Thursday, January 8, 2009

Second Opinion

The NY Times explores the issue of whether a community-based doctor has an ethical obligation to inform a patient that the proposed procedure/operation might have a better outcome if performed at a different hospital (i.e. the tertiary referral center in the big city).

This is a big topic in academic circles. It seems every month, an article gets published in one of the big surgical journals advocating that all "complicated" surgical cases get shipped downtown to the giant academic center. Whipple procedures for pancreatic cancer and major liver resections are the classic cases that have been studied with regards to the relationship between surgeon/hospital volume and outcomes. This is not rocket science. The more one performs an operation, the better the results ought to be. If you've done 1000 pancreatic-jejunostomy amastomoses in your career, it's likely that you've picked up a few tricks along the way that will help reduce your complication rates compared to a surgeon who has done 20.

But now, in this era where most general surgeons go on to do fellowships in breast or laparoscopic or colorectal surgery, we are starting to see a clamoring in the surgical literature for pretty much any case other than a hernia or a gallbladder to be sent "downtown". Here's a link to a paper advocating that "breast surgeons" need to be doing all cases for breast cancer. I mean, give me a break. Breast surgery (lumpectomy, mastectomy) is about as technically unchallenging as it gets. But if you can get a paper written and publish it in Annals of Surgery, then maybe you can proclaim yourself "Breast Surgeon Extraordinaire" and never have to take an ER acute abdomen again in your career. (Now I need to write up my lap chole/lap appy experience and publish it this summer in Annals and start a movement demanding that all cases of appendicitis be referred out to the community surgeons. I do more lap appies than the chief of surgery at Memorial Sloan Kettering. Does that he he ought to inform his patient who comes in through the ER that said patient should consider transfer to a smaller hospital in Westchester where a community surgeon {who does far more of these cases} can take care of patient's appendicitis?)

Personally, I would never do a major liver resection in my present situation. I think I could get through a case if forced to do so in an emergency (like a peripheral segmentectomy for a blunt traumatic liver injury), I would not be comfortable doing some sort of anatomic liver resection for a primary tumor or metastasis. I'd want the liver transplant guy downtown doing that case.

I have done three Whipples in the past 14 months. I always offer the option of second opinions and referrals to the tertiary care center downtown. But I don't shy away from the case. I like Whipples. I think I do a pretty good job. I was taught well and I think my surgical principles are sound. If the patient wants me to do it, I will. My outcomes (granted a small sample) are excellent. I don't have anything to apologize for. Same thing with rectal cancers. So I would be uncomfortable telling a patient that he/she will necessarily receive better care and have a superior outcome if he/she opts to have the Big Hospital do the case rather than me. As long as the patient is given options and I continue to honestly assess myself and see how I stack up, I don't see any reason to change the way I practice.

The individual surgeon is the most important factor, I believe. There are hacks at major medical centers who do 5-15 Whipples a year with awful results. Where a surgeon practices is not nearly as important as the skills he/she brings to the table. Obviously, certain ancillary services need to be in place at the local community hospital (good interventional radiology, MRI/CT scanners, a good GI consultant, etc) but ultimately how well you do depends on what happens while you lay asleep on that OR table. Your surgeon's technical expertise and clinical judgment are the paramount factors but the relative merit of them cannot always be deduced based on what the logo is on his/her white coat.

The onus of responsibility inevitably will fall on the surgeon, as it must. Even with internet research and physician ratings and all that garbage, patients want to be able to trust their doctor. If you present yourself as the best option for your patient's disease in that intimate setting of a one on one office visit, the patient is going to want to believe you. That's the essence of the patient/physician relationship. And you're the one who's going to have to live with that. So you better bring the goods.....


Anonymous said...

I agree with you about the procedural outcomes being dependent on the individual surgeon - I've seen some great ones and not so great ones at the very same academic center. However, I'd add that hospital quality measures do affect post-op infection rates and other kinds of complications or potential errors. So the facility matters too. I applaud the work of those hospitals striving to make their quality data transparent and available to the public. Surgeons might want to consider these kinds of things when they decide where to operate on their patients.

Anonymous said...

One problem I see with all this "center of excellence" trash (I mean these papers) is that they typically come from major academic centers, where in the past folks like Dragstedt figured out how to treat peptic ulcer disease and DeBakey developed CABGs. Those guys worked at "centers of excellence" but they seem to have been more interested in advancing the art of surgery and the care of patients than in building their own fortunes and reputations (which happened anyway). Look at who graduates these days from residencies at the surgical meccas: glorified PAs who have to go on to a felllowship (preferably at a center of excellence) to learn how to do one or two operations because their program only does transplants and Whipples, and most of those cases go to the fellows....