Over the next 46 minutes, they worked quickly, barely speaking. Young cut off part of the femur, and Joiner cauterized a vein to minimize bleeding. Their efficient teamwork helped to minimize the time the incision was open and vulnerable to infection. Joiner closed the wound as Young left the room to dictate notes for the medical record.
Joiner has compiled some of the lowest complication rates in ProPublica’s analysis — he performed 282 knee and hip replacements on Medicare patients with zero complications over five years. His excellence is testament to a larger truth: Many surgical injuries are avoidable.
Even as the medical community has worked to reduce patient harm, it has remained common for surgeons and hospital officials to see a certain number of complications as inevitable. Just random bad luck, like a lightning strike.
“We tend to shrug our shoulders and say this is just a natural part of doing health care,” said Dr. Ashish Jha, a patient safety researcher and professor at the Harvard School of Public Health who provided advice for ProPublica’s analysis. If a certain procedure has a 5 percent infection rate, doctors and hospitals consider it acceptable as long as they’re at that or below, Jha said.
Yet if complications are like lightning bolts, they tend to keep hitting the same surgeons, while missing others.
Hundreds of doctors compiled records that were spotless. Dr. James Porter of Seattle performed 173 prostate removals without a single complication. Dr. David Black, at Freeman Hospital West in Joplin, Missouri, replaced 171 hips with no complications. In Leawood, Kansas, Dr. Thomas Rasmussen did 348 knee replacements with no complications.
“There’s no such thing as a no-risk surgery,” said Dr. Karen Joynt, a cardiologist and another patient safety researcher from the Harvard School of Public Health, “but some surgeons are able to make elective surgeries in selected patients pretty close.”
Some in the medical community worry that pushing doctors to lower their complication rates will prompt them to cherry pick healthy patients and turn away cases that could hurt their numbers.
Joiner and his partners at the North Alabama Bone & Joint Clinic operate far from America’s health care hubs, without many of the niceties that abound at name-brand academic medical centers.
The Shoals region, along the Tennessee River near the border of Mississippi, is not wealthy. Public health statistics show it has a higher than normal percentage of unhealthy people. About a third of the population in the surrounding counties is obese, and about a third smokes.
“We take all comers,” Joiner said.
The clinic’s surgeons attribute their results, in part, to conducting more than half their procedures in pairs. They sacrifice volume and get paid little or nothing extra to have two surgeons work on a single patient. Each surgeon provides the other with backup — what amounts to real-time peer review.
“I may look at something a little backwards or get turned around,” Joiner said. “It’s nice for one of your partners to say, ‘What the hell you doing? You’re not out huntin’ this morning. You’re doing a knee replacement!’”
Joiner said the clinic’s outcomes also reflect a culture in which the work doesn’t end in the operating room.
In many other practices, it’s typical for surgeons to have physician assistants or nurse practitioners follow up with patients after surgery. Joiner and his colleagues do almost all the follow-up care themselves, personally checking with patients to make sure they know what to do and how to recognize signs of postoperative problems.
“We don’t cut corners,” Joiner said. “We do it the right way every time.”
Historically, this approach hasn’t always been rewarded by the medical payment system. In fact, when patients ended up back at the hospital because of surgical injuries or infections, it was effectively a bonus, generating more billings on top of those for the original procedure.
In recent years, Medicare and some private insurers have introduced initiatives that try to upend these incentives. For example, Medicare can dock payments to hospitals if patients who have elective hip and knee replacements are readmitted at especially high rates, or if medical facilities rank among the bottom 25 percent for certain hospital-acquired infections and injuries.
Supporters say these changes, while incremental, have spurred hospitals to focus on reducing certain poor outcomes as never before. It’s not yet clear, though, if they will prod doctors to alter their practices, too.
Dr. Paul Dworak said he’s too fed up to stick around and find out.
Between 2009 and 2013, ProPublica’s analysis shows, the Edina, Minn., surgeon performed 277 knee replacements on Medicare patients with no complications. He also did 165 hip replacements with one of the lowest complication rates in the nation.
Dworak credited his results partly to spending more time on each patient during surgery, prepping them, making sure their implants were placed properly and closing their incisions himself rather than delegating this to an assistant. After operating, Dworak said he kept patients on medication to prevent blood clots longer than other specialists, even though this meant keeping close tabs on their lab results.
But this cost Dworak. He didn’t get paid for the extra time he invested, and he couldn’t schedule as many operations.
Dworak said such frustrations, coupled with reduced Medicare payments and the stress of meeting his patient safety standards, have prompted him to wind down his surgery practice.
“My results were very good, and other orthopedists in the Twin Cities had horseshit results and made more money,” he said. “The general public never knew what the results were.”