Surgical hexing can curse outcomes

Orthopaedic surgeons rely on high-level data, objective studies, and evidence-based medicine when diagnosing and treating patients. While essential for patient care, framing this information when outlining outcome expectations and discussing surgical preparation may have some inadvertent consequences. Using best practices, orthopaedic surgeons may be guilty of “surgical hexing” simply by telling a patient what is known about their stratified risk profile for joint replacement.

Outcomes of elective surgery, like so much in medicine, rely heavily on a complex relationship between the surgeon and the patient that is founded on trust. With a patient-centered care model, the expectation should be that surgeons focus on not only the physical but also the holistic elements of the surgical process. In addition to appropriate surgical preparation, execution, and recovery, arthroplasty success has been shown to depend on the patient's state of mind.

For example, risk stratification models now point to patient depression as a major factor in less positive results, and patients with somatization behaviors have more pain and poorer function than their nondepressed counterparts [1], [2], [3]. The most ethical care guidelines mandate that we explain why modifiable risk factors should and must be changed for the patient's safety and satisfaction. But telling the depressed patient that they can expect a poorer outcome may be a self-fulfilling prophecy.

Orthopaedic surgeons have an effect on how patients perceive and grade their surgical outcome. The so-called “shared decision making” must strike a balance between, on one extreme, a disproportionate amount of time being spent going over the potential risks of the surgery, and on the other, incomplete consent where patients do not have a fair idea of the potential hazards involved.

In a recent multicenter study looking at the relationship among total knee arthroplasty patient expectations, patient-reported outcome (PRO) measures, and patient satisfaction, the investigators found that patient demographics and preoperative function do not predict preoperative expectations of surgery [4]. Furthermore, they found that higher preoperative expectations do predict greater improvement in PRO measures and fulfillment of expectations [4]. So perhaps cheering on our patients to set high expectations helps them to score higher on PROs and fulfill their preoperative outlook. Surgeons can and should instill trust, confidence, and hope as they teach patients about their diagnosis and prognosis, and guide them through their treatment.

Looking to the field of complementary medicine may offer some help. We should think of this field of holistic care not as an alternative, but rather an addition, to traditional and proven treatments like joint replacement surgery. Physician leaders in this field like Dean M. Ornish, MD, Andrew Weil, MD, Herbert Benson, MD, and David Servan-Schreiber, MD, PhD have shown evidence of the mind-body connection and how harnessing the power of that connection can augment traditional treatments for chronic and serious illness. Why not embrace these techniques for patients undergoing elective surgery?

In discussing surgical preparation and expectations, we should cover all the customary bases. In addition, offering positive, nontraditional advice on how to treat comorbidities that are known to negatively impact a patient's surgical outcome will also help our patients. Providing integrative resources can help patients to become empowered by giving them tools for stress management, physical and emotional support, and immune system strengthening in the perioperative period. This is a straightforward addition that can turn good surgical care into excellent surgical care. Evidence is mounting that these interventions make a meaningful difference.