Shaping orthopaedic care in post-truth Britain – best foot forward or a step into the abyss?

By Piers Page

We are, according to media the world over, in the ‘post-truth’ era. This term, the Oxford English Dictionary’s word of the year for 2016¹, represents depending on your viewpoint either a liberation of society from the ubiquitous ‘faceless bureaucrats’ who hold the country back or an apocalyptic abandonment of any requirement for honesty in politics. In the run-up to the contentious referendum on our future in the European Union, Michael Gove announced that the country had ‘had enough of experts’, and this soundbite, whilst publicly at least partially distanced by him, has gone on to be held up as representative of this rebalancing of power.

What about surgeons? What is our place in our new world? We are in a tenuous position, one where we must offer both expertise and advocacy, offering at the same time autonomy to our patients to make their decisions whilst first doing no harm. Thankfully our position is somewhat more straightforward – no public vote can compel us to undertake a foolhardy total joint replacement, nor silence the lifestyle advice we believe may better serve some patients. Notwithstanding, recent events show that a great deal of the population feel marginalised from those they perceive more advantaged, mobile and in control. Historically the medical profession has attracted amongst the highest trust ratings of all vocations, and this remains true in the most recent poll. The rating is 92% and has risen over recent years, but the precipitous decline in this same period for members of the clergy illustrates how one can fall, quite literally, from grace². In a time when we’ve heard that junior doctors are greedy, GPs are ignorant of the rules on or disinclined to bill overseas patients, our unwillingness to work at weekends is fatal to our patients and several thousand more patients will have been recalled for their metal on metal implants, it might be wise to remember that nothing’s a given, and the expertise for so long our friend could easily be spun to be our foe.

We need to do our bit, then. We should welcome evidence that informs our practice, even if it doesn’t support it. The ‘in my hands’ argument often used to refute any study of any quality does us no credit, nor does exploiting the zone between pragmatic studies, which some hold to compare apples with oranges, and a randomised, heavily controlled trial which we can then say does not generalise to our practice. Indeed, outlawing all fruit-based analogies in critical appraisal might give reviewers, editors and readers alike a welcome respite. ‘Cognitive dissonance’ describes the mental acrobatics we perform when trying to make the objective evidence in front of us fit our preconceptions – wondering which centres see all the patients who experience painful non-union after a dynamic hip screw for a multifragmentary extracapsular fracture of the femoral neck is just such an exercise. We don’t see them coming back to our clinics but, despite the evidence from high-quality studies such as Reindl’s, we just know they’re out there somewhere, if only we could find them³.

The danger in this approach is that it hampers our ability to be agile, as financial constraints and political intrigue are brought to bear on what we can do for our patients. ‘Divide and conquer’ has been a political and military maxim since time immemorial, and a divided profession will rapidly find itself disempowered just as an ageing, heavier society needs us most. Getting it right first time is the cornerstone of all we do, whilst at the same time a challenge to a group who, with the same intentions, provide what can at best be described as a heterogeneous set of interventions⁴. There is undoubtedly a latent challenge in the concept of more universal and generic care for patients with any given problem – for as long as most of us can remember, achieving consultant status brings independent practice rights, an acknowledgement that this surgeon’s judgement stands up to scrutiny and the right to formulate a treatment plan that is believed to be in the interests of the patient sitting before us in the consulting room. We must now, however, decide to which group this patient belongs and make our decisions accordingly. Does this really, though, hamper our ability to be individual? Will we become one of the drones, simply following the flowchart to ascertain if the patient’s BMI makes surgery permissible, whether we will use bone cement and which bearings we will use? It is easy to see this process as just that, with difficult conversations and increasing registry surveillance for those who do not follow 'the rules', but this is to ignore who we fundamentally are. We are doctors – by training and inclination we listen to patients, consider their situation and make a plan. The implants the patients ultimately receive are undoubtedly important, but their overall care is arguably more so. Was I listened to? Did I feel judged for being out of shape? Did I trust the surgeon I saw? Am I happy with the plan? These are all questions our consultations will be subject to, and these represent our opportunities to be individuals, to make patient care our personal endeavour, and to strive to excel. While a positive patient experience in outpatients will not make up for a catastrophic arthroplasty, the reality is that more patients will experience a deficit in the former than the latter.

And what of rationing? This word conjures up images of plucky Britons, nobly facing the destruction of Europe and round-the-block queues for enough cheese to make a sandwich. We should do our bit, stand tall and show what we’re made of. Or should we? If the rationing for which our country is so famous had been varied by where people lived, with those in one town allowed a half a loaf of bread and those in another three loaves and a pat of butter, would the concept be so acceptable? If the minima for entitlement were set without rigorous scrutiny, what then? Are the inhabitants of one town so much more calorie-deficient than the other that they need this largesse, or are they simply lucky? Rationing was a relatively extreme measure, introduced when no alternative existed and backed up by a great deal of evidence from the relevant Ministries. To call a variable, haphazard and non-evidence-based withdrawal of access to surgical intervention 'rationing' is to do the concept a disservice. Patients avoidably losing their dexterity, mobility and quality of life should be seen as an aberration in a developed nation, all the more so when it falls to their address to determine what treatment they may receive.

So, if we’re going to solve this, we need to break down some barriers. We’ve already ascertained that the public trust us more than politicians. We’re good (for the most part) at communicating with our patients and there is undoubtedly more musculoskeletal expertise in the typical district general hospital trauma and orthopaedic department than there is in a Clinical Commissioning Group. This isn’t to belittle the great work done by CCGs in helping keep an overstretched primary care environment afloat; they are, however, talented generalists whereas we are single-system experts. Being able to advocate on behalf of our patients may rely on us clearly being one of them, a human with human worries, fallibilities and foibles. We forget to put the bins out, get annoyed when people tailgate us and worry about how our children are getting on at school. Our expertise, a status that is both intrinsic to what we do and exceptionally hard-won must be worn lightly, for fear of it being mistaken as 'otherness', a quality which may repel or intimidate our patients and hence feed into their acceptance of a plan we know to be second-best or resource-driven. This represents a challenge to our traditional, hierarchical model of practice, and we must evolve to embrace this. Often, more junior trainees may know patients far better than we do, having talked to patients at their lowest ebb when they present to the emergency department in the small hours of the morning, heard the concerns of family members that they wouldn’t wish to trouble 'the specialist' with and discussed these worries at length with our colleagues in the multidisciplinary team. There must be room for these opinions to be heard and a willingness to concede that others may know more than we do.

Opportunities abound with which to achieve this collegiate working – trauma meetings which provide education but in a supportive environment, a proactive willingness to complete workplace-based assessments and ward rounds where juniors do more than write in the notes all offer, amongst many other such scenarios, the chance to provide personal development and encouragement to the next generation of clinicians. The perpetual churn in the more junior grades of very short posts is frustrating for those who are in it for the long haul, with a seemingly endless cycle of inductions, foundation doctors finding their feet and core trainees doing their first orthopaedic on-call. The obverse of this coin is, however, that we have a short window of opportunity to educate and support those who may never work in our discipline again but may nonetheless go on to interface with it daily for the rest of their professional lives. A general practitioner or emergency physician who has spent time in an orthopaedic department is often given that confidence to make a decision, target a referral or spot the 'just not right' that changes outcomes for the patient and the pain of the on-call for the receiving orthopaedic team.

A key facet to the public perception of orthopaedic surgery is the management of trauma. A large proportion of our patients will meet us through the happenings of just a moment – stepping out into a dark morning to fetch the papers, going for a risky tackle or just trying to go to the bathroom without switching the light on and waking their spouse. There was no plan to sustain an injury, to become an orthopaedic patient or to meet a specialist. These occasions are uniquely stressful, with a painful injury, an increasingly long wait for an ambulance and an emergency department visit lengthened by lack of beds for admission. The patient controls none of this, an enormously disempowering experience, especially given trauma respects neither pre-existing plans nor patient resource. What comes after, though, we must do our bit to control. The recent upsurge in orthopaedic trauma trials in the United Kingdom is growing in renown around the world and the advent of major trauma networks has been shown to be reducing mortality and morbidity. The 'big' decisions matter, which operation, by which surgeon and where, in a way that we are now comfortable dealing with like never before, but the 'little' ones are often the ones that the patients notice. Will this operation really happen tomorrow? If not, can we make the decision early and allow the patient to have an evening meal? Will this elderly patient who lives alone be kept non-weightbearing post-operatively, or can they get home with a Zimmer frame? For them, this may be the difference between their children flying the length of the country to be with them once they are discharged from hospital and a rapid resumption of independent living. Most readers will be familiar with the look of disappointment from the patient who is once again cancelled after yet another day fasted, who was expecting to go home but is now in plaster, unable to bear weight, and so faces weeks’ more in-patient care.

We can’t always guarantee it won’t happen, but we can certainly warn patients early and explicitly that it may happen. In such moments is our high trust rating maintained.

Some of our chances to reach out transcend the clinical relationship and can connect us with those we have never met and may never meet. Over the last few years, our patients have become used to an increasingly information-rich world, with a good deal of that information bundled and sent to them based on what they read, ask or buy on the internet. Engagement on the individual level is both essential and the cornerstone of what we do as clinicians. Engaging on a population level, however, is a new game for most surgeons in an era when 'influencers' understand how to read the opinion of a group, target the group with a message and ultimately re-shape the opinion of that group. The rise of social media, of social networking sites from which some readers derive more of their news and opinions than broadcast or print journalism and of a culture based on the absolute requirement to make any point within 140 typed characters presents us a huge challenge but also an amazing opportunity. Representation of our practice and the evidence behind it from our specialist societies, Royal Colleges and journals can be augmented by responsible voices of surgeons and other members of the multidisciplinary team. Guidance from our regulators is undoubtedly salient but risks stifling the discourse which may show our patients that we understand them and allow us to have conversations which reach not only them but also those many others who may have similar questions. Thus, some small smoothing of inequality of access can be delivered.

So, to sum up, we can and must remain the trusted professionals our patients perceive us to be. We must continue to tread the line between systematic allocations of resources and best practice, being transparent to patients and healthcare systems alike, and continue to maintain trust by the highest possible standards of communication and personal interaction. Championing the most effective interventions and helping generate and synthesise the evidence telling us what they are must remain a key element of our practice. Articulate confidence on and awareness of social media can help drive this message, thereby reinforcing the trust we continue to hold.

References

1. Oxford English Dictionaries. Word of the year 2016 [Internet]. www.oxforddictionaries.com. Oxford; 2016 [cited 2019 Jan 30]. Available from: https://en.oxforddictionaries.com/word-of-the-year/word-of-the-year-2016.
2. IPSOS. Ipsos MORI Veracity Index 2018 [Internet]. London; 2018 Nov pp. 1–12. Available from: www.ipsos.com/sites/default/files/ct/news/documents/2018-11/veracity_index_2018_v1_161118_public.pdf.
3. Reindl R, Harvey EJ, Berry GK, Rahme E. Intramedullary Versus Extramedullary Fixation for Unstable Intertrochanteric Fractures: A Prospective Randomized Controlled Trial. The Journal of Bone and Joint Surgery. 2015 Dec 2;97(23):1905–12.
4. Briggs TWR. Getting it right first time. Improving the quality of orthopaedic care within the National Health Service in England. 2012.