Who helps you make orthopedic decisions?

Have you ever been told you’re “bone on bone” — and walked out of the appointment feeling terrified, confused, and unsure what to do next?

In this episode of The Talking Rehab Podcast, Dr. Fred Bagares, DO, Sports & Spine physician and founder of MSK Direct VB, explains how medical language can influence your decisions more than you realize — and how to tell when your doctor is nudging you versus truly guiding you.

Through the story of a patient named Tom, Dr. Bagares reveals how three words — “bone on bone” — completely changed one man’s belief about his body, leading to months of fear, inactivity, and unnecessary suffering. You’ll learn how to interpret your diagnosis with clarity, ask the right follow-up questions, and stay active and informed while deciding on surgery or conservative care.

If you’ve ever left a visit with more fear than answers, this conversation will help you rebuild confidence and make medical decisions from a place of knowledge — not panic.

Timestamps + Key Themes

[00:00] Tom’s story: “Bone on bone” and the fear that follows
 [01:00] When the system fails: urgency without guidance
 [02:00] How medical words shape beliefs about fragility and damage
 [03:00] The psychology of “nudges” in medicine — why language steers behavior
 [04:00] The missing piece between diagnosis and decision
 [06:00] How to bridge the gap with actionable guidance
 [08:00] Reframing arthritis: from fragile to adaptive
 [10:00] Why injections, PT, and movement still matter before surgery
 [12:00] Spotting the difference between nudging and genuine guidance
 [14:00] Three red flags in medical communication
 [15:00] Five questions to ask your doctor to make confident decisions
 [17:00] What Tom’s story teaches about trust, guidance, and control
 [18:00] Closing reflection: urgency moves you — guidance directs you

f this episode helped you see your diagnosis differently, hit subscribe and share it with someone facing a tough medical decision.
For clarity consultations and advanced treatment options, visit MSKDirectVB.com

 or 

FredBagares.com.

Transcript

0:01

Let me tell you about a conversation that happened in my office last week. A man will call him. Tom sat down across from me and said, I need to know if you're going to be like the last doctor. I asked him what he meant. this guy told me I was bone on bone, told me I needed surgery, and basically said, call me when you're ready. That was it. No plan. No options. And then I left the office. He paused, so I stopped moving. and I've been too scared to do anything, but too terrified to do nothing. Tom is not alone. If you've ever left a doctor's office with a terrifying diagnosis. And absolutely no idea what to do next. This episode is for you because what happened to Tom happens thousands of times a day in medical offices across the country, and most patients don't realize it's a system problem, not a u problem. Today I wanna pull back the curtain on how doctors use language, when it helps you, when it abandons you, and how to recognize the difference. because if you're looking for a new physician, you need to know what questions to ask. I'm Dr. Fred Biris, and this is The Talking Rehab Podcast. Quick favor, before we dive in. If this podcast has changed how you think about your body or your recovery, hit that subscribe button. It's free. It takes two seconds, and it's how we keep bringing you these conversations every week. No fluff. Just real talk about what actually works. Thanks for being here. Now let's get into it. Tom Surgeon used a phrase that changed everything, your quote unquote, bone on bone. And in that moment, Tom's entire relationship with his body shifted. Not because arthritis was new. It had been developing for years, but because those three words created a story about what his body could and couldn't do, here's what Tom heard. My hip is collapsing. Movement will make it worse. I'm running out of time. None of those things were said explicitly, but they were all implied by the phrase bone on bone. There are several other musculoskeletal conditions that have similar effect. Your rotator cuff fist completely torn. Your disc is pressing on the nerve. You have degenerative arthritis. Sound familiar? You've probably experienced the exact same thing. These phrases are very medical, but sometimes can feel catastrophic. Here's what most patients don't know. Doctors are trained to use this kind of language on purpose. It's not necessarily to scare you, but it is meant to give you a very specific diagnosis to be accurate, but also to create a sense of urgency. There's actually a name for this in behavioral psychology. It's called the nudge. Let me tell you about two economists, Richard Thaler and Cass Sunstein. In 2008, they wrote a book called Nudge about how people make decisions. Their big idea was you can shape someone's choice without forcing them. You just simply have to change how you present the information. A cafeteria puts fruit at eye level and cookies on the bottom shelf. People tend to pick the things that are easier to get to, and that's a nudge toward healthier eating. These work because humans don't make decisions in a vacuum. We're heavily influenced by how information is framed. When a surgeon describes severe cartilage loss, they're not just reading your x-ray. whether consciously or unconsciously they are nudging you towards surgery when they say we could try physical therapy, but surgery is the definitive fix. They're not necessarily presenting equal options. Again, they are subtly nudging you towards the operating room. When they say you don't want to wait too long on this, they are trying to let you know some urgency needs to be taken and they're not necessarily wrong. Sometimes patients need urgency to take their condition seriously. Sometimes indecision leads to worse outcomes. Doctors use this language because it works. It moves people toward action, but there's a problem. Let's get back to Tom's appointment. The surgeon pulled up the x-ray, explained the severity, discussed the surgery. Tom nodded that he understood, and then he said, I'm not ready yet. The surgeon followed up and said, that's fine. Just call us when you're ready. That's it. The appointment was over. Now what just happened? The surgeon successfully communicated urgency. He gave him a formal diagnosis with a clear treatment plan. He nudged Tom toward understanding the severity. He gave him information on the benefits risks and how to schedule, but then. At the moment, Tom expressed uncertainty. The guidance stopped. Tom was left with two things, a terrifying diagnosis that made him afraid to move and no plan for what to do until he was ready for surgery. This is a very common experience I hear about from many patients over the years. This may sound very familiar in your particular case. You're told your body has a problem. You're presented a surgical answer, which seems to be the only option offered. But when you're not ready or when you want to explore other options, you're sent out of the office and back into the world. No referral to physical therapy. No explanation of what's safe to do. No follow up scheduled. No guidance on how to navigate their decisions. You're simply left with a call when you're ready. And the most simplified definition a surgeon's job is to operate, not necessarily to help someone work through their fear of surgery, not to guide them through non-operative options they might need to consider first. Not to hold their hand while they're processing the idea that their body needs a major intervention. However, in my opinion, the job of a great physician or surgeon is to help people with their difficult decisions. Again, from a simple definition standpoint, the surgeon did their job. They made a formal diagnosis, they gave a prognosis, gave a treatment plan, gave instructions on how to move forward. That should feel like it's enough, but oftentimes it doesn't. So who do they talk to now? Probably the internet, social media. Friends and family. So what did Tom do for those eight months? He went home and he googled his diagnosis. He went onto forums from people who had a variety of surgical outcomes, which again, it can also be slightly terrifying. He asked his friends who told him stories about how their mother's knee replacement went really well And about how someone else's mother's postoperative recovery was really rough. He went on YouTube and was searching for various types of surgeries. He saw social media posts claiming that his cartilage could be healed with supplements. In other words. He got his medical guidance from the internet instead of a physician. Not necessarily because he wanted to, but because he had been abandoned in the gap between diagnosis and decision. And while he was stuck there, he stopped golfing because he was afraid of grinding down what was left. He stopped working in his garage because he thought extra activity would accelerate the damage. As a result, he gained 20 pounds, became sedentary, and started to feel very depressed. The diagnosis hadn't changed, the arthritis hadn't gotten worse, but somehow his belief about his body had completely transformed, and that belief was shaped by. Urgent language and zero follow through. When Tom finally came in to see me, I asked him what would've helped after that appointment. He didn't even hesitate. I needed someone to tell me what I could still do, not just what was wrong. I needed to know if strengthening would help or hurt. I needed to know if waiting was dangerous or just delaying the inevitable. I needed someone to walk me through the decision instead of just giving me a number to call. That's when I realized the problem wasn't the diagnosis or necessarily just the language. The bigger problem was that he felt abandoned. Because here's the truth, Tom did actually need a hip surgery. The surgeon was 100% right about then. But he also needed time. He needed to feel some sense of control. He needed to understand that his hip wasn't fragile, that he could stay physically active if he could tolerate the pain, and he also needed to understand that the problem wasn't necessarily just the severity, but the impact it was having on his quality of life, which was declining. Let me tell you about what happened in our first visit. I didn't sugarcoat the x-ray. I didn't contradict his surgeon. Instead, I said, you're right. Your hip has significant arthritis, but The reality is, is that you had arthritis before. You had fairly severe symptoms, so it is possible to have better pain control through conservative management. It's not like the arthritis got dramatically worse over the past couple months, it's just that your symptoms just never got controlled. That being said, you have had a lot of conservative treatment, physical therapy, rest time over the counter medications, and even an injection. All of those did improve your symptoms, but your quality of life continues to suffer. That being said, there is no urgency to pick one or the other. While I do think surgery can help you. There is no harm in trying to stay physically active or restart physical therapy. In the end, you will be a much healthier candidate. The more you stay physically active, as long as your pain is well controlled. After all, a strong patient heading into surgery tends to have a better outcome. Postoperatively, Tom looked at me like he had just been given the permission to breathe. Then he said, the surgeon told me injections were pointless because they wouldn't fix arthritis. I said, he's right. They don't reverse arthritis. But that's not the goal of the injection. The goal is to reduce your pain so that you can move better and get stronger. We're not trying to avoid surgery forever. We're just trying to get you ready and keep you physically active while you make your decision. Over the next four months, we worked on his hip strength and mobility. I did give him a second steroid injection, which dramatically improved his pain and was enough relief to get him exercising again. He started golfing again, lost 15 pounds. He started to feel like himself again. Eventually he realized that there were certainly limitations of what his rehabilitation plan has gave him, so he decided to schedule surgery. Now, this wasn't because I pushed him, but because I helped him through the decision. Here's what I learned. Urgency creates movement. Guidance does create direction. Ultimately, patients need both. When Tom told me about his experience with the previous surgeon, I asked him, looking back, what were the signs that you weren't going to get the guidance you needed? He thought for a moment and said, honestly, it was within the first five minutes when I asked if there were any other options. He said, we could try pt, but Surgery is really what's going to fix it. And the way he said it, I knew PT wasn't a real option. It was just something to say before getting to surgery. Most patients can sense when they're being nudged versus guided. They just don't always trust that instinct. So let me give you a framework, not to make you cynical, but to help you trust what you're already feeling. Here's the first signal. Tom Surgeon said that we could try therapy, but surgery was the definitive fix. Surgery is one option and it's a good one. But let's start with PT to see how your body responds. Many people improve significantly, and even if you do need surgery later, you'll be in better shape for it. Do you notice the difference? The first version nudges you towards surgery by making everything else sound inadequate. The second version acknowledges surgery while opening space for other paths. For Tom, there was a second sign when the surgeon said, I have severe arthritis, I asked if I could still exercise. He said, you can, but you're just grinding it down faster. That freaked me out. Here's what's interesting about that response. It's technically not wrong, but it's devastating for patients to hear that, because what Tom heard was every step I take is damaging me even further, and for eight months, they were paralyzed in that belief. I contrast that with what I told Tom in our first visit. Your hip has adapted to the arthritis. It's not fragile. It's just changed. Movement with proper mechanics actually helps maintain function. We're not grinding anything down by strengthening, we're preparing you. Same imaging and diagnosis, completely different message about the body's capacity. Here was the final signal for Tom, and this is the big one. When I told him I wasn't ready yet, he just said, okay, call me when you're ready. And I sat there thinking, that's it. What do I do now? And that's the moment the doctor disappears, Tom could have called the office anytime, but because call when you're ready places all the burden on the patient, it assumes you'll magically become ready without any guidance on how to get there. It's the medical equivalent of saying, let me know if you need anything and then walking away. Compare that to what I said to Tom. I understand that you're not ready yet, that's completely fine, but let's not waste these months. Here's what we're gonna do. I'm gonna refer you to physical therapy to work on hip strengthening and mobility. I'm going to give you an injection to reduce the pain so you can move better, and I'm going to see you back in approximately four to six weeks to reassess. At that point, we'll talk about whether you're feeling better or whether there's time to consider another option. Sound good? Tom later told me that this was the first time someone gave him something to do instead of something to decide. Now you might be thinking, that's great, but how do I know all of this in the moment? How do I tell the difference between a doctor who will guide me versus one that will abandon me? Here's what I tell patients. Ask questions that force them to show you how they think. Let me give you five questions as an example. Question number one, what can I still do safely while I decide this question does something powerful? It shifts the frame from what's wrong to what's possible. Question number two, what would make me a better surgical candidate if I wait? This is a brilliant question because it does two things. First, it acknowledges that surgery might be necessary so your doctor doesn't feel like you're rejecting their recommendation. Second, it forces them to think about optimization, not just urgency. Question number three, who can help me stay functional in the meantime? This question tests whether your doctor has more of a team mindset or is a my way or the highway type. If your doctor responds with, there's not much anyone can do at this point, or you can try pt, but it probably won't change anything. I think you can pretty much deduce what options they are really, really willing to try. Question number four, what are the signs that I shouldn't wait any longer? This is my favorite question because it separates doctors who think clearly from doctors who think in absolutes. This is a very hard question to answer, and will test your physician's ability to think outside of the box and think up of different scenarios to help your overall outcome. Question number five, can we schedule a follow-up to reassess? This might seem like the simplest question, but it actually reveals whether or not you're. Physician is invested in your overall decision and outcome. These are just some examples, but I think that they can give you some insight on whether or not this physician is a good match for you And to reiterate, these questions aren't about catching a quote unquote bad doctor. They're really about revealing how the doctor thinks and whether or not they're the right person for you. I eventually saw Talon back after his hip replacement, and he said something I'll never forget. I'm glad I waited, not because the surgery wasn't necessary because it was, but because I needed to feel like I wasn't just a problem to be solved. I needed to feel like someone actually cared about the space between the diagnosis and the actual decision. If Tom's story resonates with you at all, please keep in mind that you deserve a doctor who will work you through all of your options. So if you're listening to this because you're looking for a new physician. Here's what I want you to know. You're not being difficult, you're not being indecisive, and you're not being a bad patient. You're just navigating the gap that shouldn't exist in the first place. That being said, you now have some tools to help find the right physician for you. Please be advocates for yourself and if you have any questions, please feel to reach out. I hope you have a great one. Thank you for listening to The Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement filled day. Take care.