CommentaryFrom OT Europe

Patients should not be able to demand a particular orthopaedic treatment

Regularly, I am confronted with a patient who demands a hip replacement when that patient, in my opinion, is not a candidate for surgery based upon the generally accepted recommendations that need to be followed before surgery can be considered. Such a situation usually becomes stressful for both the patient and the surgeon because, if we stay true to our professional, academic-based knowledge, ultimately, the expert the patient has been look forward to meeting will not perform the surgery and the patient cannot undergo the surgery he or she has anticipated.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

Situations like these are more common in 2019 than ever before. When I started doing hip replacement in 1989, I never had such a “conflict” with my patients. I sometimes wonder if it is a matter of me getting older and less flexible, or if it is that patients today simply take a more straight-forward approach to their health care, demanding to make their own decisions. In this case, the patient has decided to have a hip replacement and, as a result, demands the surgeon do that procedure.

Stress for patients, surgeons

This type of situation stresses my professionalism as a surgeon. On top of that, today you can have surgery within a few weeks. Yet, we see patients all the time who are unhappy if their surgery cannot be done within 4 to 5 weeks. In times when there was a 12- to 15-month waiting list to under hip replacement surgery, such demands were unheard of. Patients were simply happy to be scheduled for surgery at all.

A lot has happened in the last 30 years in terms of orthopaedic surgery practice that should be considered. Today’s patients are more informed about how various diseases may be treated. Overall, they also have a higher activity level than patients we treated a few decades ago. In addition, they consult social media, the internet, YouTube, etc., before they see their general practitioner (GP). They “know” before any clinician does that their hip is worn out and a “new” hip will solve all their problems. Along these same lines, not infrequently does a patient come in my outpatient clinic with a note from their GP that says, “I send you this patient for total hip replacement due to severe hip pain.”

Listen, view, examine and discuss

My first step is always to listen. Then, I “view” the situation and finally I perform a clinical examination. If the connections between the individual’s pain history, walking ability, level of coxarthrosis on the radiographs and my clinical examination of the hip/patient disagree in any way, I do not start to discuss THR as an option. In fact, such cases frequently require a detailed, full examination because often the pain the patient is experiencing is linked to degeneration of the lumbar spine.

The challenge comes when a patient, like the one in the above scenario, questions your conclusions and demands to be treated with THR. That type of patient would likely leave my clinic and find another surgeon who will succumb to his or her request and provide the patient with a “new” hip.

Patients can never demand any type of orthopaedic treatment, including a THR. It is the professional, academically educated orthopaedic surgeon who can provide advice about treatment, including its benefits and risks. If THR is not on the surgeon’s list of treatment options for a particular case, the patient cannot then demand that replacing the hip is what he or she wants to have done, regardless of possible risks. We must keep our indications straight-forward and, just because we are surgeons, there are many reasons why we should not always aim to perform surgery in cases with doubtful diagnoses. Most importantly, surgery should be performed only for strict indications that are clear and transparent.

Should this situation occur in your practice, ask yourself what you would feel is the best treatment if you were the patient. Whatever option you settle on is the exact one you should give your patient.

The type of patient who demands a particular orthopaedic procedure is also someone who requires more than the usual amount of information from a health care professional and benefits greatly from a lengthy discussion of his or her case. Ultimately, the goal is to win the patient over to your point of view and have him or her understand — be completely convinced — of the best treatment and not to just go “next door” and have the THR performed.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.

Regularly, I am confronted with a patient who demands a hip replacement when that patient, in my opinion, is not a candidate for surgery based upon the generally accepted recommendations that need to be followed before surgery can be considered. Such a situation usually becomes stressful for both the patient and the surgeon because, if we stay true to our professional, academic-based knowledge, ultimately, the expert the patient has been look forward to meeting will not perform the surgery and the patient cannot undergo the surgery he or she has anticipated.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

Situations like these are more common in 2019 than ever before. When I started doing hip replacement in 1989, I never had such a “conflict” with my patients. I sometimes wonder if it is a matter of me getting older and less flexible, or if it is that patients today simply take a more straight-forward approach to their health care, demanding to make their own decisions. In this case, the patient has decided to have a hip replacement and, as a result, demands the surgeon do that procedure.

Stress for patients, surgeons

This type of situation stresses my professionalism as a surgeon. On top of that, today you can have surgery within a few weeks. Yet, we see patients all the time who are unhappy if their surgery cannot be done within 4 to 5 weeks. In times when there was a 12- to 15-month waiting list to under hip replacement surgery, such demands were unheard of. Patients were simply happy to be scheduled for surgery at all.

A lot has happened in the last 30 years in terms of orthopaedic surgery practice that should be considered. Today’s patients are more informed about how various diseases may be treated. Overall, they also have a higher activity level than patients we treated a few decades ago. In addition, they consult social media, the internet, YouTube, etc., before they see their general practitioner (GP). They “know” before any clinician does that their hip is worn out and a “new” hip will solve all their problems. Along these same lines, not infrequently does a patient come in my outpatient clinic with a note from their GP that says, “I send you this patient for total hip replacement due to severe hip pain.”

Listen, view, examine and discuss

My first step is always to listen. Then, I “view” the situation and finally I perform a clinical examination. If the connections between the individual’s pain history, walking ability, level of coxarthrosis on the radiographs and my clinical examination of the hip/patient disagree in any way, I do not start to discuss THR as an option. In fact, such cases frequently require a detailed, full examination because often the pain the patient is experiencing is linked to degeneration of the lumbar spine.

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The challenge comes when a patient, like the one in the above scenario, questions your conclusions and demands to be treated with THR. That type of patient would likely leave my clinic and find another surgeon who will succumb to his or her request and provide the patient with a “new” hip.

Patients can never demand any type of orthopaedic treatment, including a THR. It is the professional, academically educated orthopaedic surgeon who can provide advice about treatment, including its benefits and risks. If THR is not on the surgeon’s list of treatment options for a particular case, the patient cannot then demand that replacing the hip is what he or she wants to have done, regardless of possible risks. We must keep our indications straight-forward and, just because we are surgeons, there are many reasons why we should not always aim to perform surgery in cases with doubtful diagnoses. Most importantly, surgery should be performed only for strict indications that are clear and transparent.

Should this situation occur in your practice, ask yourself what you would feel is the best treatment if you were the patient. Whatever option you settle on is the exact one you should give your patient.

The type of patient who demands a particular orthopaedic procedure is also someone who requires more than the usual amount of information from a health care professional and benefits greatly from a lengthy discussion of his or her case. Ultimately, the goal is to win the patient over to your point of view and have him or her understand — be completely convinced — of the best treatment and not to just go “next door” and have the THR performed.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.