“Do I really need an MRI?”
“Do I really need to see a surgeon?”
“Is there anything else I can do?”
The New Model: Independent Orthopaedic Triage Assessment before a Surgical Referral.
Every year thousands of Calgarians suffer joint and muscle injuries or experience joint pain.
The vast majority of these patients will see improvements within 30 days and go on to a full recovery.
Regrettably, the longer a pain continues without improvement, the less likely a patient will return to full activity without pain or disability.
Unfortunately pain that persists longer than a 100 days without improvement is considered a ‘red flag’ by healthcare professionals because up to 80% of these patients will likely suffer from chronic pain for the rest of their lives that surgery cannot fix. Simply put, after 100 days of pain, the chances of a return to full activity without pain are low.
Therefore the emphasis of managing muscle and joint injuries is to see improvement in three categories in the first 30 days after injury.
- A reduction in the frequency, intensity and duration of painful flare ups.
- A reduction in use of anti-inflammatory or pain medications.
- Increased ability to do more physical activity with less pain with each passing week.
Regrettably, there are a variety of reasons why patients do not improve in the first 30 or 100 days, including inaccurate diagnoses, inappropriate treatments, insufficient treatments or non-compliance with treatment.
All too often, when patients fail to see improvement the easiest solution is to refer them for an MRI or to an Orthopaedic Surgeon rather than re-visiting the diagnosis, the treatment plan or patient’s compliance.
The consequences of premature MRIs and referrals to Orthopaedic Surgeons are;
1. Increased size of waiting lists of patients who neither needed an MRI or need surgery.
2. Frustration among Orthopaedic Surgeons to see patients who were either incorrectly diagnosed, inappropriately treated or non-compliant and do not need surgery. (Estimated at 80% of patients referred to them).
3. Frustration among patients who need surgery but are forced to sit on long waiting lists clogged with patients who should never been referred in the first place.
4. Frustration among patients who sit on waiting lists with expectations of surgery rather than pursuing other treatments, only to be told they don’t need surgery.
Rather than letting patients drift without improvements in the first 100 days, this model is designed to help family physicians and patients to get an independent and experienced Orthopaedic Triage Assessment as soon as possible and revisit their diagnosis, treatment to date and patient compliance to determine if they really need to see a surgeon, an MRI or whether other treatment options exist.
If you’re a patient and haven’t seen improvement in your muscle or joint pain for longer than 30 days, we invite you to click here and make an appointment for an Orthopaedic Triage Assessment today.
Problems in Alberta Orthopaedics today
1. There are thousands of Albertans who need to see a surgeon “sooner-than-later”, but are stuck on a lengthy waiting list for their first appointment because their referral letter didn’t convey a sense of need or urgency to the surgeon on his / her first reading. These patients are at a high risk of missing a window of opportunity and developing permanent chronic pain or disability that surgery may not be able to help with.
2. There are thousands of Albertans sitting on waiting lists to see a surgeon who will likely never be offered surgery. These patients take up room on waiting lists that could be filled by those who really do need to see a surgeon. Through sitting on waiting lists, with false expectations of a surgical solution, these patients are at a high risk of suffering more pain and disability than they should, if they had only been identified early as ‘non-surgical’ .
Where the current Orthopaedic model is broken
1. Inappropriate or delayed diagnosis and treatment of orthopaedic injuries in the first 100 days post-injury.
The most important step in managing an orthopaedic injury is obtaining the most valid and reliable diagnosis as soon as possible.
If the diagnosis is inaccurate, then any subsequent treatment is prejudiced to miss the target and fail.
If the diagnosis is accurate but treatment is either delayed, inappropriate for the diagnosis or not executed (patient engagement and compliance), this prejudices the patient not to see improvements within 100 days and potentially go on to chronic pain that surgery cannot fix.
2. Inappropriate imaging or inappropriate interpretation creating false expectations that surgery is required.
Although Radiologists are highly skilled at interpreting MRIs, x-rays and ultrasounds, they would openly admit that they are not qualified to make decisions on whether a patient needs surgery or not.
Orthopaedic Surgeons are the only ones who are qualified to decide whether a patient would benefit from surgery or not.
The reality is, the vast majority of patients with an abnormal MRI are neither seen sooner by a surgeon nor are they offered surgery ahead of a patient who does not have an MRI.
Regrettably, today’s waiting lists are crowded with hundreds and hundreds of patients who have abnormal MRI and think they need surgery when they don’t.
3. Inappropriate referral letters or premature referrals to Orthopaedic Surgeons.
Orthopaedic surgeons don’t operate on pain, instead they operate on anatomical lesions (problems) they believe are the likely cause of a patient’s pain and disability.
The goal of surgery is to correct the anatomical problem and hopefully improve a patient’s function and reduce their pain BUT surgery is not without its risks and patients may not see the improvements they expected. Even after fixing the anatomical problem, some patients can continue to experience pain and disability. For this reason, surgery is always a last option and may help to explain why surgeons are cautious in proceeding to surgery without exhausting all other forms of treatment.
Orthopaedic surgeons receive dozens and dozens of referral letters every week from family physicians on behalf of their patients.
Surgeons rank referral letters based on the probability of offering surgery to a patient.
After reading your referral letter – if a surgeon has any doubt whatsoever over (a) the anatomical cause of our pain or disability, (b) whether you’ve been given a well designed treatment plan for your condition or (c) whether you’ve followed the treatment plan (including exercise) for a sufficient period of time, then you could sit on a waiting list for years only to be told you don’t need surgery.
Regrettably, today’s waiting lists are crowded with hundreds of patients who were prematurely referred without the proper treatment or a problem that can’t be fixed through surgery.
The New Model of Orthopaedic Care
1. Experienced and Independent Orthopaedic Triage Assessments ASAP.
If a patient is failing to show significant improvement within the first 30 days or there is any doubt over the diagnosis or treatment plan, family physicians and patients are encouraged to contact us and make an appointment.
The goal of this assessment is to confirm a valid and reliable diagnosis as well as evaluate the appropriateness of the treatment plan. If revisions are required, recommendations will be provided to the family physician.
2. Appropriate diagnostic imaging, at the appropriate time and with appropriate interpretation.
In the case of an orthopaedic condition, an x-ray is considered essential to the differential diagnostic process to rule out a bone related injury (i.e. fracture) or disease (i.e.sarcoma).
Beyond an x-ray, we believe that any subsequent diagnostic imaging or test, should be the result of consultation and agreement amongst all treating clinicians that the test or image is warranted to help clinical decision making. Tests and images do not dictate a diagnosis or treatment, they are only tools to help clinicians in their decision making.
In addition, we believe that all imaging must be accurately interpreted for patients for it’s clinical relevance by appropriate clinicians, not merely reporting abnormal findings that have little clinical relevance to the condition at hand.
In the event a physician or patient is questioning whether a pre-surgical consult MRI is indicated or is looking for an independent and experienced consult, we encourage physicians and patients to contact us and make an appointment. Our impressions will be forwarded to the family physician.
3. Appropriate well-written referrals at the appropriate time to the appropriate healthcare professional.
In the event a patient has followed an appropriate treatment plan for a sufficient length of time AND is not meeting expectations on-time, then we invite family physicians and patients to contact us for consideration of whether the patient is a surgical candidate or not.
In the event a surgical referral is indicated, we will author a comprehensive referral letter to the most appropriate surgeon for the given condition.
In the event a surgical referral is not indicated, we will author a report with recommendations to the referring family physician.
Three Scenarios
We conduct comprehensive orthopaedic assessments to determine if a patient has (1) exhausted all appropriate non-surgical treatment options, (2) to calculate a Joint Severity Score for a patient’s condition and (3) to determine the most appropriate ‘next’ steps for the patient.
Scenario #1 - High Probability of Surgical Solution
If a patient (1) scores high on our Joint Severity Scale and has (2) followed a well designed treatment plan for their condition and for an adequate trial with no improvement and (3) may benefit from a known surgical procedure (i.e. repair, reconstruction, debridement, replacement, fusion, etc), then chances are that they will be offered a surgical procedure. In this case, we will write a comprehensive referral letter on behalf of the patient to the most appropriate orthopaedic surgeon for their condition. The referral letter will be forwarded to the patient’s family physician for their records and so they can forward the letter as well.
Scenario #2 – Surgery would be premature at this time.
If a patient (1) scores high on our Joint Severity Scale but (2) hasn’t followed a well designed treatment plan for an adequate period of time, or (3) it’s unclear whether a surgical procedure can help, then chances are that the patient will likely be put on a waiting list for an initial appointment and ultimately will not be offered surgery. Rather than wasting a year or more to learn this news, we’ll write a letter to the patient and their family physician with recommendations on the most appropriate procedures, treatments and rehabilitation exercises that may help the patients improve and no longer need to see a surgeon.
Scenario #3 – Surgery is not the answer.
If a patient (1) scores low on our Joint Severity Scale and (2) hasn’t followed a well designed treatment plan for an adequate period of time, or (3) it’s unclear whether a surgical procedure can help then chances are they will be rejected immediately and not be put on a waiting list to see a surgeon. In this situation, we will write a letter to the patient and their family physician with recommendations on the most appropriate procedures, treatments and physiotherapy exercises that may help the patient see improvements and no longer need to see a surgeon.
The Benefits To You
At the end of an assessment, you will have answers to the following questions and these will be communicated to your family physician.
1. Is my diagnosis accurate?
2. Has the treatment I’ve received considered appropriate within the orthopaedic community?
3. Have I exhausted all non-surgical treatment options?
4. Do I need further tests or treatments? If so, what tests or treatments?
5. What is the probability of being offered surgery if I saw a surgeon today?
6. What can I do to prevent surgery and improve the quality of my lifestyle?
The Benefits to Alberta Health
Orthopaedic Triage Models, such as this have been used in other medical disciplines and healthcare systems in the world and offer the followng benefits;
1. Reducing the volume of patients with unrealistic expectations of a surgical solutions caused by premature or incomplete referrals to Surgeons.
2. Early identification and re-routing of non-surgical patients to appropriate treatment and rehab exercise programs, that may improve their condition and the risk and the impact of developing chronic musculoskeletal pain.
3. Reduced waiting lists for Orthopaedic Surgical consults (unclogging waiting lists of non-surgical patients)
4. Reduced waiting lists, means that high quality referrals may be seen earlier, thereby reducing the potential impact of chronic pain and disability, compounded by sitting on a lengthy waiting list for an initial surgical consult.
5. Reduced demand for premature MRIs.
The bottom line: Get answers to your questions. Get a plan and move forward.
If you’ve got chronic joint pain that isn’t getting better, we invite you to make an appointment to see Terry Kane (for more information, click “About Us“).
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