Shared-decision making is a combination of expertise, available scientific evidence, and what matters most (the values) of the patient and surgeon. However, surgeon bias often gets in the way of making a shared decision in a clinical setting. One study of patients with idiopathic trigger finger showed that the only factor associated with greater decisional conflict was the relationship between patient and doctor (1).  

Decision aids increase patient participation in decision-making and reduce decision conflict (2). They also reduce the use of discretionary surgery without apparent adverse effects on health outcomes or satisfaction (3). In a randomized, controlled trial, it was found that the use of an interactive decision aid prior to a first-time visit for TMC arthritis led to a measurable reduction in decision conflict (2). Decision aids can make people seeking care for TMC arthritis more comfortable with their decisions. 

Another example of surgeon bias is the medicalization of TMC arthrosis, which is an expected part of normal human aging and involves treatments that are discretionary and address quality of life. When patients first learn about their trapeziometacarpal arthrosis, the behavior of the hand surgeon may have a strong influence on return visits and eventual choice of operative treatment (4). The factors associated with a return visit– injection or splint at the first visit and recommendation for a return visit– likely reflect both patient and surgeon preferences. In contrast, election of operative treatment is strongly surgeon-related. This is counterintuitive to many hand surgeons who assume that patients that have more treatment have worse pathology. 

Treatment of TMC arthrosis with splints and injections might medicalize changes in the human body that are expected and often well-adapted. In other words, the treatment strategy can make people less adaptive and lead patients to choose more treatment, including more invasive procedures (4). If coping strategies and adaptation are seen as appealing treatment strategies, people might approach arthritis as expected and adaptable rather than a disease requiring treatment. Hand surgeons should evaluate the ability of decision aids (structured handouts, videos, or web-based tutorials) to decrease symptoms and disability and improve patient satisfaction in the treatment of arthritis and other common conditions. 

Some surgeons contend that patients are less capable of participating in decisions about traumatic conditions than non-traumatic conditions (5). We found that there is no difference in decision-making preferences between patients with non-traumatic conditions and those who sustained acute trauma. Many injuries can be treated with or without surgery, and decision aids can help people make a choice consistent with their values and not clouded by misconceptions. 

Our research on limiting the influence of surgeon bias is focusing on several areas:

1. We are addressing the ability of decision aids to reduce surgeon-to-surgeon variation, resource utilization, and dissatisfaction with care. 
2. Decision aids merit study for quality of life issues, such as arthritis, and discretionary surgeries, such as trapeziometacarpal arthroplasty.
3. We are studying new patients presenting with TMC arthrosis in order to determine factors associated with return for a second visit and eventual election of operative treatment.
4. We are examining the shared decision-making process, the determinants of expressed patient preferences, and the influence of psychological and sociological factors, in addition to the specific surgeon’s management style, on the decision for a second visit and election of surgery.

References

1. Hageman MG, Döring AC, Spit SA, Guitton TG, Ring D. Assessment of Decisional Conflict about the Treatment of Trigger Finger, Comparing Patients and Physicians. Arch Bone Jt Surg. 2016 Oct;4(4):353-358. PubMed PMID: 27847849; PubMed Central PMCID: PMC5100452.
2. Wilkens SC, Ring D, Teunis T, Lee SP, Chen NC. Decision Aid for TrapeziometacarpalArthritis: A Randomized Controlled Trial. J Hand Surg Am. 2018 Jul 18. pii: S0363-5023(17)32162-7. doi: 10.1016/j.jhsa.2018.06.004. [Epub ahead of print] PubMed PMID: 30031600.
3. Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011; 10: CD001431.
4. Ochtman AEA, Guitton TG, Buijze GA, Zurakowski D, Mudgal C, Jupiter JB, Ring D. Trapeziometacarpal arthrosis: predictors of a second visit and surgery. J Hand Microsurgery. Published online, December 2012. Hageman MG, Reddy R, Makarawung DJ, Briet JP, van Dijk CN, Ring D. Do Upper Extremity Trauma Patients Have Different Preferences for Shared Decision-making Than Patients With Nontraumatic Conditions? Clin Orthop Relat Res. 2015 Jun 4. [Epub ahead of print] PubMed PMID: 26040968.