providing exceptional patient care.
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- Anthony A. Romeo, MD, is the Chief Medical Editor of Healio | Orthopedics Today. He can be reached at Healio, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.
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