CommentaryFrom OT Europe

Harmonization, diversity are key aspects of orthopaedic and traumatology care

Major differences can be seen in various statements, decisions and rules in nearly all aspects in our daily life. Similar differences constantly impact our medical profession daily where harmonization and diversity are both critical issues to be addressed.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

Although we live in a modern Western world, where communication, information and education are considered to occur at the highest, most professional level possible level, there are still patients who are offered a particular treatment by their physician and they obtain a second opinion and are offered a different treatment for the same condition, by another physician. As orthopaedic surgeons, we understand that all encounters with our patients are not “black and white.” Frequently, there is a large “grey zone,” which is the reason more treatments and decisions are plausible. However, when this approach is seen from the patient’s perspective, this type of diversity is often misunderstood or not accepted. Our patients expect full harmonization between orthopaedic surgeons and presume that we all agree, within reason, for any treatment that is recommended and performed.

Decisions, conditions

It is natural for us to want to treat all our patients in full harmonization with guidelines, evidence and good practice. However, doing this in all situations is unrealistic, or more simply put, it is impossible. The best example of this, for me, was a study we did where four trained orthopaedic surgeons were asked to classify the degree of osteoarthrosis seen on 100 patients’ hip radiographs. Although the four surgeons practiced classifying the arthrosis they saw together on several “trial radiographs” and agreed on the use of the classification system, for about 20% of the hip radiographs, one or two surgeons disagreed with the others.

Medical science philosophy has described this phenomenon as “disagreement.” Simply, the way our perception is triggered in a given situation decides the final outcome at which we arrive. This, for sure, will scare some patients. However, we are well aware that some the clinical decisions we make each day, by ourselves, can also be questionable because evidence for these is low or does not exist.

Role of economics, traditions

On a larger scale, diversity in health care exists due to external conditions that are unchangeable because these are out of the hands of the physician. An economic situation in a particular country or society, for example, may dictate the treatment offered for a given disease. Harmonization, in this regard, is often discussed at larger global conferences, but rarely is how to overcome it addressed. Tradition is another aspect of diversity in health care. Total hip arthroplasty fixation can be different or diverse in two neighboring countries like Sweden and Denmark, where THA is more often fixed with bone cement in Sweden than in Denmark.

If full harmonization of patient care is mandatory, one would have to de-mantle the physician and switch to the use of artificial intelligence. No doubt, if a computer is given all the needed information and also the algorithm to make decision decisions, that will provide great harmonization of decisions based on comparable data. This is, however, not what we or the patients desire. It is easy to recall those cases in which we were close to providing a treatment or performing surgery, when suddenly the patient was well again.

Diversity and harmonization are key aspects that will be forever be present in and affect our daily professional lives.

For more information:

Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Road, Thorofare, NJ 08086, USA; email: orthopedics@healio.com.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.

Major differences can be seen in various statements, decisions and rules in nearly all aspects in our daily life. Similar differences constantly impact our medical profession daily where harmonization and diversity are both critical issues to be addressed.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

Although we live in a modern Western world, where communication, information and education are considered to occur at the highest, most professional level possible level, there are still patients who are offered a particular treatment by their physician and they obtain a second opinion and are offered a different treatment for the same condition, by another physician. As orthopaedic surgeons, we understand that all encounters with our patients are not “black and white.” Frequently, there is a large “grey zone,” which is the reason more treatments and decisions are plausible. However, when this approach is seen from the patient’s perspective, this type of diversity is often misunderstood or not accepted. Our patients expect full harmonization between orthopaedic surgeons and presume that we all agree, within reason, for any treatment that is recommended and performed.

Decisions, conditions

It is natural for us to want to treat all our patients in full harmonization with guidelines, evidence and good practice. However, doing this in all situations is unrealistic, or more simply put, it is impossible. The best example of this, for me, was a study we did where four trained orthopaedic surgeons were asked to classify the degree of osteoarthrosis seen on 100 patients’ hip radiographs. Although the four surgeons practiced classifying the arthrosis they saw together on several “trial radiographs” and agreed on the use of the classification system, for about 20% of the hip radiographs, one or two surgeons disagreed with the others.

Medical science philosophy has described this phenomenon as “disagreement.” Simply, the way our perception is triggered in a given situation decides the final outcome at which we arrive. This, for sure, will scare some patients. However, we are well aware that some the clinical decisions we make each day, by ourselves, can also be questionable because evidence for these is low or does not exist.

Role of economics, traditions

On a larger scale, diversity in health care exists due to external conditions that are unchangeable because these are out of the hands of the physician. An economic situation in a particular country or society, for example, may dictate the treatment offered for a given disease. Harmonization, in this regard, is often discussed at larger global conferences, but rarely is how to overcome it addressed. Tradition is another aspect of diversity in health care. Total hip arthroplasty fixation can be different or diverse in two neighboring countries like Sweden and Denmark, where THA is more often fixed with bone cement in Sweden than in Denmark.

If full harmonization of patient care is mandatory, one would have to de-mantle the physician and switch to the use of artificial intelligence. No doubt, if a computer is given all the needed information and also the algorithm to make decision decisions, that will provide great harmonization of decisions based on comparable data. This is, however, not what we or the patients desire. It is easy to recall those cases in which we were close to providing a treatment or performing surgery, when suddenly the patient was well again.

Diversity and harmonization are key aspects that will be forever be present in and affect our daily professional lives.

For more information:

Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Road, Thorofare, NJ 08086, USA; email: orthopedics@healio.com.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.