Who should cut?

I did a suction dilation and curettage (aka D&C) recently.  A woman had a miscarriage and having failed medical therapy we opted for this procedure.  The procedure went without a hitch.  What struck me about this instance of performing this procedure was that I hadn’t done one in perhaps 3 or 4 years.  This sort of case is typically reserved for junior residents because it’s so ‘easy.’  Furthermore, whether done by a junior or senior resident it is uncommon for me to do most of the case since I mostly just supervise this sort of case.  So was I lucky that despite my relative inexperience things didn’t go awry or are there surgical cases that are so easy a ‘monkey could do it?”  When is a surgical procedure ‘easy’ versus ‘hard?’

Two studies appeared in the April edition of Obstetrics and Gynecology.  Both studies addressed the effect of surgeon factors on surgical outcomes for laparoscopic hysterectomy (a relatively more difficult case than a D&C).  One study was done in the U.S., the other in the Netherlands.  Both studies demonstrated what has been seen in other related studies – more surgeon or hospital volume and better surgeon skills renders better surgical outcomes.  

These findings make sense.  Most of us understand the adage, ‘practice makes perfect.’  The results of one of the two studies stated:

In the multivariable analysis, risk of overall morbidity (relative risk (RR) 0.75), intraoperative complications (RR 0.85), surgical-site complications (RR 0.70), medical complications (RR 0.63), transfusion (RR 0.75), and prolonged hospitalization (RR 0.65) were all reduced when the procedure was performed by a high-volume surgeon.

In this study performing a mere 8 more hysterectomies per year (high volume surgeons were defined as performing 14 operations per year) rendered a minimum of 15% less risk of a negative operative outcome.  Furthermore, high volume surgeons were cheaper spending on average $867 less per case than low volume surgeons.  Do you think most women facing a hysterectomy would want to know if their surgeon was ‘high volume?’  Which type of surgeon do you think health policy organizers would like performing these cases in a day of shrinking health care resources?

The Dutch study adds an additional twist to the volume outcome relationship.  The Dutch researchers added surgical skill that they estimated using a model that included patient, surgeon and environmental factors.  This surgical skills factor led the researchers to conclude that volume alone does not “necessarily guarantee good surgical outcome.”  So if some surgeons possess better skills, either innately or by practice or both, and these skills translate to lower health care costs, why shouldn’t these issues have more sway in health care decision-making?  

The answers to this question are a mix of ethics and statistics.  First of all the overall difference in surgical morbidity is not huge between a low and high volume surgeon (although one does have to wonder if performing just over 1 hysterectomy per month is really ‘high volume’ for comparison among my colleagues we typically perform at least 4-5/month).  For example, ‘any complication’ was 5.8% among low volume surgeons but 4.7% for high volume surgeons.  That sort of difference, while statistically significant and enough to produce some remarkable relative risks, isn’t likely to catch the attention of most women or their potential surgeons.  And the surgical skills model is a bit fuzzy keeping that elusive quality of surgeon assessment still mostly out of investigative reach.  The bottom-line is that while health policy may have incentive to decide who can operate (and thereby save money); poor performers are still likely to be lost in the fog of small effect.

So should surgical training be so egalitarian?  At least in Ob/Gyn there is the view that if you finish your residency or if you do some even less formalized instruction you can operate.  Take a weekend course on how to do procedure ‘x’ wherein you practice on pig parts and poof you’re qualified.  While laparoscopic hysterectomy has grown in popularity a more precipitous rise in minimally invasive hysterectomy can be attributed to the robot.  The surgical robot offers a quirky twist to the problem of surgeon skill and experience.  It is precisely the lack of skill and experience that stimulated the popularity of the surgical robot among gynecologic surgeons.  Given no credible evidence of improved patient outcomes in using the robot for benign gynecologic surgery, it is the devices appeal among surgeons that has propelled this surgical approach.  So were back to – should all surgeons be regarded as the same?  The matter of resources again becomes relevant insofar as the robot exacerbates the cost of low volume surgeons.

All of us want to get the best care possible and in surgery the matter of volume and skill are front and center in defining ‘best.’  Among physicians there is an unspoken unease about our personal skill and experience.  There nearly always seems to be someone better qualified to perform the care expected among the patients we see in our clinics.  If we send everyone out to these ‘better qualified’ clinicians we never improve and done enough we starve.  Access to care can become a problem as physicians drop out of certain kinds of care due to lack of expertise.  This has been one problem seen in subspecialty Female Pelvic Medicine and Reconstructive Surgery.  There are not enough fellowship trained physicians and the training is so variable is it wise to only have subspecialists care for women with pelvic floor problems?  So where is the balance? 

To add to the confusion I’ll share one more story.  In the book, Switch, the authors Chip and Dan Heath share how in learning Minimally Invasive Cardiac Surgery (MICS) hospital teams, including the surgeons, have to prepare to fail.  The learning curve for this procedure is steep and only those willing to learn amidst the failures will push through to becoming successful at an approach to cardiac surgery with significant recovery benefits over the open-heart technique.  In the context of the point the Heath brothers are trying to make the example of MICS is great; however, what about the patients who are the subjects of being ‘learned’ on?  Innovation is great and clearly medicine is better today for the lessons learned via trial and error on unwitting patients in the past but who wants to be a lesson?  How many women today are undergoing robotic surgeries by surgeons who had acceptable alternative techniques but who are compelled, for reasons having little to do with better patient care, to adopt this surgical innovation?  Indeed the chairman of one of the most prestigious Ob/Gyn departments in the world confessed that the robot today isn’t a net patient good but it is a necessary step to tomorrow’s robot.

To this mess I offer a few suggestions:

1. Provide basic volume and outcome performance data for all gynecologic surgeons. 
2. Tighten the hospital credentialing process and add an independent skills assessments piece to be part of that process.
3. Develop third-party CME-like surgeon skills education opportunities that independent of industry teach surgical technique not just ‘as needed’ but as part of regular scheduled skills training.  Use these training sessions as part of the credentialing process.
4. Link advancement in residency to achievement of year-specific surgical skills and volume.  Do not make graduation from residency something only based on time on the job – particularly since that time seems to be getting less and less with residency hour restrictions.
5. Interest in surgery does not qualify one in it.  It is OK to not be good at surgery; there are other great options in and outside of medicine.  Skill can be both an innate and time-limited feature of a surgeon.  Once a great surgeon doesn’t mean always a great surgeon.  Referenced feedback will help clarify these matters.

Ultimately any balance to be found in this inexorably messy process will not come from professional organizations or evidence or government regulation; even if all these oversight mechanisms endorsed my admittedly challenging suggestions.  In the end the balance is found within the individual surgeon.  The moral character of the surgeon is the best defense to finding the right balance between honoring the patient and the profession.  Being ‘other-oriented’ is tantamount to being a true physician and surgeon.  Thankfully the D&C went well presumably due to translated surgical skills from other procedures I more regularly perform and from perhaps some innate sense of how to do what is mostly an easy procedure.  Would some feedback have helped me better assess my performance?  Sure but perhaps we should start with the robot and work backwards.