Expertise and trust a qualitative study of orthopaedic surgeons’ provision of professional care for patients with painful osteoarthritis

Background
Osteoarthritis is estimated to affect 8.75 million people in the UK, and over 600 million people globally. Osteoarthritis is characterised by pain and functional limitations and can have an extensive impact on the individual’s everyday life. Recommended core treatments used alongside paracetamol and NSAIDs are information, exercise and weight loss interventions. When these fail to provide sufficient relief from symptoms, referral to joint replacement surgery is recommended before development of severe pain. The process by which patients arrive at joint replacement and the decision-making process has been a focus of recent research. Increasingly, choice and achievement of shared decision-making are extolled as essential to quality healthcare, including in management of painful conditions. However, to understand the delivery of these ideals we need to know how professionals employ judgement and expertise about appropriate options for patients in search of pain relief and how they prioritise pain in their decision-making.
Methods
Orthopaedic surgeons who conducted hip or knee replacement operations were contacted at four participating study sites. Surgeons were sent an information sheet about the study and asked to provide their written, informed consent to participation. Of those approached, 28 took part in face-to-face semi-structured interviews structured using a topic guide addressing factors considered in decisions about joint replacement, content of consultations with patients, and experiences of working in the profession. Interviews were audio-recorded, transcribed, anonymised and imported into qualitative analysis package, QSR NVivo. Using a thematic approach, interviews were coded by the first author and coded data were grouped into analytic categories. To enhance rigour a sample of 13 transcripts were double-coded by another team member and code lists were compared and refined before application to the remaining transcripts. Once all coded data were grouped into categories, a descriptive account of the dataset was developed, including anonymised illustrative quotes.
Results
Key themes highlighted diverse aspects of surgeons’ practice, including their interaction with patients and colleagues. While surgeons’ assessment of patients during consultations were essentially holistic, pain was a key factor on which their decisions were made. Surgeons described using examinations, discussion with patients and use of x-rays in consultations with patients when deciding on surgery. They also identified the importance of providing an offer of surgery for patients for whom it was appropriate. Management of patients’ expectations about pain and function was integral to practice and seen as essential to securing a positive outcome for both patients and surgeons. Surgeons also maintained optimism and engendered confidence and trust. Referral processes were a source of frustration and there was concern that reduced waiting times and triage systems did not always benefit patients but introduced additional work. In these multiple ways, professionalism was played out in all aspects of practice.
Conclusion
Surgeons’ candid depiction of decision-making for patients with painful osteoarthritis showed commitment to best practice, the concern to appear professional and that they prioritise their expertise. To surgeons, provision of expertise was paramount, they expressed a strong sense of duty to patients and consideration of patients’ pain and limitations. Structural changes to healthcare, and unhelpful systems presented threats to this duty of care, and to professionalism in practice. Future research and intervention might address the training and development of surgeons to help them to achieve professional satisfaction and deliver expert opinion in the context of patient choice and shared decision-making.