Interview - Orthopaedics
The challenges faced by spinal surgeons

Dr Desmond Kwok MD, a senior orthopaedic surgeon at Dubai Bone and Joint Center, speaks to Middle East Health about the challenges he faces as a spinal surgeon, and as an orthopaedic surgery teacher affiliated with the Cleveland Clinic Group offers several important suggestions for orthopaedic surgeons to improve their practice.

Specialist surgeons practicing in the Middle East face a number of challenges unique to this region as well as those common to their colleagues worldwide. Speaking to Middle East Health Dr Desmond Kwok MD, a Senior Orthopaedic Surgeon specialising in spinal surgery at Dubai Bone and Joint Center, placed these challenges in four categories:

- fear
- misinformation
- expectations
- complications

Fear

“Patient anxiety is a significant issue in the GCC,” Dr Kwok says.

“In all my days practising in Canada none of my patients ever asked me ‘will I get paralysed’. Here it is an unspoken question, because people are afraid. They regard any kind of spinal surgery as a very serious surgery. And it is serious, but it is not as dangerous as they think.

“Everybody is a little bit apprehensive about surgery, simply because it is an unknown entity to them,” Dr Kwok points out.

However, patients who may have to undergo spinal surgery in particular are especially afraid because they’ve heard so often about complications with this surgery.

“So right from start a lot of patients will not go to their doctors with a complaint in a timely fashion, because they are afraid of the outcome.

He says in many cases patients will only go to see the doctor ‘as a last resort’.

Dr Kwok emphasises that surgery is not necessarily a last resort. “For example, if you have a truly mechanical problem – like spondylothesis, then surgery is necessary. But if you have a herniated disc – a structural problem – then 90% of the time this will fix itself. You have to look at the nature of the problem. If it is a mechanical problem surgery works wonders. And in this case surgery is not necessarily the last resort. The fairest way is to define what the problem is, is to decide whether the problem has the potential to heal by itself. If it has no potential of getting better by itself – then surgery should rather be sooner than later.

“Unfortunately mishaps do happen and therefore patients are justified to be scared.

“You can see their anxiety as they think ‘if I ask, maybe it will happen to me, but if I don’t ask, I won’t know’,” Dr Kwok explains.

“Nowadays, I don’t wait for the patient to ask me about the possibility of complications. I raise the issue. And you can literally see the relief spread across their face.”

Dr Kwok emphasised that by raising the issue for them you lift a big burden from their mind.

“This burden is very common,” he points out.

“Raising the issue early on is a proactive way of dealing with this important issue.”

Misinformation

Dr Kwok is an experienced teacher. Besides practising as a spinal surgeon he also works as a trainer of surgeons and as a teacher of spinal surgery with the Cleveland Clinic Group and the AOSpine group with whom he has delivered presentations at many venues around the world.

Dr Kwok says that there is a lot of information freely available to patients, largely through the Internet and, compounding this, patients tend to want the ‘latest and greatest’ techniques and devices.

“Patients will tell me ‘I read on the Internet that this or that artificial disc is good for my back … I want this latest technology! … Can you do it through the scope?’”

He says a lot of patients go to the Internet to ‘research’ their illness before consulting their doctors.

“The Internet gives you a lot of information, but unfortunately in many cases we do not know who owns those websites. They lack credibility,” Dr Kwok explains, adding that the Internet gives you raw information which cannot be considered knowledge.

“If you have a lot of information it does not help you make a decision. You have to have knowledge to be able to make a decision.

“So as a doctor it is important to be prepared to handle these issues and be prepared to discuss what is best for your patient.

“This can be difficult. When the patient walks up to the doctor and says ‘I want an artificial disc’ and the doctor says ‘I don’t think it is the best thing for you’ and then the patient says ‘well then I don’t think you are the best doctor for me, I will find another doctor.’

Doctors in competitive private practice do not want to lose potential patients.

“I have had a case where a patient came to me after spending three hours searching the Net. He then proceeded to tell me how to do the surgery.”

He points out that another important point that should be explained to patients is that medicine, like many other things in this world, has its fashions. Medical devices and surgical techniques come into fashion and go out of fashion.

“It is important for a doctor to be able to put this into perspective for a patient.”

And this leads to the next point – patient education.

“Patients think they know, but really they don’t know,” Dr Kwok emphasises.

“When a patient comes to see me I don’t want to know what treatment they want me to give them, I just want to know what their problem is. When I know what the problem is, I can provide a solution.

Dr Kwok explains that in a worst-case scenario, the patient visits the doctor and asks that he be treated with some new technique, the surgeon thinks ‘great I’ve just heard about this, let’s give it a go’.

“This can be very dangerous – where the patient influences the doctor and the doctor thinks it is a good thing to try. Unfortunately this is happening more and more often.

“It takes a lot of time to educate the patient,” Dr Kwok warns.

He notes, however, that it isn’t only patients who need to be politely shown that they do not always know best, but doctors too need to regularly update their knowledge.

“It is important that doctors attend major international courses – as opposed to small commercially driven courses – to keep up to date with the latest technology. They need to be regularly taught by doctors and it is important for them to make presentations themselves,” Dr Kwok explains.

“The interesting thing is the more you teach, the more you expose yourself to new knowledge.

“It is important to expose yourself to be intellectually challenged all the time.”

Expectations

Expectations Dr Kwok says it is crucial that patients’ expectations and the doctors’ expectations are made clear at the outset when doing a consultation for a patient.

“It comes down to patient education again. I honestly believe that if a patient fully understands their problem they intuitively know what treatment is good for them,” he says.

“If the patient understands their problem then they won’t have unrealistic expectations.”

Dr Kwok explains the issue with this scenario: a 55-year old patient in a wheelchair visits a surgeon. He cannot walk because of severe pain and nerve damage. The patient has surgery and his expectations are: ‘Fantastic, I’m going to be like five years younger again, I’m going to walk again.’

After surgery the surgeon turns to the patient and says: “Wonderful Mr Jones, you have such a fantastic result from surgery” – meaning “See I take away all your pain, however you will not be able to walk again.”

Such miscommunication of expectations can be devastating for the patient.

Dr Kwok warns that this can be difficult as the doctor needs to strike a balance when communicating with their patients. If they talk too much in layman’s terms the patient might think the doctor is a bit ignorant about the procedure. However, if the doctor uses purely medical terminology, which is quite often the case, the patient may think, “well he knows his stuff, but I don’t understand a thing he just said”.

Complications

Dr Kwok provides some suggestions about how to deal with a situation when the result of surgery is less than ideal.

What should the surgeon do in such instances? Dr Kwok suggests the following:

1. Listen to the patient – it may be a simple miscommunication

2. It could be genuine mistake – you operate on the wrong vertebra, for example.

Does it happen?

Well, it is the leading reason behind most of the law suits being brought against doctors in the United States and Canada, he points out. The way to avoid this is assess your own ability and consult with experienced colleagues. Unfortunately, this practise of consultation with another surgeon is not very common in this region, he warns

3. Do not hide your complications and do not make a small complication become a bigger complication. Do not ignore complications, Dr Kwok urges doctors.

“If surgery is done properly – what do I mean by properly? Right diagnosis, right surgeon, right patient, right team – the result will be fantastic.

What is the right patient? It is a patient who understands the pitfalls of misinformation and one who has realistic expectations. These are key challenges that must be addressed by doctors and surgeons.

Dr Desmond Kwok MD was trained University of Toronto and McGill University, Montreal, Canada. He was and Associated Clinical Professor at McMaster University from 1986 to 2001. He also served as the Chief of the Division of Orthopaedics at the Hamilton General Campus, Hamilton Health Science Co-operation, which is a Class 1 Trauma Center for the region, in Canada.

Dr Kwok practised in Canada for 15 years before moving to the UAE where he has been practising for the past seven years. He is currently a senior orthopaedic surgeon specialising in spinal surgery at Dubai Bone and Joint Center.

His key area of focus includes trauma and degenerative conditions such as disc herniations (sciatica) and spinal stenosis. He is also an expert in the management and reconstruction of fractures of the pelvis and acetabulum.