Análisis del Entorno Específico.

On the whole, the surgeons did not talk about variation in orthopaedic practice in their day-to-day work. I did not observe any instances of surgeons openly referring to variation in their own, their peers’ or their hospitals’ practice. It seemed to be accepted that ‘the way things are done around here’ was the norm at each hospital site. Therefore, it was standard practice that activities and procedures would be changed by individuals or over time. This was in relation to the enactment of surgeon preferences, contextual contingencies and the practice dependencies described above.

This lack of awareness was particularly evident amongst the senior consultants who had generally been in post for a long time. Junior surgeons who were undergoing rotations between hospitals, or who had conducted part of their surgical training elsewhere, were more able to provide insight into the differences they saw between hospitals. The quote below is from a junior surgeon describing implant selection decisions:

“I think it’s, there are slightly different reasons because the hips guys are different, the only thing I can really compare it to, because the only I know, is (name 1). I mean, I’ve worked in (name 2) and (name 3). (Name 2) teaching hospital had everything, every different brand. It’s changed now.

Places like (name 3) used to have three or four brands, and (name 1) had something like 18 different combinations of doing a hip replacement.” (INT C 119010)

It is possible that variation was not well understood or appreciated by the surgeons working in the hospital. Their frame of reference was generally at the individual and local level (their teams and colleagues to a certain extent and the patient sitting in front of them, their consultation room, or the group of patients in the outpatient waiting room). Decision-making appeared to be very much made on a one-to-one basis. Seeing variation at this individual patient level is more challenging. This is reflected in this consultant’s statement about implant selection:

“A lot of us feel very uncomfortable putting ages limits on, you can only have ceramic up to 65, because if you’re 66 and you act like a 46 year old, there’s probably an argument for giving them a ceramic, if you believe strongly in that argument. You know. So that’s, so I think policies have to be carefully worded because if you then go outside of policy and then somebody comes knocking on your door saying, “Why are you doing this?” You’re suddenly going to get stress built up, and you’re just trying to do your best for that one patient who’s sat in front of you and you’re getting

lambasted left, right and centre.” (INT C 218002)

This contrasts with a NICE approach for example, where decisions are made for populations of patients at the national level. When considering population level data, the trends and patterns in the data, including the variation that is observed, can be more obvious. National variation becomes less meaningful for an

individual with a patient who has a specific set of symptoms which need to be treated, given the limits of a surgeon’s personal skill, departmental constraints and hospital funding. This is the situation that most of the surgeons I

interviewed were working under, as described here:

“I may subconsciously be sort of following NICE guidance but… it’s not helpful to me sitting there with a patient, if we are talking joint replacement and threshold for joint replacements? I can't imagine it’s going to be very helpful at all.” (INT C 37011)

One surgeon group varied from the others in these views. At site A, surgeons had an awareness of EBM and research concepts such as statistics, sample size and

standard deviation. They were accustomed to answering questions using a bigger population frame of reference. Therefore, they were perhaps more able to apply this knowledge in their work and scale it down to understand what it meant for their individual patient. Two surgeons from site A gave their account of this:

“They (NICE guidelines)...help you look at cost effectiveness a lot more than I think about in my daily practice as an individual orthopaedic surgeon, because my responsibility during the consultation is directly to that patient whereas actually I do have a responsibility to the NHS to allocate resources appropriately. But it is very difficult to marry those two together in an individual consultation. So it is helpful to have that input there.” (INT C 218009)

“I tell my patients that. You know, I’m giving you a hip which has got the least chance of failure. If they say to me, “Why can’t I have ceramic?” I say, because that’s got a higher revision rate if you look at everybody across the country. So best practice and evidence, hopefully come together, but they don’t always, and price is important. I think we are getting there with the NJR, which is a huge data resource which, you know, is fantastic.” (INT C 218016)

The surgeons working at site A were also keen to stress though that they conduct trials and practice EBM in a pragmatic way, i.e., they wanted the evidence to fit the context so that it worked in practice and not just in academic journals. An academic clinician describes this clearly below:

“So to that extent the research we do will always remain pragmatic and that’s the stats that NIHR have as well and support. You might want to do specialist research in the very early stages when you’ve got a new procedure and you want to find out if it works, but then you get to the point of is it cost effective and when you’re answering those questions you want to know about, does it work in everybody’s hands? So we will always argue that point essentially, it’s not being done in specialist centres it’s got to be done in all centres, for those reasons research will always be pragmatic.” (INT C 218012)

In summary, the surgeons believed that the sources of evidence were contingent and dependent on their particular circumstance. The variation that this

produced was consequential not intentional and reflected their practice in their context. This did not appear to be considered as variation to evidence or best

practice. Instead it was considered as the ‘wider evidence base’ that is available to the surgeons to make decisions.

4.5.4.1 Surgeon perception and beliefs about EBM

In this section I will present further data to support my findings that the decision to operate and the procedure and implant selected are not overtly linked to traditional EBM recommendations. The beliefs, perceptions and values of individual surgeons appeared to be much more influential to practice and the decisions made than traditional EBM. The surgeons decided whether each patient constituted a suitable candidate for treatment, and whether they wished to operate on that patient on a particular day.

Some surgeons reported that difficult operations were emotionally

uncomfortable and this emotive response affected their choice of procedure. For example, this surgeon states that he transfers patients to colleagues when he is not comfortable with a case. He believes that the opinion of his colleagues is importance in his treatment choices:

“If anything gets a bit spicy in the hip arena for me either before surgery and in clinic and I’ve spotted it I’m passing the case on. And, post operatively, I want to know that I've used implants that the colleagues I’m going to refer onto, if I’ve got into trouble, are going to be happy with.” (INT C 37011)

Another surgeon quoted below referenced their emotional responses when making treatment decisions and how these impacted their ability to perform the surgery.

“I know for some people they’re really stressed by it and upset and I don’t think that’s been attended to. Ultimately you don’t have to look after your surgeons but if you’ve got a stressed surgeon doing a slightly difficult operation, I wouldn’t want them operating on me. I’d want them, you know, happy and confident in what they're doing really.” (INT 198005)

In certain situations the emotional response had a positive outcome and was an important factor in decision-making. Surgeons would refer to only performing

surgery that they would be comfortable “doing on my own grandmother” (INT C

198005). Traditional EBM approaches would struggle to deal with this level of

subjectivity and the emotional beliefs of individuals. It appeared that decisions might have been influenced by their attitudes towards patients. For example, this surgeon formed a positive belief that a patient needed surgery so that he could continue his hobby:

“I thought he should have it, so that he can get back on the golf course. That is just as important to him.” (OBS notes site C general)

Although you can appreciate that increased physical function after hip replacement is a valid reason to conduct surgery, the attitude of the surgeon regarding the importance of golf to himself may have played a part in this

decision. This personal projection is innate and might even be unconscious. In a similar way, their opinion about the presence of other diseases and medical conditions affected decisions to operate. They contributed to the symptoms which the patients reported and could increase the risk of adverse events during the surgery. For example, when discussing a patient who had a high body mass index (BMI), this surgeon suggested:

“He (the patient) had a high BMI and therefore is at more risk for surgery and revision… but I can’t discriminate based on that.” (INT C 218008)

Surgical techniques appeared to be aligned to surgical training, but there was a perception that apprenticeship-style training had an important role to play in implant selection in particular. This surgeon describe the process of teaching that “spawned” knowledge throughout generations of consultants:

“Okay, if you’re a teaching hospital, remember I said who I was taught by, so if you can keep the teaching hospital surgeons happy to use your produce, they’ll be training two different trainees a year, plus fellows and everybody else. If every one of those goes away and uses the same kit, you are like spawning a generation of people using your kit. Because I know that you’ll be teaching a generation of new guys coming through the next generation.” (INT C 37010)

hospital site (for example a posterior versus an anterior approach) it appeared to be less important to the surgeons than types of procedure that was conducted, e.g., performing a total hip replacement instead of a hip resurfacing arthroplasty, or a cemented versus a cementless procedure. Different surgical techniques can result in the same clinical outcome and therefore this was less of an area for discussion between the surgeons when reviewing patient cases.

The surgical procedure seemed to be generally open for debate between the surgeons in meetings. This was not the case when examining the decisions made about implant type. These discussions provided the opportunity to observe potential variation in practice as different surgeons selected different options. This included variation within and between the three sites, but also variation as to what the EBM recommendations might be. I observed orthopaedic meetings where the surgeons would discuss treatment plans for operations and noted the following:

“Some of the surgeons at today’s meeting reported not being able to perform either a cemented or cementless replacement because they had not “routinely done them in their previous role”. Others stated that they only carried out one type of procedure purely out of personal preference and beliefs that it was better than another option. One surgeon said “So I’ve changed from cemented to un- cemented for young patients. Why? You could argue because cement is a hassle and it’s an extra 15 minutes, un-cemented is as good as cemented and overall probably can work out cheaper if you do more cases per list. The decision over which procedure to use was not discussed in relation to EBM.” (OBS notes site B. Team meeting)

This choice in treatment options could significantly influence the variation observed in practice. It appeared that variation from the evidence reported in the academic literature was accepted as normal because the evidence itself varied so much. The surgeons implied that their own preferences and established ways of working were a deciding factor in the choice of hip procedure.