Wednesday, May 7, 2008

Surgeon Tryouts

I'm not a huge fan of this drive to designate hospitals as a "Center of Excellence" in some surgical sub-specialty. Bariatrics was the first to champion the idea. On the surface it sounds super-duper. Center of Excellence! That's where i want my surgery! Obtaining such designation, however, usually requires jumping through multiple hoops and making sure all the boxes are checked on an application form. It doesn't hurt to be affiliated with an institution that that can afford to fund the added resources required to meet the prerequisites. The emphasis is less on outcome measures, more on program compliance. For instance, a bariatric program needs to document that they have nutritionists, weight loss specialists, specialized equipment for the operating room and afterwards, and other ancillary services available for potential patients.

It seems like a good idea but now we're starting to see a push for other kinds of surgery to be restricted to such designated "Centers of Excellence". Some surgeons (i.e. academic ivory tower big shots) would like to restrict operations like Whipples and advanced laparoscopic procedures (colon resections, Nissens) to the big tertiary referral centers. Isn't that nice. Let all the community surgeons handle the gallbladders and hernias and butt pus. We'll handle the big cases, they say. Despite the fact that volume actually correlates poorly with reduced morbidity in major operations like pancreatic resections. Other factors like quality of the individual surgeon, nursing staff, and chracteristics of the hospital where the surgery is performed contribute to outcomes as well. Volume is sometimes an arbitrary number.

Anyway, I do actually like this idea. (See page 7 of the link) General surgeons in the Boston area have agreed to take the Fundamentals in Laparoscopic Surgery (FLS) exam in order to maintain laparoscopic operating privileges at hospitals such as Massachusetts General and Beth Israel Deaconess. Basically you show up, take a written exam, and then have to perform a series of timed maneuvers using a laparoscopic training module. Meritocracy in the purest sense. If you have the goods, the skills, then you get to stay in the game. Doesn't matter whether you practice at a vaunted "Center of Excellence" or not. It's based entirely on individual performance and proficiency. Now there are some things I dont like about the FLS test. For instance, moving a bunch of rubber balls from one cup to another or being able to tie a knot in a piece of styrofoam does not necessarily translate into real life excellence. It's like drafting a quarterback based on how fast they can run the 40 yard dash and how many footballs they throw through a tire in a 60 second period. Surely we can do better than rubber balls and styrofoam bowels. Perhaps an in vivo exam on an animal would be a better indicator..... just don't tell PETA.


Jeffrey Parks MD FACS said...

I agree J. As long as the designation is based on outcomes and results rather than whether or not a facility has all the "pieces in place". Center of Excellence ought to be a term associated with, you know, excellent surgical care. Not whether or not you have a specially trained "weight loss nutritionist" on the staff.

Anonymous said...

Buckeye, from a patients perspective (and experience) I have to agree with you.

Back in 1994, my husband needed to have a Nissen fundoplication. I'm not even sure if they were doing these laproscopic at that time. Regardless, he had it done locally, by a general surgeon and it was a big open surgery. He recovered good and to this day he has not ever experienced symptoms of acid reflux nor has he ever been on, or needed, any PPIs or tagamet since his surgery.

In contrast, in 2003, I was sent to one of the big acedemic hospitals (really close to where you are at) for a nissen fundoplication. The reason being, I had 6 cm barrett's esophagus, ulcers, strictures and short esophagus. local general surgeons would not touch me. I had my surgery done laproscopically by suppossedly one of the best thoracic surgeons in the country. The section head of thoracic surgery in fact. I had never met a more rude arrogant person in my entire life. My local GI wanted me to stay on PPIs for a time following surgery just to make sure all was well. Thoracic surgeon would not hear of it. "absolutely, no nexium" is what he told me..."This is why I just did this surgery on you"....Heartburn and other reflux symptoms started almost immediately. My local GI finally took me to surgery center for EGD, and I was refluxing all the way up my food pipe, 2 new ulcers and stricture. The surgery was a complete failure. my LES was wide open. GI said it was almost like I had not even had surgery, the wrap was done so loose. I do understand there is a significant failure rate with this surgery and that is not my complaint. My problem was with his arrogance and his belief that it COULD NOT be possible for him to perform a failed surgery.

Trust me, I have alot more faith in the local small hospital and small town general surgeons, than what I do these BIG academic hospitals.

Anonymous said...

From a patient's POV, another thing to fear from surgery at the BIG academic hospital, is that there is a likelihood your surgery will be performed in part or all by a doctor in training. And the hotshot surgeon you thought would be operating on you will be just standing by.

Jeffrey Parks MD FACS said...

I don't mean to paint the tertiary referral centers in a bad light. I learned how to be a general surgeon from some truly exceptionally talented doctors at such an institution. There are some disease processes that probably are better off being taken care of downtown. But I don't like this trend we see of big hospitals cherry picking "the cool cases" by declaring themselves a "center of excellence". The best surgeon for your disease might be the one right down the street. Or it could be the well published surgeon downtown. It all depends on the surgeon. Not necessarily the institution.

Gary M. Levin said...

Over the past several years, residency requirements (at the behest of the ACGME) require demonstration of skills measured by a number of metrics.
One would think that a scientific group could find a better and more accurate means of determinng dexterity and measure ethics, competence and honesty.
Consumers and health insurers will get what they deserve. How about this one for personal accountability. Surgeon does several casses with the head of his section..

Unknown said...

There's this company, Immersion, that makes Laparascopic and other procedural training simulators. You would think that this would be a better test environment than moving a bunch of balls around.

Can you imagine if we tested pilots on how fast they could turn the wheel or hit the pedals.