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In 1994, we found out that our large practice of complex knee- and hip-joint replacements lost money—actually about $2 million per year. When you are an orthopedic surgeon and working very hard and dealing with patients referred by other orthopedic surgeons, this is very difficult to accept. Partly this reflected the nature of our practice, as we do a fair number of surgeries to replace failed implants, but it also resulted from things we were doing—keeping people in the hospital too long, for instance. Most significantly, however, the loss stemmed from the implants we were using, for we were implanting 10 to 12 versions of half a dozen major designs for any one clinical indication. Clearly, things needed to change.

It is important to remember that the Mayo Clinic culture is very strong. My colleagues and I have all given up our ability to earn as much money as we could in private practice. We have bought into a culture where we labor for the common good and are focused on doing what is in the patient's best interest. When you say to these MDs, "We have to reduce cost in caring for patients," that flies in the face of what we are doing here.

Physicians revert to primal instincts when confronted with information strongly suggesting that they change the care of patients. They begin hiding behind rocks—the first is the data quality rock. They will argue, "Your data are flawed. Go back and look at this again." It is a cultural expression saying, "We are unwilling to change." So we made sure the data presented to physicians were accurate. And, since this was physician-led, it was physician-to-physician communication rather than financial analyst-to-physician. So, I was able to say, "The data are accurate, and you can't question them. But if you can demonstrate to me that they are inaccurate, then I'll rework the data. Lacking the demonstration, however, the data are accurate." So, we blew up the first rock.

Then most physicians will hide behind the clinical quality rock. It is usually expressed in some variation of this message, "I'm not going to do that because I have the best interest of my patient in mind." We needed a logical argument that enabled the physicians to see the needed change as an expression of our culture. For years we had held such a strong commitment to the best interests of the patient that there was hesitancy to question physicians' clinical preferences when they hid behind this rock. Consequently, we'd come to this wide variation in our practice based on the surgeons' personal perceptions of what was best.

The first step in change was to get my colleagues to accept the premise that each of 12 different prosthetic knee implants was probably not "in the best interests of the patient," particularly when surgeons had their favorite implants and their cost ...

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