Serious adverse events and lifetime risk of reoperation after elective shoulder replacement: population based cohort study using hospital episode statistics for EnglandBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l298 (Published 20 February 2019) Cite this as: BMJ 2019;364:l298
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The inequality in responsibilites and expectations in health care interaction and the associated implication in its delivery
Despite recent trend towards "shared decision making" and increased awareness of patient autonomy, coupled with medico-legal obligations as a result of Rogers vs Whitaker (informed consent involving specific risks relevant to specific patients) and the Montgomery case (informed consent and disclosure involving consideration of alternative treatment option not offered), the healthcare regulators and the judiciary still consider the obligation and responsibility of the healthcare professional at a much higher standard than the patient. Hence the healthcare professional in providing care is akin to the informed and trained guide to the patient undertaking the journey through healthcare services, in which the standards and expectation of the guide's action is regarded at a different level than the patient despite the "shared decision making" process.
Craig et al's paper provides a timely reminder of the issues faced by doctors in modern medicine. Unlike a generation ago, there is now a wide range of treatment options both non-operative and operative available to most conditions, ranging from biologics and cellular therapy (stem cells, cytokines) to the newest implant on the market. Not all of them are effective in providing adequate relief. Effective treatments may not be cost-effective, particularly when cheaper options are available to provide similar (but not the same) magnitude of response. There are no treatment that have no side effects; the issue is how often, how much and what are the trade-off in risk-benefit assessment. Furthermore, the role of doctors-employee as gate-keepers in a nationalised healthcare system particularly at the primary care level, may not be aligned with what the patient need. Lastly the conflict of what the patient expects/wants/demands versus what the patient actually needs, straddles between patient autonomy/provider paternalism versus standard of care and social justice.
A person who walks into a GP practice with a diagnosis of essential hypertension may expect to be prescribed anti-hypertensive medication, yet most guidelines would strongly recommend initial non-pharmaceutical management involving lifestyle and diet modification. Some patients may consider the latter management inconvenient and insists on getting the pills so as to avoid making the necessary changes. The health professional is then faced with the issue of giving the patient what (s)he wants (a shorter consultation, a happier client) or refusing the patient's demand and counsel them about the non-medicated management (a disproportionately longer consultation, often an unhappy client who may leave bad reviews or make a complaint). With modern anti-hypertensive medications whose side-effects are low risk and well-known, it is not unexpected what path some busy professionals will end up choosing.
Similarly a patient with shoulder pain and radiologically proven glenohumeral osteoarthritis may be referred to a shoulder clinic, and come to expect to be offer a shoulder replacement, yet the diagnosis and cause of shoulder symptoms may not be clear cut despite the 'proof' of shoulder imaging; frozen shoulder and cervical radiculopathy are common alternative diagnoses. Some (but rarely all) patients with glenohumeral osteoarthritis may have completed a trial of non-operative management including physiotherapy and other pain-management therapies; what is a reasonable and acceptable duration of conservative therapy is variable and debatable.
Assuming that a patient with glenohumeral osteoarthritis did had adequate non-operative management, the natural next step would then be surgery, usually a total shoulder replacement (TSR). However the issue is when should the patient be offered this option?
Some surgeons will not hesitate to offer TSR to patients regardless of their age and comorbidities; they regarded their medicolegal and moral duties discharged as long as the patient sign on the dotted line on the consent form after an "informed" consent process. They may even claim that the Montgomery case requires them to provide TSR as a possible option, even for patients whose age/morbidity is regarded as not suitable for TSR.
The question is then in a society where 85+ years is a normal life-expectancy, is 58 year old too young for a TSR? If the answer is not, how about 50 year old? How about 40 year old? By some surgeon's logic, it is possible to consider TSR at any age as long as the patient is fully informed about risk-benefit of the procedure.
However, until Craig et al's paper, there are in fact very few good population data about the outcome of elective TSR. Most involved joint registry anaylsis where the main outcome measure is implant survival or revision rate which can be pegged to age of patients. Few offer insight to risk of adverse events related to the primary surgery.
Would this study change the practice of shoulder surgeons in their decision making to offer TSR to young patients?
I suspect not. Those who had previously routinely offer TSR in patients under 59 years will continue to do so, with very little effort in "patient selection".
However for those shoulder surgeons who would actively counsel patients against TSR, this study offers more support and data why postposing TSR as long as possible is highly desirable, and allows patients to understand the concerns involved in offering TSR in younger age group. I would expect it is these surgeons who would truly appreciate the work of Craig et al.
Competing interests: No competing interests