People Don’t Walk on Their X-rays

Mar 5

In my residency program, post-op X-rays were often used to evaluate the care delivered to patients. Decision-making, procedural, and surgical abilities were judged based on the accuracy of reduction and fixation. (Direct observation was also done).

When care happened at night, this assessment was done the following morning, usually by others who were home sleeping in the middle of the night. The residents used to have a saying that “If you weren’t there, you can’t criticize”. But it was said mostly in sotto voce outside of attendings’ earshot.

There was a lot of stress about whether the X-rays would be perceived as “good enough” by others. Were they “perfect” enough?

Once I started practice, these standards continued to be ones I tended to use to evaluate myself. One day I was discussing this with an older surgeon and he said one of the most constructive (and ultimately kindest) things another surgeon ever said to me. “People don’t walk on their X-rays.”

The truth of that statement helped change how hypercritical I was about the quality of my work by reminding me that a good outcome isn’t only about what can be objectively seen and measured.

It’s not that X-rays aren’t important, because the structure and alignment of the bones are critical for normal function. However, it doesn’t tell the complete story of how someone will do, because it doesn’t show the soft tissues. It’s the soft tissues that so often determine how the person’s quality of life will be. And what their functional ability is going to be.

The same is true in life. The structure of someone’s life, and the visible external things are important. But they don’t adequately tell you about a person’s internal experience. It doesn’t tell you about what hardships they’ve endured or still struggle with. It doesn’t tell you about the thoughts they think, or the feelings they feel. That’s what genuinely determines the quality of their lived experience. Their soft tissue. On the interior.

Because structure is more objective and visible, it is often the first thing we assess. But, just because something looks “perfect” doesn’t mean it is. Structure is measurable and can be a marker for function. But it doesn’t measure function. And ultimately it’s function, how well all the pieces fit and work together, that determines the quality of life and overall sense of satisfaction.