Three Reasons Surgeons Make Poor Decisions (Orthopedics This Week)
James G. Wright, M.D., M.P.H., surgeon-in-chief at the Hospital for Sick Children in Toronto, is responsible for six surgical divisions. He has had ample opportunity to study and closely observe how surgeons come to a decision. His conclusion? There is a lot happening at the subconscious level. Dr. Wright, an orthopedic surgeon, tells OTW, “Most of us assume that because we are doing evidence-based medicine that the evidence will actually be used. This is not necessarily so, however, because the surgeon’s decision making process intervenes.”
“There appear to be three issues which come to bear when surgeons are trying to make a decision.
1) The first is that surgeons come to relatively firm decisions and aren’t good at integrating new information. We are rather entrenched in our ways of thinking and despite new information/variations on what we know, we have trouble changing mindsets. Let’s say someone comes up with a great answer to an issue—something that should solve a controversy. The researcher publishes his or her work and promotes it through talks. We still see a slow uptake in the actual use of that information. I am pleased with what we are doing with evidence based orthopedics, but I don’t think we have considered the logical outplay of that, which is behavior change.”
2) “The second issue involves decision making at work. We did a ‘secret shopper’ study where we sent blinded total knee replacement patients into surgeons and family physicians’ offices. The result? Both types of doctors were more likely to recommend knee replacement to men than to women. The most likely explanation is that doctors form unconscious biases. When we asked these physicians if they treat men and women differently, they answered ‘No!’ But we know from employment research that when people go to job interviews those who are tall, more physically attractive, etc., fare better. These ubiquitous biases subtly influence behavior…and this is highly underappreciated.”
“The unconscious thought process likely went something like this: ‘Women come to arthroplasty later in the course of the disease and people who have arthroplasty later don’t bounce back to normal.’ Surely doctors would prefer having someone come in saying, ‘I feel fantastic’ versus, ‘I’m not sure that surgery helped so much.’”
3) “The third issue involves ‘confirmation bias’ wherein people grasp onto information that substantiates their views and discount any evidence that isn’t consistent with their views. For example, we looked at two forms of spinal instrumentation for idiopathic scoliosis. The surgeons had an explicit preference for one form of instrumentation (both before and after the trial). Afterwards we found no difference between the two forms of instrumentation in any aspect of what we thought should be affecting surgeons’ decision making. The surgeons found many reasons to discount the information we shared with them and persisted in using the instrumentation despite the neutral finding.”
“In another study we surveyed orthopedic surgeons and asked, ‘How do you make decisions involving a total knee surgery?’ We found a significant difference between the surgeons; when we repeated the survey 10 years later we found no difference in the variations in opinions of orthopedic surgeons. The upshot is that they actually disagreed with themselves!”
“We really need strategies to minimize these variations. On the grand horizon is the issue of behavior change. For that, we will be working with psychologists.”