Anthony Johnson, M.D., associate professor of surgery and perioperative care, co-authored the following post.
We would like to call attention to a potential quality and safety issue: surgical jargon might increase the risk of misdiagnosis of patient preferences. Given that orthopedic surgeons are a community that is already described as poor communicators by our patients3, 8, we should strive to minimize the use of jargon as it could reinforce common misconceptions, increase the risk of choices based on misconceptions rather than values, and potentially diminish trust in the user of jargon4. Our U. S. military officers are specifically instructed to avoid jargon in official correspondences for these reasons.2
A few recent articles in the Journal of Shoulder and Elbow Surgery provide a useful point of discussion. Boorman and colleagues’1 consideration of rotator cuff tendinopathy does not distinguish disease (pathophysiology) and illness (symptoms and limitations). Nor does it distinguish treatments that are palliative (managing symptoms and limitations; addressing illness) from those that are disease-modifying (slowing, stopping, or reversing disease; addressing pathophysiology). In a reversal of standard orthopedic jargon7, their study labeled people who avoided surgery as “successes” and those who chose surgery as “failures.” In the same issue, Ranebo and colleagues add to the substantial and growing evidence that deterioration of the rotator cuff is an expected part of human development 6. And Piper and colleagues5 compare operative and nonoperative treatments with no account of human resiliency (placebo effect) and nonspecific changes like regression to the mean (which would necessitate a simulated surgery control group).
Studies like that of Boorman and colleagues demonstrate that even when the disease is not treated most people are satisfied with their illness. But what we don’t know is:
- What is the natural history of rotator cuff tendinopathy? If we address pathophysiology by surgically closing a defect, does that delay or avoid progression to rotator cuff arthropathy? If it does, then one might consider surgery even if there were few symptoms or limitations. Surgery in order to treat the disease rather than the illness. Just as one treats hypertension or diabetes not for the symptoms, but to prevent the predictable harm caused by the pathophysiology. On the other hand, even if surgery is proved to be disease modifying, one might choose to be resolute and adaptive and accept the deterioration of the shoulder. It all depends on one’s values — specifically the patient’s values — which can be appreciated and used guide decision-making in collaboration with surgeons using clear, jargon-free language.
- What is the best way to limit symptom intensity and magnitude of limitations for a given pathology? Given the limited correlation between illness (symptoms and limitations) and pathophysiology noted in these and other studies, it’s a bit puzzling that we focus almost singularly on treatment of the pathophysiology to try to improve the illness. There is mounting evidence that psychological and social determinants have a substantial impact on symptoms and limitations. When we meet someone that is dissatisfied with their symptoms, perhaps we should consider these opportunities.
Surgical jargon that does not account for the differences between disease and illness, pain and nociception, and palliative and disease-modifying treatment may devalue resiliency (less stress and distress; more effective coping strategies) by overemphasizing pathophysiology. There is a certain illogic in the surgeon tendency to offer surgery based on symptoms and limitations but ascribe post-treatment dissatisfaction with symptoms and limitations to pathophysiology. We start by treating the illness, but we persist in a single-minded focus on pathophysiology.
The finding that people are typically satisfied with adaptation to the rotator cuff tendinopathy that most of us can expect to develop matches current best evidence and promotes a more comprehensive approach to helping people get and stay healthy. Health is not a disease-free state. Health is when a person has limited effects from disease.
- Boorman RS, More KD, Hollinshead RM, Wiley JP, Mohtadi NG, Lo IKY, Brett KR. What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2018 Mar;27(3):444-448. doi: 10.1016/j.jse.2017.10.009. PubMed PMID: 29433644.
- Department of the Army, Army Regulation 25-50, Preparing and Managing Correspondence (Washington, DC: Government Printing Office, 3 June 2002)
- Frymoyer JW, Frymoyer NP. Physician-patient communication: a lost art? J Am Acad Orthop Surg. 2002;10:95-105.
- Hansen J, Wanke M. Truth from Language and Truth from Fit: The Impact of Linguistic Concreteness and Level of Construal on Subjective Truth. Personality and Social Psychology Bulletin 36(11): 1576-1588, 2010. www.army.milusapa/epubs/pdf/r25_50.pdf
- Piper CC, Hughes AJ, Ma Y, Wang H, Neviaser AS. Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2018 Mar;27(3):572-576. doi: 10.1016/j.jse.2017.09.032. Epub 2017 Nov 21. PubMed PMID: 29169957.
- Ranebo MC, Björnsson Hallgren HC, Adolfsson LE. Patients with a long-standing cuff tear in one shoulder have high rates of contralateral cuff tears: a study of patients with arthroscopically verified cuff tears 22 years ago. J Shoulder Elbow Surg. 2018 Mar;27(3):e68-e74. doi: 10.1016/j.jse.2017.10.007. Epub 2017 Dec 14. PubMed PMID: 29249548.
- Ring DC, Dobbs MB, Gioe TJ, Manner PA, Leopold SS. Editorial: How the Words We Use Affect the Care We Deliver. Clin Orthop Relat Res. 2016 Oct;474(10):2079-80. doi: 10.1007/s11999-016-4993-y. Epub 2016 Jul 25. PubMed PMID: 27457621; PubMed Central PMCID: PMC5014836.
- Tongue JR, Jenkins L, Wade A. Low-touch surgeons in a high-touch world. AAOS Now. May 2009. https://www.aaos.org/AAOSNow/2009/May/cover/cover1/. Accessed 9 March 2018.