There is substantial unexplained geographical and surgeon-to-surgeon variation in rates of surgery. If surgeons disagree about the role of surgery, it would seem that patient values and preferences should drive decision-making. However, there is evidence that surgeon preferences have substantial influence.
Surgeon preferences relate, in part, to surgeon personality. One study found that a recommendation for discretionary surgery for a musculoskeletal injury was related to surgeon personality characteristics (1). Surgeon self-awareness of how their work style can influence their recommendations might make them more receptive to techniques that ensure patient values have more influence than surgeon preferences on treatment decisions.
One would expect surgeons to offer treatment to patients in the same way they could consider it for themselves. But a study that randomized surgeons to give recommendations for discretionary surgery for a musculoskeletal injury for themselves or for a patient found that surgeons are slightly more likely to recommend surgery for a patient than they are to choose surgery for themselves (2). In addition, they chose for themselves with a little more confidence. If surgeons try to avoid surgery for themselves, shouldn’t they recommend the same for people seeking their expert advice?
In this vein, surgeons tend to be very adaptive and accommodating. Shouldn’t they help guide patients to similarly healthy mindsets and circumstances? A study of the prevalence of non-traumatic pains, treatments, and other factors compared surgeons and their patients. Surgeons noticed more non-traumatic pains than patients and were more likely to report pain at more than one anatomical site (3). Patients were more likely to receive any treatment: surgery; injection; non-opioid medication; opioid medication; physical or occupational therapy. Patients also missed work more often than surgeons. Surgeons might consider helping people accommodate pains as an important first step in helping people get and stay healthy. Increasing the appeal and availability of methods for optimizing coping strategies might help to narrow the gap between surgeon and patient health.
We also addressed the factors that surgeons use to decide between two options for treatment when the evidence is inconclusive. In one study, a total of 337 surgeons rated the importance of seven factors when deciding between operative treatment and symptom alleviation and 12 factors when deciding between two operative treatments, given a scenario where solid evidence showed no difference between the options. Ratings were on a 5-point Likert scale between “very important” and “very unimportant.” It was found that the most popular factors influencing recommendations when evidence showed no benefit of surgery over symptom alleviation were “works in my hands,” “familiarity with the treatment,” and “what my mentor taught me” (4). The most important factors when evidence shows no difference between two surgeries were “fewer complications,” “quicker recovery,” “burns fewer bridges,” “works in my hands” and “familiarity with the procedure.” The observation that surgeons use their perspective rather than the patient’s when evidence about options is inconclusive is further evidence of the influence of surgeon bias.
References
- Teunis T, Janssen SJ, Guitton TG, Vranceanu AM, Goos B, Ring D. Surgeon personality is associated with recommendation for operative treatment. Hand. Epub ahead of print. DOI 10.1007/s11552-015-9755-x.
- Janssen SJ, Teunis T, Guitton TG, Ring D; Science of Variation Group. Do Surgeons Treat Their Patients Like They Would Treat Themselves? Clin Orthop Relat Res. 2015 May 9. [Epub ahead of print] PubMed PMID: 25957212.
- Bernstein DN, Sood A, Mellema JJ, Li Y, Ring D. Lifetime prevalence of and factors associated with non-traumatic musculoskeletal pains amongst surgeons and patients. Int Orthop. 2016 Nov 18. [Epub ahead of print] PubMed PMID: 27864586.
- Hageman MG, Guitton TG, Ring D; Science of Variation Group. How Surgeons Make Decisions When the Evidence Is Inconclusive. J Hand Surg Am. 2013 May 3. doi:pii: S0363-5023(13)00292-X. 10.1016/j.jhsa.2013.02.032. [Epub ahead of print] PubMed PMID: 23647639.