The Nuances of Numbers

“Medicine’s distinction is that lives are lost in those slim margins”

To appreciate the value of perfectionism in medicine, one only needs to consider the difference between 99% and 99.5% success rates. This marginal half-percent represents entire human lives. It means that for every 1000 individuals receiving treatment, five people won’t be so lucky – or ten. This could result in five able-bodied people who can no longer live independently, five competent adults who can no longer participate in intelligent discussions, or five family members who will no longer be alive to celebrate another holiday or birthday.

When these numbers represent quality of life or mortality rates, abiding by the cliche of ‘just do your best’ feels unacceptable. In fact, the severity of medical errors is so frightening that surgeons have been compared to pilots with respect to the high degree of situational awareness and technical responses in time-pressured situations, prompting the creation of Surgical Safety Checklists similar to pilots’ checklists.

But here’s the defining difference: If a pilot makes a mistake, s/he experiences the outcome along with the passengers. If a surgeon makes a procedural error, only the patient directly experiences the consequence.

Or do they?

Enter the world of medical liability claims in which the completion of a surgical procedure can be the beginning of an emotional and professional nightmare for the surgeon.

Given its highly technical nature, it is unsurprising that orthopedic surgeons are at a higher risk of litigation for medical malpractice than other specialties. Coverys’s review of 474 closed orthopedic claims from 2013-2017 revealed that 62% of the claims were procedural-related, 90% of which cited “negligent surgical performance”. These figures seemingly suggest that we are graduating and employing surgeons with subpar technical skills, however research shows that this is untrue and the explanation is much more complex.

The abundance of medical information on the internet and fictionalized medical experiences on TV have empowered patients into adjudicators of their own surgical experiences. This is certainly not a negative; person-centred care is at the forefront of shifting North American healthcare paradigms and adds an extra level of diligence. However, it can create a gap between the patient and surgeon’s expectations of the procedural experience – whether realistic or not. This disconnect suggests that communication, as well as technical skill, plays a significant role in negligence claims.

This hypothesis is further strengthened when we look at the top allegation categories of orthopedic claims cited in Coverys’ review: technical skill ranked highest at 29%, clinical judgment ranked closely behind at 23%, and communication followed at 13%. These claims spanned pre, intra, and post-operative care and included risk factors of negligent post-operative monitoring (15%), inappropriate or inadequate testing (13%), narrow diagnostic focus (13%), and failure to obtain a referral or specialist consult (8%).

The patient safety incidents reported in malpractice claims are valuable information sources that focus on areas of concern and inform future solutions; it’s just a matter of how we transform these incidents into learning opportunities.

At PrecisionOS, we hypothesize that experiential learning is the most effective way to combat claims of negligence. Our approach to orthopedic surgery training aims to reduce the likelihood of complications escalating to the legal level by 1) facilitating a more transparent and realistic surgical experience and 2) improving best practices in decision-making.

Tools and training: a way forward

The good news is that surgical excellence is rooted in our willingness to consistently learn, adapt, and improve. Respect for risk-mitigation needs to begin in the earliest stages of surgical training – and can be maintained throughout one’s career.

At PrecisionOS, we assert that it is important to consider the fast-paced and multifactorial environment of the operating room, as well as the communication and teamwork that accompany a surgeon’s technical skills. Our high-fidelity orthopedic training platform simulates high-stakes situations without the threat of patient harm, which allows learners to confidently experiment, be challenged while making and learning from their mistakes in a risk-free setting. Further, the real-time feedback metrics offer a vehicle for improvement by analyzing the causes of failure in a systematic, controllable manner. Surgeons are able to approach their cases with higher technical preparedness and robust communication plans, thanks to the 3D structures and resulting immersive experience of the training modules.

Our autonomous and 360-degree range of movement puts the surgeon in control of his/her own training. The complete surgical workflow is simulated and taps into the user’s informational and emotional involvement in the surgical experience. This added depth of understanding transforms PrecisionOS into a valuable planning tool, allowing the surgeon to anticipate issues such as specialist consultations, post-operative supports, or communication protocols for handoffs, etc. We know that addressing a full-range of considerations can make all of the difference when the patient evaluates their experience and questions whether they received the highest standard of care possible.

The quest for perfectionism in medicine is a tale as old as the profession itself; from the first documented pledge of ethical standards of the Hippocratic Oath in the 5th century BCE to the high-achieving personalities that are drawn to medical school today, the desire to do better rings eternal. Orthopedic surgery is still an imperfect and ever-changing craft, but we believe that the quest for excellence comes down to finding more efficient ways for surgeons to use the knowledge they already possess. If the data consistently tells us that negligence claims are based on gaps in expectations, it is our responsibility to be forward thinking and institute a more effective method of communicating with our team and patients. PrecisionOS’ immersive orthopedic surgery training simulator helps surgeons translate their academic knowledge into patient-value care of the highest quality standards. We are not only changing the learning curve; we are changing the culture of safety and transparency.

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Reference

Gawande, Atul. Better: A surgeon’s notes on performance. p222.
Rynecki ND et al. Medical Malpractice in Orthopedic Surgery: A Westlaw-Based Demographic Analysis. Orthopedics. 2018;41(5):e615-e620. doi: 10.3928/01477447-20180621-06.
Marks M. The Value of Claims ‘Signal’ Data in Orthopaedic Surgery 2019. American Association of Orthopaedic Surgeons. Accessed on April 2 2019. https://www.aaos.org/AAOSNow/2019/Jan/Managing/managing04/?ssopc=1