Who deserves the blame when surgery does not turn out the way you expected?

I follow a Facebook support group for “ream and run” shoulder replacement patients. I have found some of my patients benefit by talking to others who have been through a similar operation and recovery process. Generally, the support group encourages its members to push themselves in physical therapy, and do the hard work needed to get the best result, which is wonderful. However, this sometimes leads to the perception that the end result is the patient’s responsibility. Meaning if you work hard at therapy you will do well and if you don’t do well you must not have worked hard at your therapy.

Obviously this is not a fair conclusion, and one of the support group members recently posted that it made him feel badly to hear that attitude. He had worked hard at his therapy and unfortunately did not get the result he wanted.

As a surgeon I feel that I have a pretty good understanding of what ingredients contribute to a good surgical outcome, however I now realize that patients may not have that same understanding. Frankly, it makes me sad to hear that a patient blamed himself for a poor result, so I hope to shed some light on the topic.

My shoulder fellowship mentor (Dr. Rick Matsen) likes to say that there are three P’s that contribute to a good result. The Patient, The Physician, The Procedure, and I think that is 99% true but there is definitely something more to the story. There is an extra 1% that we don’t understand. To get a good result from a shoulder replacement, you need a good surgeon (physician), a motivated patient, and you need the correct procedure for you problem. But even if you have all of those elements, sometimes things don’t turn out the way we would like. How can that possibly be, we had all three P’s? Well, There’s that extra one percent, the missing ingredient, which for now we will call “luck”.

Some patients will get an infection, struggle with post op stiffness, have a dislocation, and the list of potential problems goes on and on. Maximizing the three P’s lowers the likelihood of these problems occurring but it is never 0%. People who are not in medicine have a hard time understanding that it is unlike most other industries, because there are so many variables between each patient and many things that we do not yet understand. It is not like producing a car on an assembly line where quality can be tightly controlled. It is not even like flying an airplane which has more variables, but still not as many as the human body. Perhaps it is more similar to predicting the weather; there are mathematical models that can come pretty close to giving an accurate forecast but not 100%.(I’d like to think we do a little better than weatherman)

To put this in perspective I have many patients in whom I have replaced both of their shoulders. It always amazes me to see how many patients have a different experience with one shoulder versus the other. Patients often say, “This side was easier than the other” or “this side hurt more than the other”. I have no way of explaining that. It was the same surgeon, patient, operation, implant, hospital, and therapist. There is literally no explanation for that! For now, I have to chalk it up to “luck”. In reality, there is certainly some reason why, some slight difference, something we don’t currently understand. But until we know what that is we will call it “luck”.

So if you have had surgery and didn’t get a great result, who’s fault is it? Maybe one of the three P’s or perhaps nobody’s.

Author

Brad Carofino, MD Dr. Brad Carofino is a board-certified (American Board of Orthopaedic Surgery), fellowship-trained orthopaedic surgeon who specializes in shoulder & upper extremity surgery. Dr. Carofino is an expert in shoulder replacement surgery, minimally invasive arthroscopic rotator cuff repair, and complex reconstructive procedures of the upper extremity.