A Successful Procedure ?!?! #PM, #whyPM , #hcr #hcsm

I left the operating room the other day after finishing a straight forward case.  A colleague of mine left his room at the same time and asked how my case went… “fine”.. we accomplished our goal.  A well implanted, well aligned, well balanced knee prosthesis.  Being the friendly colleague I am, I reciprocated and asked him the same question… “It was successful”  Was it? How does he know?  Is a successful procedure one that simply accomplishes its goal (implanting a prosthesis, fixing a fractures, etc.) … or as a burgeoning Participatory physician might ask, is the procedure only *successful* after the patient has undergone months of grueling physical therapy and finally comes into the office and thanks me for giving them their mobility back.   

Can a surgical or medical procedure be termed a success if the patient did not get better? 

If not, then what should we call a well executed, well indicated procedure that did not produce the intended result (typically pain relief)????

There are no procedures with success rates of 100%.  Take knee replacments for example.  Despite a well performed procedure, only slighlty more than 90% of patients have what I would call a successful result.  If they thank me for giving them their legs back, for allowing them to play with their grandchildren, golf or play tennis without pain— then I would term the procedure a success

 

Thoughts ?

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About hjluks

A busy Academic Orthopedic Surgeon, Digital Strategist, Chief Medical Officer and father... intently and efficiently navigating the intersection of Social Media and Health Care.
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8 Responses to A Successful Procedure ?!?! #PM, #whyPM , #hcr #hcsm

  1. Chukwuma Onyeije says:

    Howard,After reading your post I was struck by the fact that we as physicians may be conflating terms when we talk about complications and successful procedures.Most of us would think of a “successful” operation as being one without complications. This makes sense on a gut level, but I wonder if it is an oversimplified approach. As you properly state, every surgical operation carries a risk of complications, and, in many cases, if a complication is anticipated, communicated and dealt with appropriately, the end result is quite often better tolerated and understood by the patient than a “successful” procedure where the patient leaves with a negative assessment of the physician, the hospital or the care team.Your post highlights a point that I think cannot be underestimated… What is the assessment by the patient when all is said and done. Have they achieved functional capacity and are they satisfied with the end result. As a fellow budding participatory physician, I’m inclined to believe that this is ultimately a better criterion for judging success. However, if we choose to make patient satisfaction the end point for determining the success of a surgical intervention it also opens up a new set of questions. For example: First: is it possible for a procedure to be a success even if there is an unanticipated complication which is well handled?Second: If we choose patient satisfaction and post-operative function as a proxy for success how do we evaluate and compare these seemingly non-quantifiable entities in order to provide patients with this type of information?Finally: (and perhaps most intriguingly), can patient satisfaction be an unreasonable or unreliable variable. I am thinking about the (hypothetical) physician who has a loyal following of committed patients despite the fact that his or her complication rate is demonstrably higher than other physicians even after adjustment for confounding variables. In my field this would apply to the physician with an excellent bedside manner in conjunction with a 60% C-Section rate while the hospital averages 30%. Can his demeanor and patient loyalty compensate for a two-fold increase in operative intervention?Thanks for another thought-provoking post.

  2. sushilbansal says:

    If the goal of a surgical procedure is to improve the life quality of the patient, as it should be, then yes, the ‘procedure will be a flagged a success’ only after the patient has recovered, gone home, finished therapy and achieved an acceptable measure of cure. You have modestly captured this thought in the last sentence of your blog; very commendable on your part!In our modern life, any complex endeavor, surgical procedure included, is more or less a team effort. A surgery is accomplished with contributions from radiologist, nurses, surgeon, therapist and family members. If, you as an orthopedic surgeon completed your task successfully in the OR, then you can rightfully claim ‘Success’. Subsequently, if the pharmacist/nurse inadvertently administered wrong medication/dosage with adverse effects, then from the patient’s perspective the ‘treatment’ was a ‘failure’.To be fair, I believe, you and your colleague were simply exchanging greetings after the surgery rather than trying to kickoff an intellectual discussion on patient’s success. I only wish and hope that a majority of the medical caregivers agree with your (and my) definition of ‘Procedure success’.

  3. Howard Luks says:

    Aside from the obvious cases where there are significant secondary gain conflicts (Compensation, no fault, torts, etc) I think that the *true* success of a procedure should be measured by the patient’s level of satisfaction (assuming their goals were *realistic* [our job, to a point, too]) BUT………….Quantifying *success*, I imagine, wld be based on one or more of the various Health scores SFS-36 ,etc which are readily available. But now we’re talking about the scientific definition of success. I doubt the true academics wld agree with our concept of a *successful* procedure. Many fractures heal, but patients still have pain, many knees/hips are implanted well and patients still have pain, etc. A paper on fracture care would indicate *success* based on fracture healing as the endpoint… otherwise is might be difficult to study a certain technique to treat difficult fractures. The residual pain in this instance is most likely a manifestation of the enormous energy of the initial trauma… so was the procedure successful… ?perhaps?. Maybe we need *success* categories… procedural or technical and end result or satisfaction? thoughts?

  4. midwifeamy says:

    Interesting post and I’m glad to see @chukwumaonyeije ‘s response. There’s a clear rift between the two “camps” in maternity care about how to define success, and attempts to reform or improve care require that we come to some common understanding. Interstingly, in OB (perhaps not the case in other medical/surgical disciplines), our mainstream culture and many if not most women/patients share the same limited view of success that is propagated by the obstetric discipline – that success means a healthy baby (which is defined quite limitedly as a live one that is discharged home with the mother) and a healthy mom (which is defined even more limitedly as one who is discharged eventually from the hospital in reasonably good condition). Other “successes” (ability to breastfeed, mental health outcomes, avoidance of iatrogenic infection or injury, longterm wellbeing, optimal mother-infant attachment, positive family functioning, satisfaction with care, etc.) are seen as trade-offs to the primary live-baby/live-mother outcome, despite the fact that you can “have your cake (live mother/baby) and eat it to (longterm health and optimal wellbeing of mother/infant/family) by providing a more participatory model of care and reducing use of high-tech procedures and medications. (Evidence supports this.)Those promoting this alternative participatory model (including participatory providers like me and @chukwumaonyeije and plenty of consumer advocates) are unfortunately in the minority, though vocal enough that perhaps change will happen eventually.The question of how to measure is of course the tricky one. Most women will say that they are satisfied with their labor and birth care, even if they endured avoidable harms, were excluded from decision-making, and were exposed to unnecessary risk. We live in a doctor-knows-best society so I think we’re all a bit predisposed to think we got great care even when we didn’t. But it takes a particularly brave person to say that she was unsatisfied with (or injured/traumatized by) her labor and birth care because there is an extra layer of cultural expectation laid upon the situation that dictates that women consider their babies’ births among the “happiest days of their lives”. There is also an underlying belief that birth is intrinsically risky and a denial of evidence that birth practices/interventions affect longterm outcomes such as breastfeeding, mental health, and family functioning. So doctors have to rescue babies routinely and if we even acknowledge that breastfeeding, mental health, or bonding problems may result from interventions, they are seen as the unfortunate collateral damage.One intriguing effort in maternity care is an evaluation instrument known as the “optimality index” that measures “maximum outcome with minimal intervention”. It does not incorporate patient satisfaction per se, but built into the instrument is the understanding that a live baby/live mother is a better outcome if the mother/baby weren’t exposed to unnecessary procedures and the system didn’t waste unnecessary resources to achieve it.Anyway, thanks for a great post. I am always fascinated when I see my familiar maternity care conundrums play out in other disciplines.

  5. Nick Dawson says:

    This is a very thought provoking post; not only Howard’s post but the reposes as well. As a disclaimer, but not an insecurity on the topic, I am not a clinician. Could it be as easy as a collaborative definition of success as defined by both the patient and the physician? That seems to be the common thread between the original post and the replies. We can call it participatory medicine or being an informed patient. But the bottom line is a joint agreement (sorry, bad ortho pun) on the success measures. Frankly, it is something people who negotiate contracts have understood for years – never sign up for a job where the contractor and contractee do not agree on the definition of success. While many patients may have consulted Dr. Google, or even a well qualified source, it is ultimately up to the physician to help educate them. To that end, I think success as defined by a quality of life improvement that both the patient and physician agree is attainable is a great definition – inspiring in fact!

  6. Nick Dawson says:

    as and addendum: what about a literal agreement? “As your doctor I’ll do X, as the patient you’ll do Y. In A months/days/years you’ll be able to do B.” Get together for a follow up visit and celebrate the success or discuss what happened that prevented it. Why can’t we think about medicine like a deal? Of course, I recognize there are many roadblocks to that idea – the idea of signing something, even if its boilterplated to no end, about outcomes being first and foremost. But is there a way to take the idea and make it work?

  7. healthblawg says:

    Classic joke, based on the extreme case of popular perception of surgeons (present company excluded, of course): A surgeon, pleased with the post-op review of the surgical site, pronounces the surgery a success; meanwhile, the patient is pronounced dead.Success cannot be based entirely on the mechanics of the operation, since the patient being treated is the whole patient. Just as choice of implant is dictated by the patient’s lifestyle/age/activity level etc., so too are post-surgical treatment, rehab and expectations about function, pain, etc.I don’t think you need a contract, but, rather, a treatment plan that addresses all of these issues and is signed off on by doctor and patient — No guarantees, but a recitation of procedures, hardware, and expectations about the outcome. All except the “just do what you think best, doc” types are likely to be very engaged in such an exercise.As you know, communication is key.But coming back to another comment — how do you quantify success, given this approach? It seems to me that measures of regained function and pain (or its absence) are the appropriate measures here (along with the more objective measures re: infection, readmission, etc.). Finally, patient satisfaction has been measured alongside these other measures in some instances via the HCAHPS tool — so there are ways of getting at this issue.David HarlowThe Harlow Group LLC

  8. Howard Luks says:

    Thanks David, Nick and others… I agree with the concept that the *true* success of a procedure should be measured by the degree of return to function or elimination of pain that the patient had a reasonable expectation to receive. Not sure that contracts, etc are necessary. Reasonable expectations are one thing… but a guarantee is never implied by informed choice/consent. The issue *we* as physicians might have with using these criterion for success are issues such as torts, comp, etc. There are a whole host of secondary gain issues that will affect the overall *success* rate of a procedure. For example… a carpal tunnel release has a *success* rate of 90+ in the general population as measured by relief of pain/numbness, etc. In the workers compensation arena, the success rate is far far lower… somewhere in the 50+ range. That certainly skews the data.

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