Results
Patients comprised 12 men and 14 women, 12 of whom had hip problems and 14 of whom had knee problems. Ages of patients ranged from 46-86 years. Details of the patients are described in Table
1. Consultation outcomes included: listing for NHS surgery; some subsequent patient decisions to opt for private surgery; alternative treatment strategies; or an offer that the patient could return for a further appointment when they felt the need (Table
2).
Table 1
Patients' characteristics by gender, age and affected joint (n = 26)
< 50 | 0 | 0 | 1 | 1 |
2
|
50-59 | 1 | 1 | 0 | 1 |
3
|
60-69 | 3 | 3 | 2 | 2 |
10
|
70-79 | 0 | 2 | 3 | 2 |
7
|
80+ | 1 | 1 | 1 | 1 |
4
|
Total
|
5
|
7
|
7
|
7
|
26
|
Table 2
Patient details and consultation outcomes (n = 26)
Mrs Armstrong | 63 | Female | Right hip | Surgeon B | Listed for TJR surgery |
Mrs Buckley | 79 | Female | Right hip | Surgeon B | Listed for TJR surgery |
Mrs Crow | 67 | Female | Right knee | Surgeon B | Listed for TJR surgery |
Mrs Darcy | 63 | Female | Right hip | Surgeon B | Listed for TJR surgery (opted for private) |
Mrs Ellis | 75 | Female | Left knee | ESP 1 | Listed for TJR surgery - later removed from waiting list pending further investigations of hip pain |
Mrs Fox | 69 | Female | Left knee | ESP 1 | Listed for TJR surgery (opted for private) |
Mrs Glover | 78 | Female | Left hip | ESP 1 | Not listed for TJR surgery - referred to back specialist |
Mrs Holmes | 48 | Female | Left hip | Surgeon B | Listed for TJR surgery |
Mrs Irwin | 55 | Female | Left knee | Surgeon D | Not listed for TJR surgery - offered open appointment |
Mrs Jones | 46 | Female | Both knees | ESP 1 | Not listed for TJR surgery - referred onward for possible trochleoplasty |
Mrs Knight | 77 | Female | Left knee | ESP 2 | Listed for TJR surgery |
Mrs Lee | 79 | Female | Left hip | Surgeon D | Listed for TJR surgery |
Mrs Miller | 82 | Female | Left knee | Surgeon A | Listed for TJR surgery |
Mrs Norton | 80 | Female | Left hip | Surgeon D | Listed for TJR surgery - later declined when given surgery date |
Mr Adler | 77 | Male | Both knees | ESP 1 | Listed for TJR surgery (opted for private) |
Mr Brown | 64 | Male | Right hip | Surgeon A | Listed for TJR surgery |
Mr Campbell | 79 | Male | Right knee | ESP 1 | Listed for TJR surgery |
Mr Dutton | 67 | Male | Right hip | ESP 1 | Listed for TJR surgery |
Mr Edwards | 86 | Male | Left hip | Surgeon B | Listed for TJR surgery (opted for private) |
Mr Franks | 54 | Male | Left hip | Surgeon B | Listed for TJR surgery |
Mr Harris | 54 | Male | Both knees | Surgeon D | Not listed for TJR surgery - patient negotiated arthroscopy |
Mr Ince | 64 | Male | Left knee | Surgeon D | Listed for TJR surgery |
Mr Johnson | 63 | Male | Right knee | Surgeon D | Not listed for TJR surgery - referred for physiotherapy |
Mr King | 66 | Male | Left knee | Surgeon E | Not listed for TJR surgery - advised to increase use of analgesics |
Mr Lloyd | 87 | Male | Right knee | Surgeon E | Listed for TJR surgery |
Mr Morris | 66 | Male | Right hip | ESP 2 | Listed for TJR surgery |
Clinical and lifestyle factors influenced the decisions made during outpatient consultations and were clearly described by patients and clinicians. Clinical factors were: diagnosis, symptom severity (pain and function), co-morbidities and previous treatment outcomes. Lifestyle factors were: leisure activities, work, and family life. In addition, roles ascribed to clinicians, their styles of approach and patients' adaptation to those approaches were central to the decision-making process. Roles, styles and adaptation were supported by aspects of verbal and non-verbal communication. These are discussed in turn with greatest emphasis on roles and communication, which includes description of styles and adaptation.
Clinical Factors
Clinical factors identified by surgeons and ESPs included diagnosis of osteoarthritis and interpretation of radiography (x-ray):
Surgeon E: You'd be a good candidate in terms of the pattern of arthritis and your x-rays.
(consultation with Mr Lloyd, age 87, right knee, listed for TJR by Surgeon E)
Symptom severity, such as pain and stiffness, was assessed in considerable detail during consultations, and pain was the main indicator for TJR:
Interviewer: Tell me the main factors that you took into account with [Mr Brown]?
Surgeon A: Pain ... and restriction of walking. But principally thinking about pain.
(brief interview with clinician after consultation with Mr Brown, age 64, right hip, listed for TJR by Surgeon A)
ESP 2: Yes the main factors are restricted range of movement with pain, a lot of pain on weight bearing when she's walking.
(brief interview with clinician after consultation with Mrs Knight, age 77, left knee, listed for TJR by ESP 2)
Similarly, the presence or absence of co-morbidity and the involvement of other joints was seen as key:
ESP 1: I mean they could have a really badly arthritic hip, but equally could have dreadful feet, dreadful knees, and then awful lumber spine, and by replacing their hip isn't going to, you know, potentially be a worthwhile investment for the patient.
(in-depth interview with ESP 1)
Finally, the failure of other treatments to manage the condition was important:
Surgeon D: I mean tramadol is a pretty powerful painkiller.... So if you need that it might be an idea to do a joint replacement.
(consultation with Mrs Norton, age 80, left hip, listed for TJR by Surgeon D)
Surgeons and ESPs described clinical factors to patients during consultations. They also related them during the research interviews, providing concise case summaries:
ESP 1: The things that we generally look for are that his sleep is being disturbed on a nightly basis, he's describing a level of activity that's unacceptable to him, his pain relief is not really helping him, um and he is fit and well.
(brief interview with clinician after consultation with Mr Adler, age 77, both knees, listed for TJR by ESP 1)
Patients also reflected on the role of clinical factors in the consultations. All patients suggested that these were the main factors that clinicians took into account:
Mr Brown: I got the impression he was assessing the amount of pain I was in, the amount of movement I had, and how urgent he considered the operation to be.
(post-consultation interview, Mr Brown, age 64, right hip, listed for TJR by Surgeon A)
Lifestyle factors
In clinicians' appraisals of suitability for surgery, they also asked patients about their preferences and needs in relation to their social and work contexts. These lifestyle factors included: leisure activities, work, and family life.
Surgeon B noted that it was appropriate for him to take lifestyle differences into account during consultations:
Surgeon B: Um and plus, you know, we're a public service, if she [Mrs Armstrong] wants to play golf and she can't play golf and I can help her to play golf, then why not?
(brief interview with clinician after consultation, Mrs Armstrong, age 63, right hip, listed for TJR by Surgeon B)
Some of the patients were in paid or voluntary work and this was identified during consultations:
ESP 1: If we take this pain away in your groin by giving you a hip replacement, what are the sort of things that you want to get back to activity-wise?
Mr Dutton: Well work.
ESP 1: What do you do?
Mr Dutton: Building.
ESP 1: You want to get back to work?
Mr Dutton: Yeah um builders never (laughs) retire, I'm afraid.
(consultation with Mr Dutton, age 67, right hip, listed for TJR ESP 1)
Clinicians also took family circumstances into account, as they were concerned to ensure appropriate support on a patient's return home following surgery:
Mrs Lee: Well the first thing he [Surgeon D] did was ask me was who lived at home. Whether I was living on my own.
(post-consultation interview, Mrs Lee, age 79, left hip, listed for TJR by Surgeon D)
Roles and communication
In the observations and interviews it became clear that clinical and lifestyle factors were not the only elements at play in the decision-making process. Patients saw clinicians as experts, deferred to their expertise, and modified their own behaviour to complement that of clinicians. Clinicians were aware of their own decision-making styles and made judgements about their own and others' ability to conduct surgery. These roles and behaviours were supported by elements of verbal and non-verbal communication.
Clinicians as experts
Patients saw clinicians as 'experts' and assigned the role of expert authority to clinicians during consultations. Patients deferred to clinicians' judgements:
Surgeon E: It's a judgment.
Mr Lloyd: Yeah your judgment, you're the professional.
(consultation with Mr Lloyd, age 87, right knee, listed for TJR by Surgeon E)
ESP 1: I don't feel that I would be in a huge rush to replace this hip.
Mrs Glover: No, alright then I'll do as you say.
(consultation with Mrs Glover, age 78, left hip, not listed for TJR by ESP 1)
Interviewer: Or were you going to ask for a joint replacement?
Mrs Buckley: Well no I was going to leave it entirely to him.
(post-consultation interview, age 79, right hip, listed for TJR by Surgeon B)
We explored why patients appeared to defer to clinicians' decisions and asked clinicians to describe their own views on their approaches to decision-making. Some provided a clear label for their style, for example: "paternalistic" (Surgeon A). Others described their style as they perceived it in action, for example: "diplomatic" (Surgeon B), "conservative" (Surgeon D) and "assertive" (ESP2). The clinicians' descriptions of their stance and behaviour matched those observed by the researchers, and patients also drew similar conclusions about the clinicians' styles. When particular approaches were combined with patients' perceptions that clinicians were experts, there was the potential that this influenced patients' behaviour. For instance, some patients deferred to the expert authority of their clinician even if the clinician's views contradicted their own experience. For example, Surgeon B described his style as "diplomatic" which may have influenced Mrs Darcy's choice to discount her own interpretation of the severity of her pain:
Mrs Darcy: If the surgeon had said, "Oh no it doesn't warrant having it done," well I wouldn't have had it done. You know, because I'd have thought, well it's me, you know, not coping with it well enough.
(post-consultation interview, age 63, right hip, listed for TJR by Surgeon B)
Patients' belief in the expertise of clinicians extended to patients' confidence that the clinicians were suitably skilled to perform surgery. This was an important reason for deferring to clinicians' decisions, even if a patient had not yet met their future surgeon as was the case for those who had pre-surgery consultations with an ESP rather than with an operating surgeon:
Interviewer: have you got any concerns about the surgery?
Mr Morris: Hmm I don't think so ... apparently this [Surgeon A] is the man ... so Mr [Surgeon A] is a very, very experienced hip surgeon, so you couldn't get more experienced than him anyway, so I've got full confidence in him anyway.
(post-consultation interview, age 66, right hip, listed for TJR by ESP 2)
Confidence in clinical abilities was fostered in consultations and affected how decisions were made. Patients' descriptions about confidence were echoed by clinicians' views as they expressed judgements about their own or others' abilities to conduct TJR. For instance, ESP 2 speculated that a more confident and experienced surgeon would be more willing to consider performing TJR on a patient with "lots of co-morbidities", while Surgeon D noted that his decision to offer surgery to Mrs Lee included "my assessment that I'll be able to do it without killing her."
In the majority of observed consultations the patients' and the clinicians' decision-making styles were complementary: for example, a paternalistic or authoritative clinician interacted with an apparently acquiescent or deferential patient; or a diplomatic clinician interacted with an equally diplomatic patient. This was not purely a chance finding, since there was some evidence that patients modified their behaviour to meet the style of a clinician:
Mrs Armstrong: I felt he was quite abrupt in his questioning, um and perhaps I had to be a bit quick off the mark in answering the questions.
(post-consultation interview, age 63, right hip, listed for TJR by Surgeon B)
Mr Harris: But, you know, with the consultants you can't argue. Well I can but um I don't think I'd get that far perhaps.
(post-consultation interview, age 54, both knees, not listed for TJR by Surgeon D)
Communication
The roles assigned and adopted in consultations, and the decision-making styles and behaviours displayed, were supported by aspects of verbal and non-verbal communication.
The perception that clinicians were experts meant that some patients did not want to ask questions. For instance, Mr Franks stated that he would give control to the "specialists" and not ask "lots" of questions.
Although patients who assigned the role of expert authority to their clinicians might still internally query the decisions about proposed treatments, they would not usually express those misgivings to their clinicians:
Mr Edwards: Oh (sighs) it's not for me to question or criticise an expert opinion, but I have to express surprise that having this hip mended is going to stop all this happening.
(post-consultation interview, age 86, left hip, listed for TJR by Surgeon B)
Mr Lloyd: So all in all, I accepted his word as a professional. I thought it would be bad of me to say - to reject. And he seemed to think that, you know, that he didn't want rejection, I got that impression.
(post-consultation interview, age 87, right knee, listed for TJR by Surgeon E)
Patients viewed their relationships with clinicians and the outcomes of consultations most positively when they felt that clinicians were approachable, understandable and informative:
Mrs Buckley: It was very good. I felt that I could talk to him, you know, he was most approachable, which I thought was excellent. Because some of them, I mean they're that stiff and starchy you're frightened to open your mouth.
(post-consultation interview, age 79, right hip, listed for TJR by Surgeon B)
Patients preferred to have the opportunity to ask questions, and reflected on the rapidity of some consultations:
Interviewer: How do you feel the consultation went overall?
Mr Brown: Um I thought it was a bit quick. You know ... he may do this the next time I go there, but I would have thought he would have asked me had I any questions?
(post-consultation interview, age 64, right hip, listed for TJR by Surgeon A)
An important aspect of communication in consultations and decision-making was the use of non-verbal cues. In particular, clinicians observed non-verbal signs to support other information gathered during consultations, for example, by noting visible tiredness as evidence of night pain:
Surgeon A: Well it's [pain] - it's something they experience. Um so if you can't - I mean the most severe one is night pain, and the patient looks exhausted. Um you can tell by their faces, their faces are grey, they're drawn um, and they're haggard.
(in-depth interview with Surgeon A)
Clinicians also used non-verbal information to decide how much information to provide during consultations. For example, when asked about discussing risk with patients, Surgeon D noted that he would delay discussing risk with patients who "look terrified":
Surgeon D: If they look terrified, I'm not going to talk about it until the pre-assessment clinic when the consenting process takes place.
(in-depth interview with Surgeon D)
The complexity of decision-making
Clinicians used consultations to appraise the information presented to them in order to reach decisions. Patients used consultations to elicit information from clinicians. Many patients were pleased with the outcome of their consultations, but some also expressed surprise about the decisions that were made at these appointments. Expressing surprise did not mean that they were necessarily dissatisfied, but indicated that the decision did not wholly match their expectations.
The complexity of surgeons' appraisals of patients' needs was identified by Surgeon A who noted that decision-making is complex, involves "various judgements", uses skills that come from "experience", and has an "instinctive" element to it:
Surgeon A: So there's various judgements that I think er are instinctive, come from experience and come from literature ... and you'll find clinicians are as good as they are old, because they've got miles on the clock, that's the key thing.
(in-depth interview with Surgeon A)
In the majority of cases, decision-making was a process that took place during the deliberations within consultations. In consultations there was usually a critical moment at which the decision to offer, or not offer, surgery was clearly stated. Deliberations that led up to this moment involved surgeons eliciting information from patients about their current status and weighing up clinical and lifestyle factors as described above. Surgeons expressed their views about patients' need through their tone as well as through literal meaning. For instance, when Mr Johnson said in his consultation that he was still able to walk around an 18-hole golf course, Surgeon D's tone of voice provided the initial indication that he considered Mr Johnson's problems not severe enough to warrant surgery:
Surgeon D: OK, how far can you walk?
Mr Johnson: If I take naproxen and paracetamols I can still get round the golf course.
Surgeon D: You can get around an 18-hole golf course?
Mr Johnson: Yeah, I might suffer afterwards.
(consultation with Mr Johnson, age 63, right knee, not listed for TJR by Surgeon D)
In the post-consultation interview with Mr Johnson, Mr Johnson himself also expressed awareness that his ability to walk around the golf course had been a key part of the decision not to offer him surgery:
Mr Johnson: He seemed to dismiss it [surgery] quite quickly as soon as I mentioned golf, fair enough as I say, I'm in no rush to get it done.
(Mr Johnson, post-consultation interview, age 63, right knee, not listed for surgery by Surgeon D)
However, in a few cases it was clear that the clinician had made some initial decisions about the appropriateness of surgery before the consultation began. For instance, immediately before the consultation with Mrs Armstrong, Surgeon B looked at her x-rays and said that in the appointment he would think about identifying the most appropriate kind of hip implant for her surgery. This indicates that he had already decided that surgery would probably be warranted for Mrs Armstrong. Patients who agreed with the offer of surgery were comfortable that some surgeons appeared to have decided that surgery was appropriate in advance of the consultations:
Mrs Holmes: But I got the impression he came in [to the consultation] and that's what he was going to do, there was no question about it. So that's fine.
(Mrs Holmes, left hip, 48 years old, listed for TJR by Surgeon B.
In post-consultation interviews with patients, many patients were pleased with their consultation outcomes, but others expressed misgivings. Some who were not offered surgery disagreed with the decision, but even those who had been offered surgery sometimes volunteered their surprise at other aspects of the process:
Mr Adler: I thought 'I doubt if they'll go for knee replacements before they try something less than that'. That was what I assumed. So I was, yes, I was surprised when she said [that a knee replacement was warranted]. But of course my knees have got a lot worse than what they were.
(Mr Adler, 77 years old, both knees, listed for surgery by ESP 1, opted to have private surgery so that both knees could be replaced at the same time)
The point at which a decision was made about surgery was clearly recognised by patients and clinicians alike. Reaching a decision about whether surgery was warranted rested on assessment of clinical and lifestyle factors, and these stated, 'explicit', factors were well recognised in the process. However, the processes through which decisions were reached were complex because of the roles that clinicians and patients played within them. The possibility that consultation outcomes might be surprising to patients was not tackled within consultations, which orientated towards making decisions rather than whether these decisions matched patients' expectations.
Discussion and Conclusions
Agreement between clinician and patient on a course of treatment is based on the process of decision-making. The shared model of decision-making, whereby doctors and patients work together to choose the best treatment option, is recognised by the General Medical Council as a fundamental duty of doctors [
41], and is the most commonly preferred style of decision-making from patients' perspectives [
42]. Shared decision-making has been advocated as the ideal in TJR [
38], and the Musculoskeletal Services Framework advocates patient choice, which may hinge on shared decision-making [
43]. Our study has explored the process of decision-making in TJR and highlights some of the challenges of implementing shared decision-making. While decision-making in orthopaedic practice involves clinical and lifestyle indicators, roles and communication are also key. The influence of roles and communication on decisions is subtle, varies between cases, and is not described in existing guidance and recommendations.
When reflecting on their consultations, some patients later stated that they had not raised their disagreement or misgivings with surgeons and some expressed surprise about the decisions that were made. Elsewhere we address how the potential for patient dissatisfaction relates to differing perceptions between patients and clinicians about the urgency of need [
44]. The findings presented here focus on the process of decision-making and the factors that are taken into account. They indicate that some patients modify their behaviour in order to better match the styles of their clinicians and that this may manifest itself as deference to the expertise of surgeons during consultations. This may be a key reason why patients do not necessarily mention any disagreement or surprise within consultations. In turn, this raises the question of the nature of a power imbalance between clinicians and patients, which may also be sustained by differential awareness of the importance of role and communication in decision-making processes. The evidence of a mismatch between clinicians' and patients' perceptions of consultations echoes findings from other secondary care settings, notably in rheumatology clinics [
45]. Within orthopaedic consultations, it has been suggested that patients only raise approximately half of their concerns with their specialists [
46]. Our findings provide insight into the mechanisms through which this occurs.
Furthermore, clinicians' views about their styles of practice provide important windows onto how and why patients might modify their behaviour or opinions within consultations and not raise important issues. Certain styles lend themselves to discussion and deliberation, whereas others (more 'paternalistic' ones) do not. In literature about decision-making styles it has long been suggested that there is the potential for clinicians to modify their decision-making style to suit the preferred style of individual patients [
37], but it has also been shown that it is difficult to define a patient's preference purely on the basis of their communication behaviour [
47]. In primary care settings it has been noted that clinicians underestimate the degree to which patients want to be involved in decision-making [
48]. To achieve greater patient involvement in decision-making, our study indicates that it may be important to address the possibility that patients are modifying their behaviour to match that of clinicians. It may also be valuable to confront the issue that patients are likely to feel but not express their surprise about the outcome of their consultations. Patients may benefit from information about the unstated elements of decision-making for elective procedures (such as understanding different decision-making styles). Informing patients about these may enable them to participate more fully in shared decision-making, thus empowering patients, and meeting the requirements and recommendations of policy and guidelines [
41,
43].
The study's limitations included its focus on only one location and the relatively small sample of patients and clinicians. Although not ethnically representative (all participants were white) the study did include patients with a range of ages, and nearly equal representation of gender and joint type. There was also good distribution across age and experience among clinicians, although precise details are not included here in order to preserve their anonymity. Further research in this area including members of different ethnic groups would be useful. There is the potential to ask whether further variation in decision-making processes and communication may influence equity in service provision? However, a particular strength of this study was the inclusion of a number of data collection points. Interviews with clinicians immediately after observations of consultations enabled us to access their views about specific decisions. Subsequent interviews with patients up to three weeks after consultations gave patients the opportunity to reflect on the decisions and processes that occurred in their appointments. This approach appeared to enable patients to reflect on their consultations in some detail, including any misgivings or surprise. Additionally, because a researcher had been present in all consultations, there was the scope to ask questions of particular pertinence to each consultation.
The presence of the researchers (AS/JH) during consultations may have influenced the behaviour of the participants, but the researchers endeavoured to minimise this risk by being as unobtrusive as possible. Clinicians said that the presence of a researcher did not affect their practice as they were well used to the presence of others (e.g. medical students) during consultations. During the in-depth interviews, clinicians were asked to self-report on their behaviour and thought processes. It is possible there may have been some self-censoring and modifying of these reports. However, the researchers were able to evaluate whether reported behaviour matched actual behaviour during the observed consultations and were of the opinion that there was good congruence.
The findings of our study may be relevant to other elective procedures. Further research is needed to find out if the implicit elements we identified in TJR consultations are also relevant to decision-making in other conditions. Closer examination of unstated criteria used in clinical decision-making may provide greater understanding of the decision-making process and may provide subsequent opportunities to address variation and inequities in provision.
In conclusion, clinicians make judgments using unstated factors when deciding whether to offer joint replacement surgery and patients modify their behavior within consultations. If both patients and clinicians become aware of these issues and their potential influence on decision-making, then decisions about surgery could be based on a fuller range of factors. This could lead to more balanced shared decision-making and enhanced patient choice.