Orthopedics in Glass Houses

“We got another disaster from the outside hospital,” my resident reported (Figure 1). “Does this guy know anything about ankle fractures?” Upon examining the radiograph I paused to consider the situation that the surgeon may have found himself in. But what do I tell my patient? What lessons can my resident learn? Much has been written regarding the disclosure of medical errors to patients, and there is increasing literature regarding disclosure of errors made by one’s colleagues. Gallagher et al recently convened a panel of experts from various fields including patient safety, malpractice law, bioethics, and health policy and published various recommendations for disclosure of a fellow clinician’s harmful errors. The authors recommended improved colleague-to-colleague communication and transparent disclosure of errors as a shared professional responsibility with a collective approach to accountability. Although the same ethical, moral, and legal issues apply regardless of medical subspecialty, the field of orthopedic surgery has unique considerations. Although the detection of substandard care in other specialties may require exhaustive examination of the medical record, often a single radiograph is all that is required in our field. The assessment we make of a radiograph for healing, alignment, positioning of implants, etc is a by-product of our orthopedic training. It doesn’t take much time to determine what was done, how well (or poorly) it was performed, and prognosticate on outcomes. However, the assessment we make of the surgeon who performed the surgery is a far more complex process and often subconscious in nature. During our weekly trauma rounds, I occasionally hear a trainee denounce a surgeon when examining a poor radiographic outcome, especially when performed at the well-known “outside” hospital. “Bad” surgeon (or usually a more descriptive term) is often what is said. However, although “bad” surgery may be closer to the truth of things at times, usually there is more to the story. In this context, for the sake of collegiality, consider the following when examining a colleague’s work.