Friday, July 27, 2007

Experience = success?

What is the effect of surgeon experience on outcomes? It's a tricky issue to navigate. Conventional wisdom would seem to indicate that surgeons who do an operation frequently would have fewer complications than surgeons who perform said procedure less often. The classic paper from Hopkins describes this effect, with regards to pancreatic cancer. Conceptually it would seem to make sense. The whipple procedure is fraught with morbidity. Technically it can be quite challenging. Ergo, one should go to a major tertiary referral center for one's pancreaticoduodenectomy. Or should one? The paper, in all honesty, isn't a compelling piece of hard science. It compares results from Hopkins with results from all Whipples done at hospitals classified as "low volume". So some yahoo in Bethesda who kills three patients during hack job whipples gets lumped in with a technically brilliant surgeon at some community hospital outside Baltimore who does 5-8 whipples a year with morbidity/mortality numbers that are actually better than the national average. The numbers are going to be unfairly skewed when all comers are included. Moreover, plenty of papers have been published supporting the opposite conclusion; that complex gastrointestinal procedures can be done just as safely in community hospitals.

So what's the answer? I have no idea. There are academic surgeons at my residency training program that I wouldn't let come within 100 feet of my ampullary cancer, and there are surgeons here in my community hospital that I would feel very comfortable having operate on me. Finding the "right surgeon" isn't as simple as heading downtown to the big center where all the big names are. Surgery isn't set up like sports where the best in a field head the surgery departments at universities. There's no "Surgery Olympics" held every four years where surgeons compete for gold medals in "fastest, safest cholecystectomy" or "Best pancreatic anastomosis". Manual dexterity and technical excellence doesn't always correlate with whether you work in a communtiy hospital or an academic institution. Someone becomes Chairman of Surgery at Harvard because of an extensive, research-driven resume'; not because they can tie intracorporeal knots better than anyone on the east coast.

Given all that, here's when you should go to a tertiary referral center:
1. If your PCP recommends a specific surgeon for your procedure. If he/she just says, "I'll give you a number to the people downtown", you may end up with the junior attending on staff.
2. If you're comfortable with the idea of residents providing a significant chunk of the care.
3. If you live in Chicago; call Dr Doolas.
4. Inquire about night coverage at your community hospital. If physicians aren't in-house (hospitalists or house officers) consider going to the big center for your whipple or gastrectomy. Residents have saved many a life (and made mortality figures look better) at 3 in the morning.

If you need your gallbladder taken out or breast surgery or a hernia repaired, chances are you'll be able to get quality surgical care from your local General Surgeons. Ask around. Get references from other patients. Ask people who work in the hospital about Dr. So and So. Trust your PCP. Bottom line is, surgical excellence is very individualized. Some have it and some don't. Just because your surgeon's name tag says "Cleveland Clinic" or "Stanford", it doesn't necessarily guarantee a good outcome.

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