As many readers of this blog know, there is little evidence that knee arthroscopy to “clean up” knee arthritis is effective. In fact, this type of knee arthritis surgery has been shown to be ineffective, yet it’s still performed. Our colleagues in Great Britain have just published an article about the uphill battle the NHS has in convincing it’s orthopedic surgeons to drop the procedure. The reasons given by surgeons why the ineffective procedure gets done offer a rare look into why physicians often perform procedures that we know don’t help patients.
Knee arthroscopy to “clean up” a knee is called debridement. The concept was that since there are pieces of cartilage floating around and hanging off of bone as well as meniscus tears, that performing a knee arthroscopy surgery to “tidy up the dirty room” of the joint was a good idea. However, ever since the seminal Mosely study in 2002 showing that the procedure was no better than placebo surgery, the number of debridement surgeries has fallen. However, from what I see in my community and apparently from what the British NHS has observed, the procedure is still being performed.
A research team in the U.K. recently published a paper on why surgeons were still using this surgery which has now been excluded from the NHS’s NICE guidelines. The responses by surgeons and the beliefs they expose are a unique view into the mind of physicians who still perform procedures we know are ineffective. Here are some interesting beliefs from the article:
-Fully 1/4 of surgeons didn’t get the memo that the procedure was ineffective! 10% flat out disagreed with the findings of the randomized controlled trials showing that it didn’t work.
-A large number of surgeons responded that they were unwilling to resist the pressure from patients who wanted the surgery or wanted “something done”.
-Some surgeons cited their belief that more experienced surgeons may be able to produce better results than the studies showing that the procedure didn’t help.
-Some surgeons cited the fact that private insurers would still reimburse for the procedure as a reason the surgery was still being utilized.
-Time pressure was cited – as in “you need more time to explain to the patient that the procedure doesn’t work and often it’s quicker to just to schedule the surgery”.
-Habit-in that “it’s hard to break old habits”.
The upshot? How do we get surgeons to drop this and other procedures such as menisectomy that have been shown to be ineffective? In the end, in the U.S., the solution is as simple as not reimbursing the procedures through Medicare and private insurance companies. I can see that in socialized medicine systems where doctors are compensated with a salary no matter what they do, getting them to stop an ineffective procedure can be quite an uphill battle!