Reply to the Letters to the Editor: Safety in Surgery and Overall Health: What is the Responsibility of the Patient?

To the editor, I appreciate the letters to the editor by Drs. Woo and DiCuccio. The incentive to optimize a patient’s health for surgery is often countered by the financial incentive of productivity. Orthopaedic surgeons generally are not compensated to engage in smoking cessation, weight loss or glycemic optimization. As Dr. Woo points out, if Surgeon A delays elective surgery until a patient is healthier, there is nothing stopping that patient from going across town to Surgeon B who is willing to offer the surgery immediately. As a result Surgeon A gets nothing for trying to improve a patient’s health, and Surgeon B gets paid for rendering lower-quality care. It would be easy to see how in the long run, Surgeon A can get frustrated in this system and perhaps change his/her practice patterns. This is not to say that surgeons or physicians are incentivized solely by financial gain. However, we would be naive and delusional to assume that finances play zero role in physicians’ decision-making. Dr. DiCuccio suggests that healthy patients with treatable disease are often denied treatment either inexplicably by surgeons who refuse to operate, or by the preferential utilization of health care resources for sicker patients with worse prognoses. Though curious, it is a situation that I have not observed, at least for patients with orthopaedic pathologies. In my experience, a healthy, employed, well-insured patient with appropriate indications and good prognosis is unlikely to have difficulty finding a surgeon willing to offer surgical treatment. Patient selection is clearly critical in obtaining a good outcome. In his last statement, Dr. DiCuccio warns that surgeons need to regulate themselves or the Center for Medicare & Medicaid Services (CMS) will do it for them. Such third-party regulation is not only distasteful to surgeons, but more importantly may have unintended consequences. There are several risk factors for poor outcome: workers compensation status, lower socioeconomic status, multiple medical comorbidities, extent of surgical treatment, and patient noncompliance. Ultimately, the decision to recommend or not recommend surgical treatment is dependent upon the surgeon’s judgment of a situation. I am loath to offer an elective microdiscectomy to a neurologically intact, IV-drug-using, chronically unemployed, noncompliant patient. However, I would be willing to offer the same procedure to a workers compensation patient with multiple treated comorbidities, if I judged the patient likely to obtain relief and return to work. Both patients have risk factors for poor outcome, but the presence of risk factors should not be universally applied by a third party to deny care. Therein lies the danger of third-party regulation of surgical indication. That being said, we should heed Dr. DiCuccio’s statement that if surgeons do not consistently demonstrate good judgment, then CMS and other payors will do it for us. Regulation and incentives (whether they are productivity based or ‘quality’ based) are not necessarily bad things in healthcare, but they can be hard to control and may carry unintended results.