Dissecting a medical decision

When people receive a serious diagnosis or face an important medical decision, most instinctively start looking for the "best" doctor.

They ask friends.

They search Google.

They join Facebook groups.

They read forums.

Eventually they find the expert they trust, pay a considerable amount of money for a consultation, spend fifteen or twenty minutes together, and leave with a recommendation.

This is generally considered good healthcare.

I disagree.

Not because expertise isn’t valuable - it is.

But because expertise alone is not enough.

The quality of a medical decision depends not only on who is making it, but on how the decision is made.

Surprisingly, that process is often hidden from the very person who has to live with the consequences.

This really hit me when I was chatting to a friend of mine recently who fractured their knee playing sport.

He underwent surgery, and a metal implant was inserted to stabilise the bone while it healed.

The operation was successful.

The fracture healed.

Life moved on.

About a year later he returned to playing sport, but every time he ran he developed pain and a limp.

It wasn’t severe enough to stop him living his life, but it was frustrating enough that he began wondering whether the metal implant was responsible.

Should it be removed?

He booked an appointment with a well-known orthopaedic professor.

After reviewing the scans and examining the knee, the professor said,

“I’d leave it alone.”

A few weeks passed. The symptoms still bothersome, he returned to the surgeon who originally performed the operation - another well-known high-throughput surgeon.

He reviewed the same knee and said,

“I think we should take the implant out.”

You see the problem?

Both surgeons sound certain.

Yet the recommendations are literally exact opposites.

Unless you believe one surgeon is simply incompetent, their disagreement accidentally exposed something deeper about each individual consultation.

They disagree because somewhere between examining the patient and making the recommendation, each surgeon made a series of judgements under uncertainty.

Those judgements were different - so much so that they completely flipped the recommendation.

Yet that reasoning and assumptions that led to those recommendations were never shown to the patient.

Instead, what the patient heard was a confident recommendation.

Imagine my friend had accepted the first recommendation and gone home.

He would never have known that another equally experienced surgeon would have recommended the exact opposite.

He would understandably have assumed the recommendation was “the answer”, rather than the end result of a chain of assumptions, judgements and estimates that another expert interpreted differently.

That is not a robust healthcare system.

Let’s be honest - this makes no sense. That is exactly the information a patient needs in order to decide whether surgery is worthwhile.

The patient is the one who has to live with the consequences of the decision.

My friend could decide to undergo surgery to remove the implant.

Or he could leave it where it is.

Or he could try physiotherapy or another conservative approach first.

The consequences are potentially wide ranging:

If he opts for surgery…

• the symptoms might disappear completely,
• they might improve only slightly,
• nothing might change,
• they might develop a complication that leaves them worse than before.

If he opts not to…

• the symptoms might gradually settle anyway,
• they might remain exactly the same,
• physiotherapy might solve most of the problem,
• they might simply learn to live with the symptoms, knowing they are not causing long-term damage.

You may be starting to see why I think the process of decision making needs a radical upgrade.

Imagine our alternative world where this is how we work through the same decision:

The doctor’s first job is to understand where the symptoms come from and (after ruling out dangerous possibilities), and specifically are they related to the implant or not?

If the answer is no, then removing it - even with perfect surgical technique - is not going to help.

That sounds obvious. Yet remarkably often the consultation skips straight to discussing treatment before properly working through this question.

It is unlikely that the answer will be certain either way - so it is necessary to try and tease out the likelihood that the implant is the cause of much or all of the symptoms.

History taking can help push us in one direction or other:

• Where exactly is the pain?
• Can the patient point to one specific screw?
• Or is it spread throughout the knee?
• Does it occur while kneeling?
• Only while running?
• Only after thirty minutes?
• Has it been present continuously since surgery?
• Did it disappear for a year before returning?
• Each answer changes the probability.

Then comes the examination.

• Does pressing directly over the implant reproduce the pain?
• Is there evidence of tendon irritation?
• Muscle weakness?
• Joint instability?
• Restricted movement?
• Next comes imaging.
• Has the fracture healed completely?
• Is one screw prominent?
• Has the implant loosened?
• Is it irritating nearby structures?

Then comes perhaps the most neglected question of all. What else could explain these symptoms?

• Maybe the cartilage was damaged during the original injury.
• Maybe the muscles around the knee never fully recovered.
• Maybe there is early arthritis.
• Maybe scar tissue is responsible.
• Maybe the patient’s running mechanics changed after the injury.

Every plausible explanation competes with the implant as the cause.

The stronger those alternative explanations become, the less likely it is that removing the implant will solve the problem.

This entire process exists to answer one question: How likely is it that the implant is actually the culprit?

Reasonable doctors may disagree.

One might conclude the implant is highly likely to be responsible.

Another might think it is only a minor contributor.

What isn’t acceptable is for the patient never to be shown where those conclusions came from.

Maybe they didn’t even properly run through this process?

Maybe they did, but some of the reasoning rests on incorrect assumptions resulting from miscommunication that the patient could fix?

Suppose both doctors agree that the implant probably is responsible.

There is still another entirely separate question: How difficult would it be to remove the implant?

• Has bone grown around the implant?
• Would removal be technically straightforward?
• Is it close to important nerves or blood vessels?
• How high is the risk of infection?
• Bleeding?
• Fracture?
• How long would recovery take?
• Would the patient need months away from work or sport?

Again, reasonable doctors could disagree.

Again, the patient deserves to understand why.

Only now are we in a position to make a recommendation.

Notice how much work has happened before anyone has even answered the original question.

Perhaps Doctor A concludes:

“I think there is a high chance the implant is causing your symptoms. I think removal is technically straightforward, carries relatively low risk, and has a good chance of improving your symptoms.”

Doctor B reaches a different conclusion.

“I think the implant is unlikely to be the main cause. I suspect most of your symptoms come from the original injury itself. Although the operation is feasible, I think the chance of meaningful improvement is relatively small.”

Now the recommendations become interpretable.

It also shows that a completely different recommendation could be produced from reasonably small changes to each stage of the reasoning process:

• The extent to which the implant is actually responsible.
• The level of risk associated with its removal.
• The expected improvement from a successful surgery.

Each disagreement shifts the balance.

Each disagreement can legitimately lead to a different recommendation.

If this chain of reasoning remains hidden, the recommendation may be:

• great, because it is based on sound reasoning,
• terrible because the reasoning was good, but it was based on flawed assumptions,
• a guess, because they didn’t go through the process at all

Now comes the final step.

Ironically, this is often treated as the least important.

In reality, it is one of the most important.

What does the patient actually want?

One patient might say: “If there’s even a small chance this surgery fixes the problem, I’m willing to take that chance.”

Another might say: “There is only a small chance this surgery will help?! Absolutely not. If we’re not even confident the implant is causing my symptoms, I’d rather avoid another operation.”

Neither patient is right. Neither patient is wrong.

They simply value the trade-off differently.

One is more willing to accept surgical risk for the possibility of improvement. The other is not.

That isn’t a medical judgement. It is a personal one.

Only the patient can answer it.

Doctors can estimate probabilities. They cannot decide how much risk is worth taking for someone else’s life.

This example isn’t really about orthopaedic surgery.

It could just as easily have been about abdominal surgery.

Or cancer treatment.

Or starting lifelong medication.

Or prostate screening.

Or whether to continue chemotherapy.

The setting changes.

The process does not.

Good medical decisions require us to answer a series of difficult questions.

• What is most likely causing the problem?
• What are the realistic options?
• What are the likely benefits and harms of each?
• How uncertain are those estimates?
• Where do experts disagree, and why?

Finally, given all of that...

• What does this particular patient actually want?

This is what good healthcare should look like.

Not simply finding the most famous expert.

Not blindly accepting the recommendation.

Not collecting more opinions until someone tells us what we hoped to hear.

A transparent process.

Clear reasoning.

Explicit uncertainty.

And a decision that genuinely reflects both the best available evidence and the values of the person who has to live with the outcome.

If this were my knee, this is the process I would expect before making a decision.

I would not simply assume it had happened because I had seen an expert.

Too often, it hasn’t.

And even when much of the thinking has occurred, it remains hidden inside the doctor’s head.

Patients are then asked to consent to treatments without ever seeing the reasoning that led to the recommendation.

That is not good enough.

At the Decision Clinic, this is the problem we are trying to solve.

Not by replacing experts. Not by collecting endless opinions.

But by making the reasoning itself transparent.

Because better decisions rarely come from simply asking more experts what they would do.

They come from understanding why they think what they think, where the uncertainties lie, and how those uncertainties fit with the goals, preferences and values of the person whose life will ultimately be affected by the decision.

To me, that is what better care looks like.