Navigating patient selection in Orthopaedics

As consumer-focused health insurance plans become more popular, patients play an increasingly active role in selecting their surgeons and healthcare providers. This shift presents new challenges for orthopaedic surgeons – not only in being chosen by patients, but also in how best to navigate patient selection. Surgeons must be more vigilant in assessing whether a patient is truly suitable for surgery, not just clinically but holistically. They must also consider whether the procedure is one they are clinically comfortable with.

While patient selection has traditionally been more associated with cosmetic surgery, the increase in elective procedures in other specialties and expanding treatment options means patients are seeking interventions, not just for urgent medical need, but for quality-of-life improvements.

Choosing the appropriate intervention requires consideration of all patient factors and aligning patient-specific needs with established treatment indications, including taking no action. When treatment is recommended, surgeons are advised to be wary of operating on all-comers or expanding surgical interventions beyond their remit or expertise.

Depending on how a patient has been made aware of your surgical practice, for example through online research or word-of-mouth recommendations, this may alter your approach to understanding their expectations and to what extent these can be met.

This article discusses important issues to look out for, key factors to look into, and finally, how best to protect yourself.

Key considerations in patient selection:

Patient selection involves aligning patient-specific needs with appropriate intervention, while also evaluating whether you are the right surgeon for the case.

What to look out for:

When assessing a patient who presents to you, keep the following key characteristics in mind:

Self-awareness: Reflect on whether the procedure is one you are clinically comfortable performing. Is it outside your area of expertise? If in doubt, involve colleagues for second opinions, shared care, or refer for further input – doing so is not just good practice, but also a protective measure.
Unrealistic expectations: Be cautious of patients who expect dramatic improvements or rapid recovery.
Disregard for risks or urgency: Watch for patients who rush decisions or dismiss alternatives.
Non-compliance: Consider a history of missed follow-ups or poor adherence to post-op care such as physiotherapy.
Mental health history: Look out for indictors of chronic pain, OCD or mood disorders that may affect outcomes or exacerbate pain.
Serial patients: Those who have seen multiple surgeons seeking a specific outcome or are known to you to be ‘serial complainers’.

Key factors to investigate:

Referral Pathway: Why did the patient come to you or how did they come to you if not through onward referral? Have they sought out objective evidence in support of the treatment they are seeking?
Surgical history: Number and outcomes of previous procedures; how did they respond to previous surgery, even if unrelated?
Pain profile: History and response to previous analgesia may offer insight into or provide an indication of their pain threshold.
Healing potential and risk factors: Consider psychosocial factors and comorbidities. Explore less invasive options, nonsurgical treatment, or offering no intervention where appropriate.
Expectations: Are they realistic given their age, activity level and recovery/healing potential? Are they an active sportsperson with hopes of returning to competition? Are the desired improvements limited by factors outside your or the patient’s control, such as age or comorbidities? Take time to investigate the patient as a whole, understand their motivations, and don’t be afraid to clarify if expectations are unrealistic.
Holistic view: Sleep hygiene, stress management, exercise, and diet can have a significant influence on recovery.

Ultimately, if the surgeon and patient decide to proceed with surgery despite known negative risk factors, it is essential to explain those risks and set appropriate expectations.

Both of these sections can be summarised into two key strategies: proper patient selection and choosing the right treatment:

Individualised consideration of patient factors such as patient history and medical non-compliance (quantifying risk) will lead to better selection criteria. Quantifying these risk factors is important to understanding the patient holistically.
Choosing the right treatment through exploring the clinical considerations, like the patient’s healing potential and your own self-awareness, is of equal importance.
Optimising clinical outcomes requires a structured approach to clinical decision making.

ow best to protect yourself:

Get colleagues involved – obtaining a second opinion, and documenting both the findings and any discussions, can go a long way in both your patient assessment and overall outlook.
Document all patient discussions thoroughly – particularly those regarding treatment options, risks and expected outcomes, and follow this up in correspondence to the patient and their GP.
Always present the option ‘to do nothing’.
Provide patients with a cooling-off period to go away with and review procedure-specific information regarding risks and recovery.
Provide the patient with comparative data (e.g. infection rates, dislocation rates or revision rates in joint surgery). This will ensure the patient is suitably informed both on the intended procedure and the operating surgeon.
For paediatric cases , appraising the parents is as important as engaging the child.

Ultimately, a balance must be struck between assessing the patient and assessing yourself. Allow time for these discussions to take place and ensure they are documented comprehensively. Surgeons must educate patients thoroughly on risks and recovery, and guide them toward realistic and safe treatment plans. If this cannot be achieved, reconsider whether the patient or procedure is appropriate.

If you have any further questions regarding patient selection, please refer to the BMA or GMC for guidance.