By Mary O’ Connor, MD
As an orthopedic surgeon, I am often asked why I co-founded Vori Health, a company that promotes non-surgical musculoskeletal care. I am not anti-surgery; I know first-hand that the right operation can dramatically improve quality of life for the right patient. What I am is anti-inappropriate surgery.
There is no surgery without risk of postoperative complications for patients, some of which can be devastating. Patients should only be exposed to these risks when surgery is warranted, but far too often, this is not the case. Studies show that more than one-third of knee replacements and 50 percent of back surgeries are inappropriate (HBR, 2017; Riddle, 2014). Even our most elite hospitals ranked in US News are complicit in these statistics. Given the dramatic post-pandemic surge in elective orthopedic surgeries—with a 176 percent and 139 percent increase in hip and knee replacements projected by 2040, respectively (Shichman, 2023)—inappropriate surgeries should be declared a public health crisis.
Even payors are rumbling about the financial implications of these forecasted upswings in expensive procedures. For the sake of all involved, it is time to break the costly and ineffective cycle of unnecessary surgery. It not only strains our resources but also harms the patients we took an oath to protect. As a society, we must address the underlying causes of unnecessary surgery and prioritize better care models that put patients first.
Exposing the need for more shared decision-making
There are several root causes of unnecessary surgery, including a broken healthcare system reliant on the financial margin generated by surgical procedures for economic stability. But how we as clinicians talk—or don’t talk—to patients also plays a significant role.
Historically, shared decision-making (SDM) between clinicians and patients has not been the norm in medicine, including orthopedics and spine care. As a result, many patients go to the operating room without truly understanding alternatives to surgery or how possible outcomes may or may not align with their individual values and goals. Surgeons often do not take the time to listen to, or prioritize listening to, patients sharing their preferences. As a result, patient preferences and goals rarely make it into the clinical decision-making process.
I recall a very elderly woman with terrible knee arthritis who came to me for a second opinion regarding knee replacement surgery recommended by another surgeon. Her adult son and daughter accompanied her and wanted her to proceed with the surgery so she would walk more; the patient, however, was perfectly happy with her functional level and had no desire to have surgery. Doing surgery on this woman would have been inappropriate. Moreover, her outcomes would likely have been suboptimal—I do not think she would have engaged with the necessary postoperative physical therapy essential for a good outcome. She would have been one of the 30 percent of patients who are dissatisfied with the outcomes of their total knee replacement procedures (Canovas, 2018). Thankfully, her adult children were receptive to my non-operative recommendation. Identifying patient preferences is essential to avoiding inappropriate procedures.
Even the American Academy of Orthopedic Surgeons recognizes the lack of SDM as a critical pain point in the orthopedic space. In a review article, co-author Robert A. Probe, MD, FAAOS, highlights how widespread the problem is among fellow orthopedic surgeons: “Our experience suggests that many orthopaedic surgeons lack an understanding of how to actually engage in SDM or received insufficient communications skills training in medical school and residency. While some physicians can naturally communicate and already incorporate SDM in patient care, there are still a lot who don’t” (AAOS, 2020).
Keeping patients out of the operating room unnecessarily requires both a fundamental shift that puts patients back at the center of their treatment decisions, as well as adequate access to effective non-operative care.
Changing gears to patient-centric, doctor-led care
In my many years practicing as a Mayo Clinic trained orthopedic surgeon and as Chair of the Department of Orthopedic Surgery at the Mayo Clinic in Florida, I learned a simple but powerful lesson: For medical care to be successful, the needs of the patient must come first. When patients have a seat at the table alongside their clinicians, they can more clearly understand their treatment options and choose the one that is best for them.
My experience at numerous medical centers taught me that traditional care provision often struggled with this lesson—not for lack of good intention, but rather by misunderstanding the needs of the patient. We built Vori Health to redress this and place the patient at the heart of the care team. When patients come to Vori, they get access to medical doctors who specialize in non-surgical care, plus physical therapists, nutritionists, and health coach navigators—a true care team that looks at the whole patient, not just their knee or back. And with convenient telehealth visits, patients can gain this multi-disciplinary support from the comfort of home.
Truly personalizing care for back, knee, and joint pain means getting to know the person. Our care teams spend time actually speaking to patients about quality-of-life goals and preferences before personalizing treatment accordingly. We focus on what matters to our patients, not just what is the matter with them. We make sure patients understand their options and recommend surgery only when it is clinically appropriate and aligned with the patient’s preferences and values.
As evidenced by our experience with patients with low back conditions—with less than three percent referred for surgery and more than 91 percent reporting improvements in pain—Vori Health’s patient-centered model is proven to improve outcomes while reducing unnecessary surgeries and costs.
Want to learn more about how Vori Health can provide effective, non-surgical MSK care for your population? Connect with us today.
- Shichman, 2023: Shichman I, Roof M, Askew N, et al. Projections and Epidemiology of Primary Hip and Knee Arthroplasty in Medicare Patients to 2040-2060. JB JS Open Access. 2023;8(1):e22.00112.
- BCBSA, 2019: Planned Knee and Hip Replacement Surgeries Are on the Rise in the U.S. (2019, January 23). Blue Cross Blue Shield Association, https://www.bcbs.com/sites/default/files/file-attachments/health-of-america-report/HoA-Orthopedic%2BCosts%20Report.pdf
- Canovas, 2018: Canovas F, Dagneaux L. Quality of life after total knee arthroplasty. Orthop Traumatol Surg Res. 2018;104(1S):S41-S46.
- AAOS, 2020: Shared Decision-Making Empowers Patients with Information and Options to Benefit Bone and Joint Care [Press Release]. (2020, December 8). AAOS, https://www.aaos.org/aaos-home/newsroom/press-releases/shared-decision-making-empowers-patients/
- Riddle, 2014: Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol. 2014;66(8):2134-2143.