Editorial Commentary: Causes of Patient Dissatisfaction May Be Modifiable

In his 1878 novel titled Anna Karenina, the first sentence that Leo Tolstoy wrote was “Happy families are all alike; every unhappy family is unhappy in its own way.” We, as arthroscopic surgeons, might be grateful (even relieved) for our happy or satisfied patients. After all, a good result validates our good judgment and surgical skills. However, the unhappy or dissatisfied patient challenges us. Happy patients receive the same procedures for similar indications as unhappy patients—perplexing and vexing! However, adapting the quote from Tolstoy, we can suggest that “Satisfied patients are all alike; every dissatisfied patient is dissatisfied in their own way.” Concerning the last part of Tolstoy’s quote, we need to learn the reasons why patients are dissatisfied. As a means to standardize treatment, we try to categorize the patients displeasure: adverse events, poor patient-reported outcomes, failure to meet patient acceptable symptomatic state, didn’t return to sport or work at the same level, didn’t meet patient’s expectations, etc.

Optimizing preoperative screening and treatment improves outcomes. Take smoking, for example: nonsmokers tend to have better surgical outcomes than patients who smoke. Patient-centered care recognizes patient-specific factors. As Ostermeier and Siebert write in their Editorial Commentary, “we are painfully aware that there are multiple “special factors” out there that influence our even most sophisticated efforts to heal our patients.” Fortunately, by increasing our body of knowledge about each patient, we will be better informed to make our preoperative decisions.

Hall, Dandu, Sonnier, Rao, Holston, Liu, Freedman, and Tjoumakaris published an article titled “The Influence of Psychosocial Factors on Hip Surgical Disorders and Outcomes After Hip Arthroscopy: A Systematic Review.” Within their systematic review of 9 investigations, the authors find consistent evidence supporting the association between negative psychological function and worse preoperative and postoperative outcomes for patients with hip disorders. Five included investigations found a lower rate of achieving minimal clinically important difference with lower mental health status. As a systematic review, the investigation doesn’t add to the findings of the source investigations; rather, the value added by the authors is large combined numbers, summary of pertinent findings, and an expert level perspective.

Like the smoking example, this systematic review makes us question whether better mental health treatment leads to better outcomes following hip arthroscopy. Severity of the condition matters, at least for depression. Greater levels of depression impact patient-reported outcomes to greater extent than milder depression.^, Mental health is complex and multifaceted, with many diagnosis that are not fully considered by this and other investigations that treat mental health as a categorical variable. Either the patient has a mental health condition or they don’t. In reality, depression and anxiety, two of the most commonly considered diagnoses, exist on a spectrum from mild to incapacitating. From this and other similar investigations, effective treatment of mental health conditions and their effect on patient-reported outcomes are not fully explored. While our happy patients reward our skill, knowledge, and experience with their positive outcomes, the unhappy patient with their multiple presentations might be where we can make most improvement in patient care. As Dr. Aoki stated in his Editorial Commentary for the work of Sochacki et al., the findings “…demonstrates the close relationship between psychological well-being and pain/function. In orthopaedic surgery we tend to be mechanically driven in our patient approach, but we would all benefit from paying more attention to the psychosocial issues in our patients and refer for counseling (or other indicated treatment) if appropriate.”