UW Shoulder and Elbow Academy: Since the surgeon is the method, how can surgeons improve their method?

Intelligence that is not artificial

As craftsmen, each of us surgeons want to get better at our craft.

Because much of what we do turns out well for our patients, our greatest opportunity for improvement comes from studying the instances in which the outcomes are adverse for them.

One way to do this is to keep an eye on the world's best population-based resource, the Australian Orthopaedic Association's National Joint Replacement Registry.

These data may inform the implants we use

the use of implant modifications

or the type of adverse outcomes we may encounnter

A complementary approach is presented in a recent JBJS article: Learning From Surgical Failures. The essence of this approach is asking the couterfactual question: what might have been done differently to lower the risk of this complication?

For example, one could consider the cases of failed pyrocarbon implants shown below and ask: "what could have been done differently in each case?"

While this kind of analysis is invaluable, the degree to which it applies to each of our own practices is uncertain.

An approach to learning from our own failures is presented in How a surgeon can learn from their own adverse outcomes - an example of intrapractice analysis in reverse shoulder arthroplasty. As illustrated in that blog post, this approach to introspection is straightforward.

For each adverse outcome in each of our own practices: (1) identify the mode of failure (e.g. displaced acromial stress fracture), (2) identify the important parameters of our treatment (e.g. position of the reverse total shoulder components), (3) compare these parameters in the case to those in similar patients in our practice who did not have the complication (controls), and (4) note the difference between the case and controls and consider adjusting our surgical technique in the direction of the controls (e.g. making sure that the distance between the glenosphere center of rotation to the acromion is greater than the distance between the glenosphere center of rotation to the greater tuberosity).