Editorial: The Shortcomings and Harms of Using Hard Cutoffs for BMI, Hemoglobin A1C, and Smoking Cessation as Conditions for Elective Orthopaedic Surgery.

Abstract

Most orthopaedic surgeons I know pride themselves on engaging with their patients as individuals. Many bridle at the idea that trendy, shared decision-making models are somehow something new, as they feel they’ve been sharing decisions with their patients all along; I believe many of them are right about this. And yet some of those same surgeons adopt heavy-handed approaches that seem to misunderstand how surgical risk really works when they insist on binary cutoffs for parameters like BMI, hemoglobin A1C, and cigarette smoking as a condition to offer elective surgery to their patients. When a surgeon unilaterally defines and applies such cutoffs in practice, by definition shared decision-making cannot take place. When the risk factors only seem modifiable, but in fact are not (or when they are only minimally modifiable), the use of rigid thresholds may become coercive. For these and other reasons, orthopaedic surgeons should stop using hard cutoffs for parameters like BMI, hemoglobin A1C, and smoking in the context of deciding whether to offer a patient elective surgery. The idea of using surgery as a “carrot” to nudge patients towards healthier behaviors—with the endpoint of offering an elective procedure the patient seeks as the inducement for efforts made—is entirely reasonable. When done with care and sensitivity, it can be one portion of a healthcare partnership in which both parties take some responsibility for achieving a result that both will be pleased with. But surgeons don’t have to operate on anyone we don’t want to treat, and increasingly we’re being held to financial account for the complications that result from our elective procedures. I believe this combination can result in surgeons setting unrealistic or impossible health goals for patients who seek particular interventions, and withholding those interventions from patients when they inevitably (or nearly inevitably) fall short [9]. This strikes me as potentially coercive. It’s also not well-supported by the available evidence.