Orthopedic surgery has made huge advances over the years. These advances have come about because of the revolutions that have occurred in different technological disciplines, such as 3 D print manufacturing and artificial intelligence.
As recently as forty years ago, we did not have dependable techniques to diagnose and treat even common lesions such as meniscal tears. Much of orthopedic surgery, like many other fields, was guesswork. Now, with great precision, orthopedic surgeons can diagnose and treat a multitude of musculoskeletal diseases to an extent that was previously unimaginable.
However, with great precision comes great expectations and high standards of patient care.
The orthopedic surgeon medico-legal expert must look at a case from a neutral perspective and decide whether the conduct of a peer constitutes a breach in the standard of care. This is not an easy task, or one that can be taken lightly. Many cases concern surgeon conduct that evolves over numerous patient visits and includes one or more surgeries. It is not rare that one is required to sift through thousands of pages of medical records and numerous radiological studies to arrive at an opinion that is “within a reasonable degree of medical certainty”.
There is a large variation in the cases that an orthopedic surgical expert can be involved in, but when surgeons make medical errors, there are frequently one or more cognitive biases that come into play. (To understand the concept of “cognitive biases” please see the work of Daniel Kahneman, especially his book “Thinking Fast and Slow”.) In numerous cases the surgeon, through the process of one or more cognitive biases, goes into denial and perpetuates a myth that nothing is wrong.
Some common examples: A bad post-operative infection occurs, but the surgeon fails to recognize the extent of the infection and fails to take the appropriate action. (“Halo effect”, “sunk cost fallacy”, “ostrich effect”). A component of a total joint replacement is mal positioned during a routine surgery. After surgery, the X-Rays document the poor positioning of the prosthesis, but the surgeon notes numerous times in the medical record that the positioning is “adequate”. (“Halo” effect, “sunk cost fallacy”, “anchoring effect”.) A surgeon evaluates a patient who has had chronic stable low back pain over the course of many years. An MRI shows chronic degenerative changes in the spine. The surgeon determines that the patient has severe spinal stenosis that requires an extensive back fusion. Not only is surgery not indicated, but in the postoperative period numerous complications arise, many of which are predictable, but the surgeon is slow to identify them and slow to respond appropriately. (“Narrative bias”, “cause and effect bias”, “halo effect”, “anchoring bias”, “information bias”.)
Perhaps the hardest part of the job of an expert is to identify their own biases. When evaluating the work of a peer, experts need to put themselves in the shoes of the surgeon in question and ask themselves at each decision point “would a prudent and diligent surgeon in the same circumstances take this same specific action?”. In doing this type of in-depth study experts must assure that they do not succumb to their own
