Guest Editorial

In our penchant for providing high- Surgeon quality care for our patients, each of us will steer our patients toward a particular treatment depending as Hero on a variety of factors, including our personal experiences with the particular condition or disease, the various relevant nonsurgical and Jess H. Lonner, MD surgical alternatives, and surgical risk. Not all conditions are for all surgeons; hopefully, each of us has the insight to know when to refer n decades past the surgeon seems to have the patient to another surgeon who had an almost mythical ability and willing- may be better qualified. Moreover, ness to take on the most challenging and not all conditions should be treated risky cases. While most of us have been with surgery if the risks exceed the touched by surgeons who are legendary in potential benefits. Clearly a balance Itheir own right, few have had the honor of training must be struck. A risk-benefit analysis under or working beside such legendary surgeons, should be considered in all patients with names like DeBakey and Sabiston, among before the treatment is advocated. others, including luminaries in our own specialty Idealistically, it would be my hope that of orthopedics. These surgeons were revered by our decisions are always made with the lay community as deities and admired by their the purest of intentions and that those peers because they were skilled, fearless, above- “...sundry other extraneous issues play a very the-fray. They took on the most challenging cases, extraneous minor role. But are they? Do they? with little overt fear of failing. They were heroes. In an ideal world, those sundry Today, we have equally skilled surgeons, factors... extraneous factors wouldn’t con- particularly in our specialty. But while many of put the found our recommendations regard- us have tremendous confidence in our surgical ing treatment, but they naturally skill and competence, external forces present a set ‘hero-surgeon’ do. These very distractions put the of pressures that are more prevalent (and perhaps at risk for “hero-surgeon” at risk for extinc- unique) in this new millennium than in past tion. This reality may trouble those decades. These pressures may confound our good extinction.” idealistic surgeons who were drawn intentions and impact our decisions. It’s just natural to the field by the romantic notion of that they should. Each of us has likely been affected healing the sickest patients, with the on some level by these factors—medical risk, liability concerns, shrinking most complex and challenging prob- reimbursements (particularly with threatened Medicare cuts of 10% and lems, and by the cast of characters payments that could be linked to performance and outcomes measures). I can who were impacting the field when think of but a few orthopedic surgeons who retain that unadulterated passion we were students, irrespective of for the most complex and challenging cases despite all of those extraneous the other “distractions.” The fearless, issues. I know many others, who for one reason or another, choose to refer but selfless and undaunted surgeon the challenging, high-risk (and often low paying) cases to other surgeons, with a “never-say-never” attitude is even though they still “love” the profession. For instance, despite escalating being threatened! In fact, they are so numbers of failed hip and knee arthroplasties, relatively few surgeons take on uncommon in this day and age that revisions, even if they have performed the primary procedure. Still fewer will the rare throwback surgeon is often accept revisions of arthroplasties that have been performed by other surgeons. dismissed as a “cowboy” (no offense Is it that they don’t have the skills to take these on? In many cases, I suspect to cowboys), even if they are using the answer is “no.” evidence-based medicine to support their decisions. A recent personal experience has Dr. Lonner, this journal’s Associate Editor for Adult Reconstruction, is Director, Knee restored my faith in the purity and Replacement Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania. good intentions of some surgeons. Am J Orthop. 2008;37(10):503-504. Copyright 2008, Quadrant HealthCom, Inc. All rights My otherwise healthy 80-year-old reserved. (Continued on page 504)

October 2008 503 Guest Editorial (Continued from page 504) J. H. Lonner father was recently hospitalized with a bedside, and explained the options: in his conviction regarding the best challenging intestinal problem, related live on baby food for the rest of your course of action. I suspect this surgery to sequelae of a partial colectomy and life or undergo risky surgery. For my would not have been performed in adjuvant therapy dating back 18 years father, the choice was clear. some of the most modern societies and several more recent surgeries to The surgery was extremely around the world because of rationing treat adhesions and hernias. While complicated, lasting 7 hours. The based on age, risk, and diagnosis. I my father had been having symptoms recovery has been slow, but my father suspect many US surgeons would also for quite some time, his stoic manner has been eating solid food now for a have “punted” on this case because of shielded all of us, except perhaps my few weeks and was home in New York those extraneous issues I mentioned mother, from the fact that for perhaps City 2 weeks after surgery to celebrate earlier (risk, reward, etc). My father’s a year he was experiencing recurrent his 46th wedding anniversary with my surgeon had put the interests of his “mini”-small-bowel obstructions that mother. I think the meal was a poached patient above all others, including were becoming more pronounced and his own (although I suspect that more frequent, to the point where he “Each of us has he would self-effacingly claim could no longer keep food down. likely been affected that his greatest joy is to see his Because the risks of further patients get better). surgery were considerable, an initial, on some level by The bottom line is that my father’s well-advised trial of nonoperative these factors—medi- surgical care was provided by a care (nasogastric decompression and competent, confident, and skilled diet modification) was undertaken, cal risk, liability surgeon who loves what he does and in the hope that the condition concerns, shrinking who also ministers to his patients with would improve and surgery would a level of patience and compassion be avoided. Several weeks with total reimbursements.” that embodies the standards that parenteral nutrition, nasogastric Hippocrates urged nearly 2500 years decompression, a battery of tests, ago. He is a throwback. He represents and unspeakable boredom ensued. At egg, boiled chicken, and soup . . . a the purest in what motivated many of this point, the surgeon caring for him veritable feast. For my father and the us to pursue a career in surgery, but proved to have the perfect blend of rest of us, his 50-something-year-old which few of us realize in our own what my father needed—confidence, surgeon is truly a “hero.” The surgeon practices. Most of us take good care candor, and compassion. My father earned very little financially, despite of our patients, we make a difference welcomed his frank delivery after performing lengthy, high-risk surgery in their lives, and our patients 4 weeks in the hospital. After that took him well into the evening appreciate what we do. But most of reviewing his limited progress and and kept him from his own family. He us are not heroic. He is a hero, just the studies that had been completed took ownership of the case, assuming like some other great surgeons, like by then, the surgeon came in to his the care of another surgeon’s highly Drs. DeBakey and Sabiston, from room one night, sat down at his challenging patient without wavering years ago. n

504 The American Journal of Orthopedics®