Purpose: Only 30% or less of patients who see an orthopaedic surgeon are surgical candidates. Thus, orthopaedic surgeons’ role in the management of musculoskeletal conditions is wider than surgery and, accordingly, their treatment recommendations include much more than surgery as well. This paper examines the delivery of recommendations not for surgery (NFS) in routine orthopaedic surgery consultations.

Method: Audio-recordings of routine consultations between 121 patients and 14 surgeons from two tertiary care hospitals in a large Canadian city were collected and analyzed using Conversation Analysis, a rigorous, empirical approach to the study of interaction which seeks to reveal sequential structures and patterns in naturally occurring talk, and to explain why these patterns are important.

Results: In contrast to recommendations for surgery, which tend to be delivered fairly quickly and straightforwardly, the delivery of NFS recommendations tends to be elaborate and complex. Orthopaedic surgeons recurrently utilize a cluster of interactional devices in the lead-up to NFS recommendations, including:

projecting turns – turns which indicate that the surgeon will produce an extended turn;

Additionally, even though surgery is not being recommended, NFS recommendations are positioned in relation to surgery. Surgeons use this cluster of devices to manage a range of competing demands, for example, showing that they are taking the patient’s problem seriously, being attentive to the patient’s treatment expectations, explaining the rationale for the recommendation, and positioning the recommendation not for surgery in relation to surgery – e.g., explaining why surgery is not being recommended now, and/or the conditions under which surgery would be offered in the future. Through this cluster of devices, surgeons forecast the nature of the recommendation to come, lay bare the evidential basis for the recommendation and work to obtain patients’ subsequent acceptance of the recommendation. The cluster, as a whole, constitutes a persuasive argument for the upcoming recommendation.

Conclusion: Delivering not for surgery recommendations is a complex task, one which surgeons handle skillfully using several interactional devices. Surgeons treat these recommendations as requiring a persuasive case. An appreciation for the complexities and constraints of delivering NFS recommendations can be used to inform clinical practice and the teaching of communication skills.

Purpose: Factors influencing patient willingness to undergo elective surgery are poorly understood.

Method: We prospectively evaluated patient concerns prior to surgical consultation for elective spinal, hip, knee, shoulder/elbow (S/E), or foot/ankle (F/A) conditions. Patients were surveyed for demographic data, SF 36 quality of life (QOL) scores and asked to report their greatest concern about considering surgery for their condition, as well as their willingness to undergo surgery if it was offered to them by their treating surgeon.

Results: In our prospective cohort of 743 patients, 364 (51%) were male and 293 (39 %) were evaluated for a spine condition, 74 (10 %) hip, 192 (26 %) knee, 69 (9 %) S/E, and 115 (16 %) F/A. Mean QOL scores were similar for patients across specialities. The top three greatest concerns for undergoing elective musculoskeletal surgery were potential complications (20%), effectiveness (15%) and recovery time (15%) of surgery. When categorized by specialty, concern of surgical complications was the most prevalent in spine (23%) and F/A patients (30%). However, patients were most commonly unsure of risks associated with their respective subspecialty surgery (spine – 56%; hip – 53%; knee – 44%; S/E – 48% and F/A – 33%). The majority of hip patients (89%) perceived a high success rate for hip surgery, while 65% of spine patients where unsure of the success of spine surgery. Patient willingness to undergo surgery was greatest for hip (84%), knee (78%), and S/E (82%) surgery and least for spine (68%) and F/A surgery (74%).

Conclusion: Although patient willingness to consider surgery is clearly a multifactorial decision, patient perception of surgical risk or success prior to surgical consultation are significant factors.