Surgeons “overoptimistic” in predicting outcome after back surgery

New research shows that patients are generally less satisfied with the result of their surgery than doctors expect. While surgeons typically predict at least moderate improvement for all patients undergoing back surgery, nearly 40% experience little or no improvement one year after their operation. “This study shows the importance of encouraging a healthy skepticism,” senior author Dr John-Paul Vader (University of Lausanne Medical Centre, Switzerland) told rheumawire. “Both patients and physicians tend to overestimate the outcome of surgery, and it is important to have a realistic expectation.”

The study is published in the June 15, 2005 issue of Spine.Vader says he has participated in a number of expert panels that pointed to this problem. “Surgeons operate and then they don’t generally see the patient one year down the road, so they may assume that no news is good news, but other practitioners see the varying results and may not share the surgeon’s positive viewpoint.” Vader notes that some surgeons he has worked with have been surprised to hear the opinions of other professionals.Vader adds, “While we weren’t necessarily taken aback by these findings, the magnitude of the result did surprise us.” In their paper, the researchers point out that studies of physician predictions are important because the ability to make a correct individual prognosis is a vital component of clinical work. It’s important that physicians look for actual outcomes to test their prognostic skill. Some might be surprised by what they find. In this prospective study, led by Dr Bertrand Graz (University of Lausanne Medical Centre), the investigators compiled patient and physician questionnaires, clinical documentation, and imaging records. Studying physician expectations of surgery and patient outcome, the researchers looked at 197 consecutive patients with low back pain or sciatica. They found that physicians predicted “a great improvement” in quality of life after surgery for 79% of patients and “moderate improvement” for 20%. After surgery, 39% of patients had no “minimal clinically important difference” in back pain despite physician prediction of great improvement. Vader and colleagues observed no significant correlations between physician expectation and various dimensions of patient outcome, and agreement with patient global judgment of one-year outcome was poor (=0.03). However, in a subgroup where the indication for treatment was not considered appropriate, they found physician prediction of great improvement was followed by greater improvement outcome on Short Form-36 mental component score (p=0.05), mental health (p=0.02), and general health (p=0.03) compared with patients where the physician did not predict strong improvement.A “curabo effect?”To explain the positive result of this one subgroup of patients receiving treatment despite not meeting criteria for the procedure, the researchers propose a new term they call the “curabo effect.” Unlike the placebo effect, which refers to patient expectations, the curabo effect would be attributed to physician confidence in his or her own work. The term curabo is Latin for “I shall deliver a good cure,” and the research team links this concept to the self-fulfilling prophecy and quality of treatment alliance discussed in other literature. “This idea is still very preliminary, but we wanted to give our observation a name,” Vader said during an interview.He adds that among the limitations of the work are the “fairly crude” questionnaires used in the study. Vader says it was difficult to quantify outcomes using appropriate language. “What do a lot, some, and none really mean?” he noted. But despite what he refers to as “not very fine-tuned instruments of expectation,” Vader says the results are probably accurate and are supported by previous findings, including a 1999 study by Dr Gabriele Lutz, et al.”It’s important that physicians look for actual outcomes to test their prognostic skill,” Vader told rheumawire. “Some might be surprised by what they find.”(Source: Graz B, Wietlisbach V, Porchet F, et al. Prognosis or “curabo effect?” Physician prediction and patient outcome of surgery for low back pain and sciatica. Spine 2005; 30:1448-1452: Joint and Bone: July 2005.)