The gold-standard surgeons took a production line approach to practice. In this sense, these surgeons would characteristically perform the same types of
surgery using established prostheses repeatedly, because to them these procedures were effective and proven. A number of surgeons I interviewed
described their hip replacement practice as “run of the mill” (INT C 218008) or a
“production line” (INT C 190004). These surgeons seemed to know what their
typical practice should be, and the outcomes they could routinely achieve for their patients by selecting evidence-based standard implants. Gold-standard surgeons appeared to have little motivation to change practice unless they were given a valid and evidence-based reason to do so. The quote below reveals this desire to follow the established practice:
“Well orthopaedics is fortunate in that we have got quite a few operations that work well with large treatment effects. So you don’t need to tinker too much with it because the treatment effects are so large that the patients are going to do very well. So yes just deliver the service as simply and safely and as reproductively as you can which is where following protocols is best.” (INT C 218009)
In my study, gold-standard surgeons represent two elements of standard
practice. One group aligned to the standardisation which emanates from closely following the clinical evidence base and standards for implant selection
established by organisations such as ODEP and NICE. The second group had developed a standardisation in their practice from a lifetime of performing the same surgery. These elements are represented in the quote below:
“I operate within a fairly limited framework of prostheses, all of which are ODEP 10A rated. I don’t do any experimental procedures on patients at all, and the choice of prosthesis I think would come down to really essentially the same prosthesis but minor variations in the bearing surface. So for example, at the moment I have for hip replacement all patients receive some variant of a (brand). In the over 70s, it’s a metal on plastic bearing. If you’re between 60 and 70, it’s a ceramic femoral head, and if you’re under 60, the emphasis is more towards a ceramic on ceramic bearing. I think the evidence base for the latter two is fairly strong. The evidence base for the under 60s is probably not
as strong as it could be.” (INT C 190004)
The theatre nurse who coined the term “gold-standard surgeon” in my research
was describing a surgeon with whom he had worked for nearly twenty years,
whose practice was so predictable that the theatre nurse could “set his watch by
him” (INT C 218013).
It appeared that two different types of evidence were important for the gold- standard surgeons. First, their personal experience that an intervention is effective, and secondly that clinical evidence in academic literature suggests certain options are preferable when compared to others. In both of these, there was a focus on attaining proof over long periods of time. These surgeons were reluctant to change their practice overnight to match the trends of innovative or maverick colleagues. The surgeon below reflects on the long term negative consequences of changing practice:
“I don’t think it’s helpful or innovative for me as a surgeon to be trying something new on my own in the hospital, whereas lots of surgeons would genuinely believe that but they, I don’t think they fully understand what they’re doing or the implications of what they’re doing and that’s because they are not, they’re not research trained to understand like that, they’re trained surgeons, they know how to put the implants in but they may not really fully understand the implications of what they’re doing and that’s the issue. So on a very personal level they feel that they’re doing something useful for them and the patients but actually probably something really rather unhelpful for everyone.”(INT C 218011)
4.3.4.1 The use of metaphor to describe the characteristic types
The surgeon types represent characteristics types of behaviour and decision- making processes that appeared to be dependent on the evidence each characteristic type deemed important. For the innovators, seeing something new work first hand was key. The mavericks needed to have the latest products for their practice. The gold-standard surgeons would perform what the clinical evidence and surgical tradition suggested was best.
Throughout the interview process, the surgeons repeatedly used metaphors to describe their practice and the characteristics and stereotypes of their
colleagues. One particular metaphor is linked to cars and vehicle manufacturing. For example, a gold-standard surgeon compared the use of traditional metal-on- polyethylene hip replacements to the Ford Model T car. The production of this car is renowned for its standardised processes, and focus on effective replication. He was suggesting that a similar approach should be used for hip replacements in the NHS. He also compared the technologically advanced and more expensive hip replacements to a Rolls Royce, and argues against their selection in the quote below:
“I don’t think the NHS was ever built to give every patient a Rolls Royce implant. And I think there's too many Rolls Royces being put in … it’s unnecessary. They could have the Ford Model T, they could have a metal and plastic. I think a huge number could have been metal and plastic.” (INT C 37011)
The surgeon below describes the innovation between new types of hip implant by comparing it to small differences in the performance between two types of supercar. He suggests that hip replacement surgery is well-established, and therefore only small improvements can be made through innovation:
“The innovation…[of different hip replacement types] has got to a point, really, where you’re tinkering between the performance between a Maserati versus a Ferrari in terms of your particular performance domain, you know, you’ve got to be really confident that you know what you’re doing to mess with that.” (INT C 190004)
When reflecting on the maverick behaviour amongst himself and his colleagues,
the surgeon quoted below suggests that “most people” want the latest and
greatest car, not the unrefined Beetle. This was a metaphor for the next generation implants compared to the established and reliable prostheses:
“It’s like when you go to buy a car. Do you say I want the latest and greatest car with all the
features on it or do I want a VW Beetle from 1970s because they never broke down. Some people like the idea of a car that just never breaks down. It’s not the most refined thing, but it does the job. Then obviously most surgeons probably think well I want to go for the latest thing.I just think we’ve got to always have an eye on the next generation. Otherwise we’ll never get beyond … essentially we’ll live with the obsolete. We’ll be driving around in Volkswagen Beetles forever.” (INT C 218007)
The important feature of these surgeon characteristic types is that the variation in individuals and their typical behaviour may lead to variation in the practice of hip replacement across sites, and across the country. The characteristic surgeon types were associated with the preferences of surgeons in relation to their autonomy and the discretion they enacted over decisions. These preferences varied and differences were enacted in practice. I observed representative examples of each type of surgeon at each case study site. The only seemingly majority group was at site A, where the surgeons tended towards the gold- standard type. I believe that this was linked to their focus on academic research and EBM. However, I also observed maverick and innovator types in site A. In practice, patients scheduled for hip surgery would not know which type of surgeon would be operating on them. This variability amongst surgeons and their choices might be a legitimate source of concern, if decisions regarding the type of procedure and/or the implants selected were driven by the
characteristics of the individual treating them, not by the evidence-base.
4.4
Autonomy, discretion and decisive decision-making
One distinguishing trait consistent across all these surgeon types was the autonomy, discretion and decisiveness that each surgeon held over their
decision-making and practice. This was a function of their role and identity as an orthopaedic surgeon, not the result of their characteristic type. I propose that autonomy and decisiveness are associated with their elite professional status within hospitals. The short quotes below demonstrate the autonomy, discretion and decisive decision-making that were the norm across all three sites:
“I’m confident that what we do is the right thing to do.” (INT C 198003)
“I am confident about the decision. It might not be the right decision. There is an old adage about Trauma and Orthopaedic Surgeons that “they are often wrong, but they are never in doubt!”.” (INT C 218008)
“Whereas a physician might sit back and go and think about a problem in the sort of coffee room there and deliberate, our job isn’t like that. You know, it’s sort of immediacy, you need to have an immediate decision. And you have to recognise that some of your immediate decisions are often incorrect and accommodate to that.”(INT C 37011)
Orthopaedic surgeons are a professional elite with a prestigious occupation within the medical profession. Their decisive sense of discretion and ownership over their decisions was aimed particularly towards the individuals outside their elite, such as managers, researchers and policy-makers. Surgeons who are not autonomous and decisive might look and feel out of place in their working environment. The quote below shows how these surgeons believed that colleagues and patients would lose confidence in them and their skills if they showed indecisiveness:
“There’s a sense that you sort of have to make decisions and you become very sort of quick to make decisions. “Okay let’s do this and we stick to it” because as you can imagine uncertainty for patients is quite difficult to comprehend, “Oh bloody hell I’m not having an operation with that person” and so you ... and I think for whatever reason patients, well patients don’t like uncertainty and if you show that to patients they lose confidence.” (INT C 218011)
4.4.1 Tactics surgeons used to change the evidence through resistance,