Difficulties associated with musculoskeletal decision-making
Currently, clinical decision-making is predominantly idiosyncratic, with
the risk of unnecessary imaging and overuse of surgical funding. In New
Zealand (NZ), elective surgeries have increased by around 30% from
2010-2015.5 This situation is not unique to NZ: the
overuse of expensive musculoskeletal tests and treatments is considered
a common problem.2,3,6 Factors which have been
identified as contributing to the problems of increasing numbers of
patient referrals include clinicians with less experience, and
clinicians working in isolation.4
The challenges in primary care are significant, with clinicians having
limited time for decision-making and patient information being complex
to synthesise. Additionally, processing information is complicated by
styles of communication, patients being unable to accurately recall
pertinent information, and providers misinterpreting the information.
Decision-making in musculoskeletal conditions is based upon a mix of
hypothetico-deductive reasoning and pattern recognition, regardless of
whether the decision-maker is a novice or an expert.7Irrespective of whether a novice or expert; this leads to
decision-making variability.
Clinical guidelines have been developed as an important tool to enhance
decision-making; however, these are often divisive. Guideline use can be
hindered for several reasons, including lack of awareness, clinical
knowledge beliefs, and additionally by not being up to date. Updating a
guideline requires considerable expertise8 and unless
regularly updated the guideline becomes redundant. Guidelines have their
place, however, they are not all-inclusive.
Other factors affecting decision-making include both the significant
influences of the patient and the health provider, with each having
their perspective and beliefs on the benefits of prospective treatment
pathways. This introduces decision-making bias: for example, the patient
may be fixed on one solution, such as imaging, and may compel the health
provider to feel obliged to refer for imaging.
Nonetheless, hypothetico-deductive reasoning, intuition, and the use of
clinical guidelines do not enable consistent transparent decision-making
as evidenced by the increasing numbers of imaging requests and
surgery,3,9 despite the apparent effectiveness of
conservative rehabilitation.10-12 Regardless of the
clinical pathway, it is recognised that clinical outcomes can be
variable. A recent study found little difference between operative and
non-operative treatment groups for full-thickness tears of the rotator
cuff, using the quality-of-life index score. At 5 years post enrolment
in the study, 75% of participants responded to conservative treatment
and remained successfully treated.10