Mrs. X lay in her hospital bed, anxious and in pain, while her husband sat stoically at her bedside. She had been re-admitted the night before, just three days postoperatively from what had been a routine hip replacement. Interestingly, it was abdominal pain and constipation that had brought her back to the hospital, though on rounds that morning she was complaining of an atypical amount of pain in the operative leg. Follow-up X-rays demonstrated a known but uncommon complication following hip replacement: a periprosthetic fracture of the femur. Though it was the weekend and I wasn’t on call, it was now my duty as her operating surgeon to explain the situation, the options, the expected outcome, and the plan going forward.
These situations, while rare, are always challenging for a physician. I scrutinized the immediate postoperative X-ray taken in the recovery room looking for any missed clue or explanation as to what had happened. Zooming in and out, changing the contrast, critically assessing the work I had done. Despite my rigorous search, I could find no explanation as to why the fracture had occurred. Though these fractures can occur at the time of surgery and be so subtle they are missed, there was no evidence on the X-ray of a fracture line. Putting in a femoral stem that is too small or too big for the patient’s anatomy can also lead to fracture. If the stem is undersized, it can sink down inside the bone and act like a wedge, splitting the femur. If it is oversized, the bone will separate in an attempt to accommodate the overly large implant. In this case, the femoral stem I had placed looked to fit the patient’s anatomy well, neither too big nor too small.
Frustrated by a lack of an obvious cause for the complication, I searched for other explanations. Had the patient fallen? She was adamant this wasn’t the case, and I had no reason to doubt her. Should I have cemented in her femoral stem? The patient was in her 70s, but her bone quality was good and templating of the preoperative X-rays had demonstrated an appropriate anatomical fit for the chosen implant. I have used the same implant in patients of similar age (and older) thousands of times with great success. Cemented stems, while less likely to lead to fracture, present some of their own unique complications including possible early loosening, difficulty of removal, and pulmonary side effects. Despite my best efforts to understand what had happened, it was becoming clear that this would be a complication without obvious explanation.
Medicine is increasingly shifting from a fee-for-service model, in which physicians are paid a set amount based on the work performed, to a pay-for-performance model designed to incorporate quality measures and cost effectiveness into the reimbursement equation. Part of the argument for pay-for-performance (and against fee-for-service) is that it holds doctors accountable for the quality of care instead of encouraging larger volumes of procedures. Some have even gone so far as to suggest that a fee-for-service model rewards complications by allowing physicians to bill even more for the additional care. Others have pointed to lack of accountability on the part of doctors as a significant contributor to the shortcomings of American medicine with its high cost and (perceived) middling outcomes. Ratings systems, bundled payment programs, accountable care organizations, insurance tiers, and other measures have been put into place under the guise of increasing doctor accountability.
While it is still largely too early to determine if such programs will have the desired effects of improving the quality of care and controlling costs, the underlying theme of physician unaccountability is a sore spot. Certainly there should be mechanisms in place to ensure that patients are receiving evidence-based, cost conscious care. Cases in which physicians have defrauded Medicare, Medicaid, and/or private insurance companies lead to attention-grabbing headlines but are the exception to the rule. And there is more to accountability than can be captured by CPT codes, RVUs, complication rates, or other such objective measurements. To assume that physicians aren’t held accountable in a system that rewards quantity over quality ignores aspects of accountability that aren’t easily measured by costs and outcomes. As physicians, our greatest source of accountability is our patients. It is difficult, if not impossible, to hide a complication or poor outcome. While there are different strategies and approaches to these difficult situations, transparency and honesty work best; attempts to ignore or downplay the situation often lead to poor interactions and sometimes lawsuits. No physician enjoys complications or poor outcomes, no matter how much money could be made treating them. Personally, I would trade any future income from treating my own complications to never again have one.
In addition to being held accountable by patients, as physicians, we hold ourselves accountable for outcomes. Doctors are trained to remain analytical, objective, and stoic even in the face of difficult situations. Complications are treated as unanticipated clinical challenges. But despite outward appearances, many physicians internalize poor outcomes and “therapeutic mishaps.” We are human after all. Most doctors are, by nature, self-critical, competitive, and driven. But these same traits that lead to success in a medical career also contribute to burnout, depression, and loss of confidence. While it may appear on the surface that doctors are cold and clinical in dealing with complications, underneath there is often internal struggle and self-doubt.
I spent a lot of time with Mrs. X and her family that morning. I printed out the immediate postoperative X-ray and the new X-rays showing the fracture. I discussed the problem and the proposed solution in detail. I gave them my cell phone number and encouraged them to call me with questions. The next steps were to ensure OR availability, order the necessary equipment, formulate a definitive operative plan, and anticipate any unexpected challenges. At the same time, a sense of frustration and failure nagged at my consciousness. Hip replacement is an overwhelmingly successful procedure for greater than 90-95% of patients with low complication rates and excellent outcomes. But when hip replacements fail, the effect on patients can be significant and addressing these complications can be complex. I didn’t sleep well the night before Mrs. X’s revision surgery, alternatively racking my brain to determine what I could have done differently during the original surgery and making sure my operative plan was appropriate for the revision. The surgery went fine and Mrs. X is recovering well so far, though the case still nags at me.
In the current health care climate, physician accountability will gain even more focus as payment models, quality ratings, and patient reported outcomes gain traction. However, to assume these measures are the only means by which physicians will be held accountable disregards the doctor-patient relationship and high standard to which most physicians hold themselves. No degree of external measures can substitute for this high level, impactful, and often unseen pressure to perform. Doctors have been and will continue to be accountable to their patients and themselves first and foremost.
Dr. Benjamin Schwartz is a fellowship-trained joint replacement surgeon practicing on the North Shore of Massachusetts. He enjoys working out, taking road trips with his family, and cooking. He is a paid surgeon consultant for Medacta USA, a manufacturer of Orthopedic implants and devices. He serves on the Editorial Board of the Journal of Arthroplasty and is a member of the AAHKS Practice Management Committee. Dr. Schwartz is a 2019-2020 Doximity Fellow.
Illustration Collage by Jennifer Bogartz / uzenzen / Getty Images