Do Patient Preferences Influence Surgeon Recommendations for Treatment?

Document Type : RESEARCH PAPER


1 Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

2 Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA

3 Department of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands


Background: When the best treatment option is uncertain, a patient’s preference based on personal values should be
the source of most variation in diagnostic and therapeutic interventions. Unexplained surgeon-to-surgeon variation in
treatment for hand and upper extremity conditions suggests that surgeon preferences have more influence than patient
Methods: A total of 184 surgeons reviewed 18 fictional scenarios of upper extremity conditions for which operative
treatment is discretionary and preference sensitive, and recommended either operative or non-operative treatment.
To test the influence of six specific patient preferences the preference was randomly assigned to each scenario in an
affirmative or negative manner. Surgeon characteristics were collected for each participant.
Results: Of the six preferences studied, four influenced surgeon recommendations. Surgeons were more likely
to recommend non-operative treatment when patients; preferred the least expensive treatment (adjusted OR,
0.82; 95% CI, 0.71 – 0.94; P=0.005), preferred non-operative treatment (adjusted OR, 0.82; 95% CI, 0.72 – 0.95;
P=0.006), were not concerned about aesthetics (adjusted OR, 1.15; 95% CI, 1.0 – 1.3; P=0.046), and when patients
only preferred operative treatment if there is consensus among surgeons that operative treatment is a useful option
(adjusted OR, 0.78; 95% CI, 0.68 – 0.89; P<0.001).
Conclusion: Patient preferences were found to have a measurable influence on surgeon treatment recommendations
though not as much as we expected-and surgeons on average interpreted surgery as more aesthetic. This emphasizes
the importance of strategies to help patients reflect on their values and ensure their preferences are consistent with
those values (e.g. use of decision-aids).
Level of evidence: III


Main Subjects

1. Chewning B, Bylund CL, Shah B. Patient preferences
for shared decisions: a systematic review. Patient
Educ Couns. 2012; 86(1):9-18.
2. Dardas AZ, Stockburger C, Boone S, An T, Calfee RP.
Preferences for shared decision making in older adult
patients with orthopedic hand conditions. J Hand
Surg Am. 2016; 41(10):978-87.
3. Hageman MG, Reddy R, Makarawung DJ, Briet JP, van
Dijk CN, Ring D. Do upper extremity trauma patients
have different preferences for shared decisionmaking
than patients with nontraumatic conditions?
Clin Orthop Relat Res. 2015; 473(11):3542-8.
4. Charles C, Gafni A, Whelan T. Decision-making in the
physician-patient encounter: revisiting the shared
treatment decision-making model. Soc Sci Med. 1999;
5. Shay A, Lafata J. Where is the evidence? A systematic
review of shared decision making and patient
outcomes. Med Decis Making. 2015; 35(1):114-31.
6. Joosten EA, DeFuentes-Merillas L, De Weert GH,
Sensky T, van der Staak CP, de Jong CA. Systematic
review of the effects of shared decision-making on
patient satisfaction, treatment adherence and health
status. Psychother Psychosom. 2008; 77(4):219-26.
7. Brody DS. The patient’s role in clinical decisionmaking.
Ann Intern Med. 1980; 93(5):718-22.
8. Janssen SJ, Molleman J, Guitton TG, Ring D. What
middle phalanx base fracture characteristics are most
reliable and useful for surgical decision-making? Clin
Orthop Relat Res. 2015; 473(12):3943-50.
9. Guitton TG, Ring D. Interobserver reliability of
radial head fracture classification: two-dimensional
compared with three-dimensional CT. J Bone Joint
Surg Am. 2011; 93(21):2015-21.
10. Doornberg JN, Guitton TG, Ring D. Diagnosis of elbow
fracture patterns on radiographs: Interobserver
reliability and diagnostic accuracy elbow. Clin Orthop Relat Res. 2013; 471(4):1373-8.
11. Neuhaus V, Bot AG, Guitton TG, Ring DC, Science
of Variation Group, Abdel-Ghany MI, et al. Scapula
fractures: interobserver reliability of classification
and treatment. J Orthop Trauma. 2014; 28(3):124-9.
12. Hageman MG, Becker SJ, Bot AG, Guitton T,
Ring D, Science of Variation Group. Variation
in recommendation for surgical treatment for
compressive neuropathy. J Hand Surg Am. 2013;
13. Hageman MG, Jayakumar P, King JD, Guitton TG,
Doornberg JN, Ring D. The factors influencing the
decision making of operative treatment for proximal
humeral fractures. J Shoulder Elbow Surg. 2015;
14. Ozkan S, Mellema JJ, Ring D, Chen NC. Interobserver
variability of radiographic assessment using a mobile
messaging application as a teleconsultation tool. Arch
Bone Jt Surg. 2017; 5(5):308-14.
15. van Wulfften Palthe OD, Neuhaus V, Janssen SJ,
Guitton TG, Ring D. Among musculoskeletal surgeons,
job dissatisfaction is associated with burnout. Clin
Orthop Relat Res. 2016; 474(8):1857-63.
16. Dy CJ, Lyman S, Boutin-Foster C, Felix K, Kang Y,
Parks ML. Do patient race and sex change surgeon
recommendations for TKA? Clin Orthop Relat Res.
2014; 473(2):410-7.
17. Chhabra KR, Sacks GD, Dimick JB. Surgical decision
making challenging dogma and incorporating patient
preferences. JAMA. 2017; 317(4):357-8.
18. Hajjaj FM, Salek MS, Basra MK, Finlay AY. Non-clinical
influences on clinical decision-making: a major
challenge to evidence-based practice. J R Soc Med.
2010; 103(5):178-87.
19. Bernheim SM, Ross JS, Krumholz HM, Bradley EH.
Influence of patients ’ socioeconomic status on clinical
management decisions : a qualitative study. Ann Fam Med. 2008; 6(1):53-9.
20. McKinlay JB, Potter DA, Feldman HA. Non-medical
influences on medical decision-making. Soc Sci Med.
1996; 42(5):769-76.
21. Birkmeyer JD, Reames BN, McCulloch P, Carr AJ,
Campbell WB, Wennberg JE. Understanding of
regional variation in the use of surgery. Lancet. 2013;
22. Janssen SJ, Teunis T, Guitton TG, Ring D; Science of
Variation Group. Do surgeons treat their patients like
they would treat themselves? Clin Orthop Relat Res.
2015; 473(11):3564-72.
23. Teunis T, Janssen SJ, Guitton TG, Vranceanu AM, Goos
B, Ring D. Surgeon personality is associated with
recommendation for operative treatment. Hand.
2015; 10(4):779-84.
24. Paulus MC, Braunstein J, Merenstein D, Neufeld S,
Narvaez M, Friedland R, et al. Variability in orthopedic
surgeon treatment preferences for nondisplaced
scaphoid fractures: a cross-sectional survey. J Orthop.
2016; 13(4):337-42.
25. Stacey D, Légaré F, Col N, Bennett C, Barry M, Eden K,
et al. Decision aids for people facing health treatment
or screening decisions. Cochrane Database Syst Rev.
2014; 1(10):CD001431.