Surgeons, Please Stop Telling People They’re Broken
Words can hurt
“My surgeon told me I have the worst hip he’s ever seen, I’m only here so insurance will pay for my surgery.”
What a start to the visit. I’m here to provide this patient non-operative treatment for their hip, and they’re already convinced surgery is the only solution. They’ve never tried anything besides Advil, and now they’re on board for the most invasive and risky solution possible.
This happens on a weekly basis. Someone comes in with an archaic view of joint pathology from their surgeon and has resigned themselves to surgery.
As I go through my evaluation, the patient starts to notice that physical therapy could be helpful. With each session, we slowly start decreasing their pain, while increasing their activity level.
By the end of their treatment sessions, about 75% of the patients feel great and decide they don’t want surgery — the other 25% are the ones who actually need it.
Telling someone they’re broken can influence their outcome
Very rarely do I think an activity is off-limits for a patient. Some activities may be more difficult for a person due to their genetics and previous injuries, but there’s almost always a way to get it done — as long as their surgeon doesn’t fuck up their whole psyche along the way.
Patients of mine have come into the clinic in tears because their surgeon said told them what they cannot do. “He told me I can never run again”, or “they said I can never play baseball again.”
When someone comes in with these beliefs, it influences their outcome.
Expectations are predictive of how someone will do with treatment
When researchers have studied predictors of success with a musculoskeletal injury, we’ve found that people who expect to recover have better results than those who do not.
A research group studied people with shoulder pain. They measured pain levels, demographic information, and expectations of results with treatment. They found that people who expected to get better had superior outcomes, regardless of their initial pain level.
You’d think people in more pain would have worse outcomes, but pain level did not predict how well the patient would respond to treatment — expectations did.
In a different study of people with low back pain who were out of work, we see similar results. The people with higher expectations of recovery were much more likely to return to work — regardless of pain levels.
The mind is powerful, and personal beliefs influence how well someone will respond to treatment.
It angers me when someone’s self-worth and expectation of recovery is shattered by another healthcare provider. Our job is to build people up, not tear them down.
An X-ray or MRI does not predict recovery
“My surgeon told me knee is bone-on-bone, I’m not sure what physical therapy will do for me.”
Numerous imaging studies have been done on people who have no pain. The researchers will take MRIs or x-rays of asymptomatic individuals to see what they find.
Many people have “abnormal” imaging findings even if they have no pain:
- Pain-free disc degeneration is found in 37% of younger spines, and 96% of older spines
- 40% of asymptomatic shoulders have rotator cuff muscle tears
- Arthritis is found in 19–43% of pain-free adult knees
- 69% of adult hips have pain-free labral tears
These numbers are high. In some studies, the majority of people with no pain have “abnormal” imaging findings. We’ve stopped calling these findings abnormal because they are so common!
If disc degeneration is present in 96% of older spines, how can we blame it for someone’s pain?
Imaging doesn’t predict outcomes on its own. It is one piece of the clinical puzzle, and it all has to fit together before making a big decision like surgery.
Disc degeneration is one of my least favorite diagnostic terms, and a prime example of why language is important in healthcare. The word degeneration makes the spine sound fragile, as if it’s crumbling.
This could not be further from the truth, disc generation simply means the discs between each vertebra slowly lose pressure with age — it doesn’t lead to instability. In fact, in some areas of the spine it actually increases stability by increasing the surface contact area between each vertebra.
The changes in the discs of the spine are very similar to what happens to the skin with age. As the skin ages, it loses some of its elastic properties. It starts to sag and form wrinkles. The discs also lose some of their youth. Instead of being plump and elastic like a full water balloon, they slowly lose this firmness with age.
We don’t refer to wrinkles as skin degeneration, so why should we use the term disc degeneration when the same process happens in the spine?
The path forward
When someone doesn’t want to get a surgery, that’s when surgeons like to say “well, then you can never run again.” This sounds like a threat to me. What I hear is “get this surgery, or you can’t run.”
These words can cause lasting harm to the patient. Threats don’t belong in healthcare. We are in the business of helping people, not scaring them into paying for our treatment.
I’m not anti-surgery. Many diagnoses do better with surgery: shoulder dislocations, knee ligament injuries, achilles ruptures, large rotator cuff tears, and a few others. In these cases, I will actually recommend the patient goes to see a surgeon.
In most cases, we should pursue thorough non-operative management before someone goes under the knife.
It makes my job as a physical therapist exponentially harder when a surgeon convinces someone they are broken, and have no way out except surgery. We all need to look at what’s best for the person sitting in our clinic, and recommend the best treatment — regardless of our skillset.