A popular animated Web video is circulating among members of my anesthesia department. It depicts a fictional exchange between an orthopedic surgeon and an anesthesiologist. The surgeon wants to book a case for the operating room: "There is a fracture; I need to fix it."1 The anesthesiologist pushes him for more details, but the surgeon simply repeats his line: "There is a fracture; I need to fix it." Finally, the surgeon is asked whom the fracture belongs to, and he responds: "The fracture belongs to . . . a femur." The dialogue eventually reveals that the patient is a 97-year-old woman who was found unresponsive after a fall and presented to the hospital in cardiac arrest; attempts at resuscitation have failed.
The macabre humor of the video — a surgeon negotiating operating-room time for a patient who had already died — struck a chord with a number of my colleagues in anesthesiology. The fictional exchange, however exaggerated, recalled some of their own past discussions with surgeons. The orthopedic surgeons also found some truth in it; overhearing a discussion about the video, one resident chimed in, "There is a fracture. I need to fix it!"
Despite the video's glib tone, it speaks to problems that carry important implications for the escalating costs of medical care in the United States. Some of these are exemplified by the experience of Madelyn Dunham, who underwent hip-replacement surgery to repair a hip fracture 2 weeks before she died from complications of cancer. Reflecting on his grandmother's care 6 months later, her grandson, President Barack Obama, recalled, "I don't know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she's my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else's aging grandparents or parents, a hip replacement when they're terminally ill is a sustainable model is a very difficult question."2
In the months leading up to and following the passage of the Patient Protection and Affordable Care Act in March 2010, grappling with the President's "difficult question" — how to deliver health care that respects patient and family preferences while also controlling rising health care costs — has become a national priority. As a physician who works weekly in the operating room, I find that many of the conversations I hear on this topic ignore key gaps in our knowledge about how "those decisions," in the President's words, actually get made. Indeed, understanding physicians' choices to recommend for or against advanced procedures for patients in late stages of illness, frailty, or disability is a complex task. It is also a prerequisite for reforms that can limit the potential overuse of advanced medical procedures while also expanding the role of patient and family preferences in determining the goals of health care.
When I have asked surgeons about their experiences in making recommendations about procedures for patients near the end of life, their individual responses have ranged from the matter-of-fact to the emotional. They almost universally mention a reluctance to "give up." Some note that decisions to forgo surgery alter their own perspectives on their professional roles as doctors. A colleague in orthopedic surgery reflected, "It's so strange — thinking about it, I realize that once I've decided not to operate on a patient, I forget all about them. It sounds terrible, but it's really like `follow up in 6 weeks,' and that's it."
The challenge surgeons face — to refrain from recommending a treatment whose overall potential to contribute to the duration or quality of a patient's life may be equivocal — is nothing new in U.S. medicine. However, the centrality of these decisions to surgical practice has decreased over time, as technological advances have lessened the risks associated with anesthesia and surgery, allowing patients previously deemed "too sick" to be cared for safely in the operating room. Indeed, a chapter titled "Surgical Judgment" in the 1960 edition of Christopher's Textbook of Surgery, the precursor to a major contemporary surgical textbook, states, "Often the highest product of a seasoned and responsible surgical judgment is the decision not to operate." It advises surgeons to "effectively resist . . . a number of influences irrelevant to the patient's welfare [that] may be brought to bear upon the surgeon in the formation of this important decision."3 By 1972, the chapter on surgical judgment had disappeared from the textbook.4 The current version, published in 2008, contains little advice on how to make a recommendation for or against an operation in a patient with progressive illness.5
In this context, the simple language of the video — "There is a fracture; I need to fix it" — becomes more profound. Anesthesiologists routinely state that a particular surgeon wants to operate, assuming that this desire arises from a belief that the surgeon can cure or palliate disease, a hope for gratification in the technical work of surgery, or in the most cynical view, an opportunity for financial gain. But the video points to something beyond volition: rather than saying that he wants to fix the fracture, the fictional orthopedist says he needs to fix it. It is as if, on some level, a decision-making process has been passed over, and an inevitable operative course, however absurd, set in motion not by a patient, but by the fractured bone itself.
These fictional and real depictions of surgeons' decisions highlight a neglected challenge for the next phase of health care reform: improving the way that physicians approach decisions to recommend for or against medical and surgical procedures whose potential benefits may be equivocal. Recognizing the centrality of this challenge to controlling the financial and human costs of hospital care in the United States will be essential to any progress we may hope to make toward achieving the system of health care that we deserve.
