Patients often come with an expectation that the doctor will sort out their problems, with a simple pill or a simple operation.  People often say to me that they "don't like taking pills" and would rather have an operation to sort the problem; this demonstrates that a lot of people underestimate the risks associated with surgery.  We are, to a degree, victims of the success of modern medicine. 

Sometimes the longest, hardest consultations involve explaining why I don't have an operation to fix the problem.  But even if we are considering surgery, we still have to go through a proper consent process that incorporates and expands Dr Mjaset's 4 questions:

What are we treating?
Are there other options, what happens if I don’t do anything?
What does the operation involve?
​What is the aftermath of the operation like?
What are the risks? 
​Is this the right thing to do?

This good TED talk discusses this at more length.

 I actually don't see this as a re-framing - it is how I was taught to practice .

My old Professor, Jimmy Hutchison always urged us to seek non-surgical options first - "there is nothing that you can't make worse by operating on it".

  I can't speak for other surgeons around the country.  I choose to use the same hip and knee replacements for all of my patients, private and public.  That choice is made on the long-term published results of those replacements.  

​Choose the best equipment available and get consistent at using it well for the best long term results.

  click here to see the original article:  Warrnambool Standard

 
I feel a bit like a “stuck record”, although this is an analogy that younger people might not understand.  Maybe a “GIF” stuck on repeat.   Anyway.  Here we go again, let me say it once more:  The indication for ACL reconstruction is not "ACL injury".

Rather, the reason for a patient having an ACL reconstruction is "instability after ACL injury, in spite of a period of good rehab".  So, there is actually nothing different about Karen’s approach.

This is how I have treated ACL injuries for years.  And about ⅔ of the patients that I see with ACL injuries end up having surgery.   So, not everyone, but it still has a place when rehab doesn’t quite get the patient where they want to be.   This is supported by a paper that I co-authored some years ago (the patients were all under my care), published in the Journal of Knee Surgery:

​Is anterior cruciate reconstruction superior to conservative treatment?
A Dawson, JD Hutchison, AG Sutherland. J Knee Surg 2016; 29(1): 74-9.
 
I’m slightly surprised that St John of God  Warrnambool should support an article that only shows one side of the discussion, but there you go.
 
If you have an ACL injury, you should start rehabilitation with an experienced physiotherapist early.  You should discuss your progress and your goals.  You should also consider a discussion with a surgeon who regularly treats ACL injuries, about the practicalities and goals of surgery.  Some people do really well with rehab, and go back to sports.  Some people do well enough with rehab, but decide not to go back to sports.  But some people want to go back to sports but cannot because the knee is still unstable, or the knee is still unstable in daily activities, despite good rehab.  Those are the people who should consider ACL reconstruction.
 
So many shades of grey.

Of course, the answer is "yes". Still very much needed ("kneeded"?  Ha Ha).

What this review ACTUALLY says is this:
The indication for ACL reconstruction is not "ACL injury".
Rather, the indication for ACL reconstruction is "instability after ACL injury, in spite of a period of good rehab"

Which is how I have treated ACL injuries for years.  And about ⅔ of the patients that I see with ACL injuries end up having surgery.  So, very much still needed, just not by everyone.

You can read the full review here www.physio-network.com/acl-surgery-no-longer-kneeded/

It goes both ways!  In this excellent article, the remarkable Atul Gawande delves into the impact of computers in healthcare, sharing his experience and exploring some of the alternatives.  Gawande is a smart man, and a very perceptive writer, and his books are well worth a read, particularly "Complications" and "Better".

Deep vein thrombosis (calf blood clot) is an important complication after joint replacement, and strategies to reduce the risk include early mobilisation, compression stockings and medications.  For many years, I have prescribed aspirin for my patients having joint replacement, as prevention of DVT.  Although this was initially controversial, we felt that the evidence supporting that position was strong, and gradually this has become a mainstream approach.  Aspirin provides similar prevention of DVT to more expensive approaches, without the associated increased risks of wound leak that many of the alternatives have been dogged by.  There is now increasing evidence, including this recent paper , that the use of aspirin also provides a survival advantage for joint replacement patients.  Patients should discuss the risk of clots with their surgeon as part of the informed consent process.

Click here to go to the original piece in The Age 

I spent a really interesting and challenging 6 months as Julian Feller's Fellow in 2003, and took away his ACL reconstruction technique with me when I returned to Scotland to set up practice.  During the intervening 15 years, we have both made a few tweaks to our respective surgical approaches to ACLs, in line with new evidence as it emerges, but we remain pretty much aligned on the important points - put a good quality biological graft in the right place and fix it firmly, then do good rehab.

When I was learning from him, I asked about Julian's approach to placing the bone tunnels into which the graft was secured - do you use the lateral meniscus and/or PCL to guide placement?  "Put it in the right place" was his response.  An idiosyncratic answer at the time, but over the years I have increasingly appreciated his point that the individual patient's anatomy governs where the graft should go.

I now bring that and other insights to my clinical practice in Warrnambool.  I learnt from the best, and aim to reproduce that for all of my patients.

Julian Feller 2003

I recently created the following video for our local medical students.  Many people think that surgical consent is just a process of listing all the possible complications of an operation.  Of course it is both simpler and more complex than that.  I find that following a structured 5 point plan helps me to be sure to cover the important points and helps patient realise just what it is they are agreeing to.  Given the new legal requirements that demand that consent should reflect what the patient thinks is important, rather than what the surgeon thinks is important (radical thought, that one?), the emphasis should be on an open discussion rather than the old-fashioned "sign here" approach.

I recently created the following video for our local medical students, but offer it here to a wider audience.

http://www.freewanderer.net/wp-content/uploads/2016/05/8149-1038x576.jpg
​

​The recent ABC 4 Corners film about gap charges for private surgery raises many important questions.  There are many surgeons in Australia who think that ethical behaviour is all about following rules on advertising, but there is a great deal more to “doing the right thing” than that.  The programme presented a more or less balanced view, although it did focus on some extreme examples to make its point.
 
In the film it was pointed out that while we might consider private healthcare to be a free market, it rarely is because patients do not have all of the information required to make informed choices.  Asymmetric relationships generally put the surgeon in full control and patients at a disadvantage as they do not know their options.
 
The idea of “you get what you pay for” does not always hold in healthcare, and surgeons can play upon this to extract the highest possible fee that the market will stand.  The 4 Corners film focused upon a patient charged an out-of-pocket surgery fee of $7500 for his hip replacement, but there is more to high fee-structures than a minority of surgeons charging that far over the odds. The Australian Medical Association (AMA) has a recommended surgeon fee schedule that would leave even the best-insured patient out of pocket by $1000 for a hip replacement.
 
The value proposition of private health care balances coverage and faster access with price.  If the private system is perceived as being unfair, with excessive out of pocket fees, then patients will drop out and turn to the public system.  For the balanced system of public/private provision current in Australia to be sustained, confidence in the private system is critical.
 
So, what can I do as a surgeon?

1. Reasonable fees– my standard fees are those paid by BUPA.  If a patient has BUPA insurance, no gap.  Where other insurance companies pay less than that rate, then there will be a gap, generally under $450 for a major surgery such as joint replacement.  I do not think currently that the AMA fee schedule is justified in a regional setting where median incomes are lower than those in metro areas.
2. Charge only the gap – where there is a gap, that will be discussed.  The remainder of the fee will be billed to the Insurance Provider, rather than the patient paying the whole fee up front and claiming for themselves from their fund.
3. Informed financial consent– I discuss fees with patients directly; it is not passed over to a practice manager.
4. Predictable anaesthetic fees – I work regularly with two anaesthetists, and don’t take part in a roster, so I always know who my patients will meet in the anaesthetic room.  In that way, I am able to advise patients (in advance) what fees they will face from the anaesthetist (currently no gaps from either anaesthetist).  We are also able to develop sound co-operative care for patients.
5. No booking fees or hidden charges – policy excess charges differ between funds, but I will be completely transparent in what I charge.  No nasty surprises.
6. High quality, local, personal care – daily visits while patients in hospital, co-ordination with physios etc, easy access to out-patient review, patient-centred care including shared surgeon/independent physio review of joint replacements over the long term.  All while trying to take a balanced view on reasonable remuneration for that service. 

 
What can GPs do?

1. Find out what surgeons you refer to charge – not just for outpatient clinics, but what are their surgery gaps?  And if you think it is excessive, tell them and tell your patient.  If it is not easy to find out from the surgeon, then ask why and ask why you should refer to them.
2. Think local – surgery in the city will generally be more expensive for the patient, but is it better?  And what are the secondary costs for patients being far away from their surgeon and aftercare when they come home?  We value and support the GPs who choose to live in the region, and hope that surgeons who make the same choice will be valued by you.
3. Support local services - Currently, at least 40% of insured patients from south-west Victoria get their orthopaedic care outside the region, often in Melbourne, placing greater pressure on St John of God Warrnambool, which is under financial pressure.  The surgeons providing local private orthopaedic services are the same surgeons providing local public services, including trauma care, and for the system to remain viable, both sides have to function effectively.

 
What can patients do?

1. Ask questions – find out your costs and options, shop around.
2. Think local –local services can be cheaper and more convenient for you than metro services, without necessarily compromising care.
3. Support local services – so that they are there when you need them.

 
 
Alasdair Sutherland
June 2018