What I’ve learned from calling out my orthopedic colleagues

What Ive learned from calling out my orthopedic colleagues

Six months ago I posted a story about a demented 94-year-old patient who’d fractured her hip. She’d lost more than thirty pounds in the preceding months and had already had a collarbone fracture from a previous fall.

Her son wanted her to be made comfort care only, and avoid a trip to the operating room since she was likely within six months of death and was immobile (bedbound) even before her hip fracture. She was going to be referred to hospice. We called off the orthopedic consultants who had been kind enough to recommend (and set her up for) hip stabilization.

I felt like this was the right course of action, and the family members (the ones I’d met) supported this decision. The patient appeared comfortable, able to sit up in bed and hold conversations (albeit demented ones), and not in any distress from her fracture.

The next day, I came to the hospital to find out she was already on the operating room table to have her hip pinned. No one had called me to discuss the change in plan.

I was furious. I felt betrayed by my orthopedic colleagues, who hadn’t seen fit to discuss their thinking or the change in planning (or the subsequent conversations with the family) with me. After all, I was the physician in charge of the case, the one legally responsible for the decision making and the outcome.

I’ve learned a lot from the case, and from my posting of something so fresh and full of emotion. Namely, that with the perspective of time, I now see that it was inappropriate of me to:

  • blog about something so recent
  • call out my orthopedic colleagues without discussing the situation with them first
  • use profanity in a blog post about something important and meaningful, thereby likely putting off the audience I would hope to capture

I apologize for my boorishness. I was quite angry, and I let it get the best of me.

Many people wrote asking what the resolution of the case was, and what the upshot of my post-hoc conversation with orthopedic colleagues would be.

I spoke with the department chair, after he’d had ample time to review the case and hear from the players.

I respect his approach and fact-finding, and he acknowledged that the communication over the patient’s fate (and consent to surgery) was mishandled. But he also helped me see the situation through the eyes of an orthopedic surgeon, which addressed my concern about their motivation(s). I will tackle his points one by one:

Hip fractures are an endemic problem. With our aging population and the thinning bone that comes along with it, hip fractures are an inevitability in communities and growing as a problem along with our aging loved ones. Primary care doctors do a lousy job treating osteoporosis.

Hip fractures are a local problem. At this one 500-bed hospital in a medium-sized American city, there were more than 800 hip fractures last year — more than 2 per day. The weekend before I spoke with the chairman, there had been seven hip fractures.

Orthopedic surgeons are not motivated by money when it comes to hip fractures. Unlike much of orthopedics which provides elective surgeries, hip fractures are a form of trauma, and therefore do not conform to surgical scheduling. Orthopedists perform fracture repairs as add-ons to their regular cases, and most surgeons don’t like to perform them as they occur at off-hours, over and above their regular caseloads. Medical outcomes in hip fracture improve the sooner they are repaired; therefore the addition of time pressure to these cases is another stressor for surgeons.

In the case I blogged about, the orthopedic group collected $819.27 in professional fees (i.e. the doctor’s charge) for the pinning of the 94 year-old patient’s hip.

“Half of that goes to taxes, another quarter to overhead,” the chairman told me.

That leaves a collection of about $205 net for the procedure. The implication is that no one is getting rich repairing hip fractures.

Communication is a two way street. Much as I was displeased with the lack of communication in this case, the chairman provided several examples of where internists had simply not communicated with his team regarding a patient’s care. He’s absolutely right about this. It’s a fail for all of us.

They have created a center of excellence. One of the doctors who read my initial post works at the hospital in question. He pointed out, correctly, that not  pinning the elder woman’s hip (even though she was emaciated, demented, and fragile) would be cruel. She would have pain with any position changes and likely develop bedsores. The standard of care is to repair hip fractures, not let them heal (they actually can!) over time. The time cost (and risk) is too great.

That physician (an internist) has partnered with the orthopedic group to form a center of excellence in hip fractures, devoting resources to tackling this growing and costly problem in a systematic fashion. This is a great response–and I’m pleased to work and teach at a hospital that’s ready to tackle problems like this.

At the end of our chat, the chairman handed me copies of pages from the patient’s chart.

“Is that your note?” he asked me. I nodded.

“I can’t read a word of it,” he told me.

Touche.

John Schumann is an internal medicine physician who blogs at GlassHospital

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  • PrimaryCareDoc

    Thanks for an excellent post. It’s always great to hear the resolution of a case. I also appreciate the reminders about the importance of excellent communication on all sides.

  • southerndoc1

    I call bullshit on the orthopedic chairman.
    Nobody calculates their earnings based on what may be left after taxes. And if overhead for them is only 25%, they’re way ahead of the rest of us.
    Cry me a river.

  • Steven Reznick

    Osteoporosis being treated poorly by primary care physicians is a pretty poor justification for taking the patient to the OR without informing you or convening a meeting with the family and the doctors to discuss the choices.
    You created an environment in which if this type of situation arises again, there will be a better chance of communication between all the parties who should be involved before definitive action is taken.

  • ninguem

    How’s the old lady?

    Did this hip pinning do her a bit of good?

    Maybe it did……….

  • buzzkillerjsmith

    My mom just fractured her femur, a bad break. She is doing much better now. Her orthopedist is very kind and in her case he is motivated by compassion and not by by money. I can see that.

    Yours is a tough case. Untreated hip fractures can be very painful, so pinning makes sense. The pt is hospice or pre-hospice, so not pinning makes sense.

    Kudos to you for apologizing to your colleagues and thus becoming a better doctor and for having the courage to share this with us. The next case like this, when it comes, will still be very hard.

  • Nancy Richard Colburn

    I have no respect whatsoever for your profession, but you sir, seem to have some ethics. Kudos!

  • Daniel

    “… that not pinning the elder woman’s hip… would be cruel. She would have pain with any position changes and likely develop bedsores.”

    All of the other points just don’t seem relevant.

  • DryBones

    Pssst – I think you mean “colleagues”

    • Guest

      Or the person who wrote the title and appended it to this piece did.

  • ninguem

    The part I’m missing is how this patient got to the OR for a pinning, if the attending doc did not agree with surgery, and family did not agree with surgery.

    C’mon, orthopedic surgeons see the world as a broken bone surrounded by someone else’s problem.

    They usually want operative “clearance” and all that.

    They also need consent for surgery.

    Who signed the consent?

    I have to conclude that the “no surgery” decision did not reach any orthopedic surgeons, nor was it clear on the chart.

    “Orthopedic surgeons are not motivated by money when it comes to hip fractures.”…..if they’re not making money on major bone fractures, where ARE their profit centers? Ortho does well economically, and I don’t begrudge them that, they earn it……but now I’m curious.

    Where DO they earn money, if not hip fractures?

  • Suzi Q 38

    You had every right to be told about an upcoming surgery for your patient. They should have told you directly, rather than you finding out when your patient is already in the O.R.

    At least you have come to the conclusion that there are other opinions that may not be the same as yours, and you had to be understanding.

    I still don’t agree with what they did, but it happens.

  • Stephen Rockower

    I have commented on this before. “Comfort Care” is really a misnomer with a fractured hip. It is a miserable way to die. The Constitution prohibits cruel and unusual punishment, and leaving an elderly person in bed with a fractured hip is just that, in my opinion. I’ve done it both ways, and the patient (even when they die) are usually more comfortable moving around in bed without bedsores after they were fixed. The operation shown above is minimally traumatic, no worse than putting in a pacemaker or G-tube, which our medical brethren do at the drop of a hat. And yes, the payment isn’t really enough to motivate anybody. Often these cases happen at 8PM or on a weekend when the OR can find a spot to fit it in. No one loves to do these cases. We, too, are motivated to care for the patient and to prevent suffering.

  • Steven Davidson

    All the clinical care aside, your post teaches many lessons of professionalism and communication that can benefit our students, residents and colleagues. Osler’s “Aequanimitas” reminds us to strive for balance–our humanity guarantees occasional failure. Public acknowledgement and using the episode to teach colleagues is in the finest tradition of our profession–unfortunately not on frequent enough exhibit. Thank you, Dr. Schumann.