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