Relevant TDF domains | Specific belief | Facilitator or barrier | Example quote (participant code) | Frequency out of 20 |
Knowledge | I am aware of the literature that up to 20% of patients do not have a CMI from TKA. | Facilitator | ‘I think 22 per cent is the high end. But there are a lot of different papers that all suggest 10, 15, 20 per cent’. (012) | 19 |
I think that this % is lower in my patients. | Barrier | ‘I don’t count it, but I think around 10 per cent would be saying they aren’t entirely satisfied by surgery’. (016) | 17 | |
Any improvement in pain is still an improvement; it depends how you define ‘meaningful’. | Barrier | ‘If the surgery is done for the right reason, the pain would decrease, the question is whether the decrease would be 10, 50 or 100 per cent depending on whether there are other reasons for the pain. But there would be an improvement’. (025) ‘To me a good result is: they are going to have some intermittent ache in the knee, they’re not going to be able to kneel or squat. Others on some assessment scale might consider that a failure. So you have get those parameters right’. (010) | 7 | |
Behavioural regulation | I am aware that the feedback I get from my patients may be biased. | Facilitator | ‘To please you, patients often say it is doing better than it really is. So I would think my outcomes are better than 20 per cent, but I am aware of the glasses that I see it through as well as what patients might tell me’. (014) | 6 |
I would be interested in feedback on the percentage of my patients who achieve a clinically meaningful improvement. | Facilitator | ‘There’s always a difference between how well you think you are doing and how you are doing. Having formal feedback on patient outcomes gives you the opportunity to change things if you are not doing as well as you want to’. (023) ‘What I would like to know is the patient who overall is unhappy with their results and didn’t get the result they expected’. (010) ‘I would like feedback on the number of patients who are in each category of satisfaction and I would like to see how my personal results are compared to the group’. (016) | 20 | |
Memory, attention and decision processes | Patient expectations are an important consideration in surgical decision making. | Facilitator | ‘If the patients’ expectations are not meeting mine, I won’t do the operation because then the patient isn’t happy and sometimes they have 2/10 pain and they are not happy. And that is silly. So it is about telling the patient what they can expect and after the operation it is about you remember what we said’. (013) | 20 |
The lack of effective non-operative alternatives influences my surgical decision making. | Barrier | ‘You have to be able to say ‘although we don’t think you would benefit from surgery, we’re going to put you in this intense physiotherapy program with dieticians to improve your knee pain. They need to be offered something. The problem is these things are available at an individual component level… but I don’t think there is anything formally put in place that patients can be referred from arthroplasty clinics into these program’. (029) ‘Well if you make an alternative plan and say we are not going to do surgery we are going to lose weight, do some physiotherapy, take pain killers, you send them off and they come back and say they have done all of that. It means you don’t have another option to offer them and those patients often just want an option and if there is an option you can give them it is easier to push them away from surgery’. (016) ‘I think there are limitations on what you can improve with non-operative measures’. (016) | 12 | |
My threshold of acceptable risk for surgery is >80 per cent likelihood of good outcome. | Facilitator | ‘You have got to be 95 per cent and above. I wouldn’t accept anything less than that. I wouldn’t offer the operation. It is too big an operation, to bigger deal, too bigger cost’. (024) | 8 | |
My level of acceptable risk is patient dependent. | Facilitator (of shared decision making) | ‘It is all about risk for reward. When you think about… the person is not unwell, they can safely have an anaesthetic, even risks as high as 50 per cent one in two that the patient will have no benefit, are worth considering… A patient may be so severely impacted that a 1 in 2 shot is worth it…it is totally patient dependent’. (023) ‘I would rather a 10 per cent chance of getting better than sitting in a wheelchair in a lot of pain’. (022) | 11 | |
Beliefs about capabilities | I find it difficult to assess the patient-related factors that can influence TKA outcome. | Facilitator | ‘It is patient factors more than anything else. Because it is easy to look at xrays and say Kellgren-Lawrence scale, 1, 2, 3, 4 for disease severity. There’s not much argument over that. It’s about the patient factors, the psychology and behavioural aspects of it which you want reassurance for’. (016) ‘Obviously I am not very good because 1 in 5 come back with a problem… so no I didn’t know how to identify them pre- operatively. Something is happening from my assessment to the patients’ outcome and I don’t know what the link is’. (024) | 8 |
I am reasonably good at picking the patients who will do well. | Barrier | ‘I think I am reasonably good… I do have a little bit of a gut feeling about patients’. (013) | 12 | |
It can be difficult to say no to patients. | Facilitator | ‘Most of the time if we bring a patient to the case conference it is to get the support of everyone else to say no don’t do it. Because if want to do the operation, you just go ahead and do it. If you don’t want to do it and you want support that is when you take them along’. (016) ‘It is always easier to consent than decline’. (025) | 5 | |
Skills | I mostly rely on my experience when it comes to surgical decision making. | Barrier | ‘You spend all your life looking at patients and assessing them and you start to develop a bit of a gut feeling as to what might be happening. Sometimes you sit in front a patient and think: I know you are telling me this, but I know something else is happening’. (015) ‘I don’t use any formal tools. I use I guess old fashioned clinical acumen is what I would call it…I have been doing this for a while and you develop a way of assessing people’. (028) | 10 |
Social/professional role and identity | Surgery is an art and a science – it is not just about the evidence. | Barrier | ‘The human body is not a scientific machine. Medicine is an art and science and the art isn’t always represented in the research’. (028) ‘I think that medicine is not about numbers, it is about patients. Each patient has their own different pathology and own different personality’. (017) | 10 |
Beliefs/attitudes towards a decision aid | ||||
Intention | I would use a decision aid to support, not replace my decision-making. | Facilitator | ‘I don’t think it would really influence my surgical decision making, I think it would more affirm my decision to not offer a patient an operation’. (029) ‘If I think they are ok and they score badly I will relook at it and say why is that? Am I missing something obvious? But at the end of the day if an aid says one thing and my sniff test says there is something not right, I’m still following my nose’. (010) | 16 |
Beliefs about consequences | I think a decision aid would be a useful objective tool to help me say no to patients. | Facilitator | ‘It would be clinically helpful in the patient cohort who we don’t think will do well from surgery, giving us an evidenced based approach for saying this is the reasons why we don’t think you will benefit from surgery’. (029) ‘I think that the main benefit of an aid would be making the patient understand if I am saying no to the surgery it’s not because I don’t like him or her, it is because there is data written black on white that they are not going to do well…It will not just be my gut feeling. I can give them data and say sorry it is written here. It’s not me it’s the computer. So it backs up what I am saying’. (013) | 9 |
I think an aid would be useful for gaining patient informed consent and shared decision making. | Facilitator | ‘I think that is one of the important things about a decision aid and part of the consent process is that they know what to expect and it is still the patients decision to decide if they want to have surgery or not, but they have to be appropriately informed and have the appropriate expectations to weigh up the risk and benefit’. (019) ‘It comes back down to getting patient consent, as part of that I would incorporate it into my consent form and say preoperatively you have a 50:50 chance and that has been discussed with a validated tool’. (021) | 10 | |
I think a decision aid has the potential to improve the use of resources and save costs. | Facilitator | ‘If you could use a decision aid to triage patients and push them somewhere else, it would be more effective for the patient and there would be cost savings for the hospital and the community’. (016) | 7 | |
A disadvantage of a decision aid is that it may not capture the nuances of the individual patient and some patients may miss out on surgery. | Barrier | ‘There are always reasons why people will fall on one side of the line or the other and the data will show that the tool might predict you will do really well but you happen to fall in that small group who are set to do really well but don’t, similarly the tool might say you will do really badly we better not operate on you but someone took the punt and you turned out really well so there are always those smaller groups and at times it is possible for the tool to miss certain nuances’. (015) | 13 | |
I have concerns about the legal/ethical implications of a decision aid | Barrier | ‘You have to think of the medico-legal implications of a patient having a risk value documented in their notes. If they don’t have a good result and then lawyers look through and say you had this validated tool and you still went ahead, where would we lie medico-legally?’. (024) ‘I guess the ethicists would say you are denying patient-centred care, so that is where there is a potential for a can of worms’. (021) | 8 | |
Environmental context and resources (how the tool might be implemented) | I would not like to see a decision aid with mandatory cut-offs implemented. | –* | ‘I don’t think there are things that can become compulsory in terms of a decision aid as I mentioned because it takes away patient-centred care’. (025) ‘No you can’t make anything compulsory like that. Not in medicine. Medicine is not black and white, it is grey, you can never make anything compulsory because a surgeon will operate according to their experience’. (024) ‘Surgeons wouldn’t care if it was compulsory to use an aid, as long as they didn’t have to do any work. Making it compulsory to follow it would be dangerous. Because we’re all individuals, what you are doing is taking the human experience aspect of the consultation out and then you turn us into proceeduralists that just look at a tick box and operate on someone’. (016) | 17 |
I don’t think surgeons could ever agree on a cut-off level on a decision aid. | –* | ‘A lot of surgeons would say in their hands they will get better results, that is just an inherent bias associated with surgical procedures and surgeons themselves so it would be hard to agree on a level’. (019) ‘Unless you can clearly demonstrate a certain cut-off does better, so until there is almost black and white there will be some shades of grey and surgeons will differ in those shades of grey. And even if there is evidence you will still get surgeons that will reject it. That is just my feeling’. (021) | 17 | |
I could see an electronic or online tool working well in my practice. | Facilitator | ‘I can imagine something working on the phone, just an app. Simple and intuitive so you put in a little info - BMI, age, degree of arthritis etc tick tick tick. And then it gives you the number, bang’. (013) ‘A lot of patients look on my website. You could have a thing on your website saying: ‘sometimes patients with certain problems may not be appropriate for a TKA, this test can give you a rough idea of your likely success rate’. You could put it out there before they even come to see you. ‘Is this operation for you?’ type of thing’. (028) | 6 | |
Time would be a key concern to using a decision aid in my practice. | Barrier | ‘I just couldn’t use a tool that is going to take up more time. There is already so much demands on our time and there is not enough time as it is. So the tool may only take 5 min but then you add 4, 5, 6 patients and that is half an hour extra of your time that you didn’t have’. (022) ‘It is frantic getting patients through and there is always that rush to see all the patients in a really short time and to spend 5–10 minutes to do a questionnaire with a patient… it is hard to justify that. But if there was something validated and it was done as a routine process, the patient came in with a form filled out with a score that would be really nice’. (016) | 6 | |
Reinforcement | Evidence that tool had been widely validated would not convince me to use it. I would need to correlate it with my own clinical decision making. | –* | ‘I never trust evidence because you only have to go to Dr x …even in research, there is a lot of doubtful stuff. You’ve got to be careful about basing something totally on results. I know we have got to be evidenced-based but the evidence may apply to a certain situation in a certain individual at a period in time and there is always variations or exceptions around that. So I would try and correlate them in my own mind and if after a while I am seeing well that person is a bit odd and they are scoring badly on the aid, well ok, this has legs’. (010) ‘I trust [the research] but I want my data no doubt about it because I think I am better… I know lots of faults in techniques or little things that really can comprise outcome. So everyone has a different hand and surgery is very touchy practice…. So I believe what happens around but at the same time I want mine as well because I know what I do differently or I am more careful about’. (013) | 9 |
I would be more likely to trust a tool developed and implemented by my peers. | Facilitator | ‘If a decision aid is implemented and I see my colleagues implementing it and it is working in their hands then possibly that would convince me’. (024) ‘I think people are mistrustful of things that come out of other institutions but I would trust that a study from [the Department] would be a rigorous design. Where people are invested in something, they’re much more likely to use it. If the results showed an aid was valid, I guess I would be prepared to try it and see whether I thought it was valid in my hands, in my practice’. (026) | 4 | |
Goals | My goal is to optimise patient outcomes. | Facilitator | ‘Certainly, surgeons want results. If you say you are going to reduce our risk, then why wouldn’t we be happy with that’. (012) | 20 |
*‘−’ denotes that the belief may be either a facilitator or barrier depending on how an aid is implemented.
TKA, total knee arthroplasty. BMI, body mass index. CMI, clinically meaningful improvement