"Building a foundation of trust".

Jens Chapman, MD

Trust is one of the most important components of an intact care provider-patient relationship. Of the many issues brought to the forefront by global changes affecting health care delivery, the erosion of trust between patient and physician has been identified as one of the most serious developments as it affects the core of care delivery.

In his book, “On the Take” written in 2005, Dr Jerome Kassirer identified several possible causes for this loss of trust between patients and physicians, such as commercialization of medicine, increased reliance on technology and excessive sub-specialization, while absconding general responsibility for the patient as a whole.1

In the lead article of a recent Focus Issue in Spine© titled, “Do No Harm: The Balance of ‘Beneficence’ and ‘Non-Maleficence’”, Dr Gunnar Anderson and co-authors identified the subject of complications and a lack of clear and effective communication from medical providers with their patients as a major foundational aspect in the erosion of trust.2 They suggested a renewed dedication to straightforward reporting on complications from physicians in research reporting, as well as patient disclosures as an important step in reestablishing trust, by following the ancient wisdom, “Honesty is the primary foundation of trust in any relationship”.

In the same Spine Focus Issue, Dr Mark Dekutoski et al identified a lack of readily available data on even common complications in spine surgery.3 While this should not be used as an excuse for not disclosing potential complications in spine surgery to patients, it seems fair to demand an increasing effort from medical publications and educators to make readily available realistic data on complications. This would go a long way to serve as a platform for improved and clear physician-patient interactions and to create realistic expectations on results for patients, care providers, insurance carriers, and government agencies alike. It goes without saying that establishing realistic expectations—from complications to outcomes—is in everyone's best interest.

In current practice, a commonly heard response to a patient question on outcomes may be, “There is a fifty 50% chance that this procedure will alleviate your pain”. While well intended and certainly not overly optimistic sounding, the factual basis for such a statement is often dubious and usually has been handed down from attending to resident for many years without really knowing if there is a basis for the answer. It may be ‘surgical folklore’, an easy and quick response to a difficult question. We may believe that it is true but have never really verified its veracity.

What if your answer was based on a true critical appraisal of clinical evidence available? And what if that answer was not clear cut for your patient? Our patients look to us for guidance. Even when the evidence does not provide clarity, we are duty-bound to provide our best, honest appraisal of that evidence. This is the foundation of building the trust with our patients and our colleagues.

Giving our patients information based on evidence from current clinical research begins a two-way conversation that could lead to a trusting relationship between patient and clinician. We gain the opportunity to learn more about our patients as we begin to engage them in the decision-making process, weighing our options based on the most current honest assessment of the outcomes.

In this electronic age, patients have access to a plethora of information. To help them put information in the appropriate context, we need to rely on an honest assessment of what is ‘surgical folklore’ and what is truly based in evidence.

One of the main objectives of the EBSJ is to help surgeons build trust with patients by providing an honest appraisal of evidence. We identify gaps in the evidence and assist authors to bridge these gaps and enhance the quality of the studies they design.

To this end, our second issue of the EBSJ includes:

Three original research submissions encompassing a range of topics. Dr Michael J Lee, from the University of Washington Medical Center, presents two multivariate analyses; one on the “Risk Factors for Cardiac Complications after Spine Surgery” the other on the “Risk Factors for Pulmonary Complications after Spine Surgery”. Dr Marcelo Gruenberg, from the Italian Hospital of Buenos Aires in Argentina, addresses the “Influence of anatomy (normal versus scoliosis) on the free-hand placement of pedicle screws: Is misplacement more frequent in patients with anatomical deformity?“

To improve the methodology and reporting of future studies, we support research with an editorial perspective that help us understand the limitations of the studies. This in turn will improve both the credibility and quality of the evidence in spine care and will help give our patients the best possible outcomes.

Our two systematic reviews in this issue take an in-depth look at two very contentious areas associated directly and indirectly with complications. First, Dr Paul Anderson from the University of Wisconsin addresses the question, “Does lumbar decompression in overweight patients assist in postoperative weight loss?” Next, Dr James Schuster, of the University of Pennsylvania, addresses whether “Chemical Antithrombotic Prophylaxis is Effective in Elective Thoracolumbar Spine Surgery”.

Our evidence-based case discussion in this issue was submitted by Dr George Ibrahim, from the University of Toronto. Dr Ibrahim discusses “Arachnoiditis ossificans associated with syringomyelia: An unusual cause of myelopathy”.

As an outlook of ongoing AOSpine research activities, we are honored to include seven abstracts presented at the 8th Annual AOSpine North America Fellows Forum held in Banff, Canada, this past April.

Finally, our educational piece covers study design basics. Here we describe the strengths and weaknesses of three common study designs: the randomized controlled trial, the cohort study, and the case series. Understanding the potential biases that can result from each of these study types can assist researchers in avoiding such biases and creating higher quality evidence.

EBSJ is dedicated to finding, describing, and developing the highest quality evidence in spine care. In doing so, we facilitate the communication of an honest response based on critical evaluation of the research and not on folklore. Not only do we build trust with our patients, but that trust and credibility extends to colleagues outside of the spine-care arena.

I hope you enjoy this issue of the EBSJ. And the next time a patient asks what success rate is for the surgery they are considering, think about responding, “Based on the most current evidence in this field…” and see where the conversation leads you.