Thursday, July 26, 2007
Are You Experienced?
The news of the week includes reference to an article about a study of surgeons doing prostate cancer surgery. Experience counts, it reports; surgeons doing fewer than ten prostatectomies for cancer have significantly poorer results than those doing more than two-hundred fifty (now there's a hell of a range!) The researchers also conclude: if you have cancer surgery, you ought to go to a teaching hospital. They're half right.
In the early years of my practice it sometimes happened that I'd lose a patient to the big city surgeons. Typically it was for breast cancer: I'd see her, do the appropriate workup including a biopsy of some sort, have a lengthy discussion of the surgical options. Back then, given a less-than-full schedule, I even went to people's homes to break the news, sometimes. Very appreciative: "You've done a really great job, doctor. I like you a lot. But my friend had a surgeon in Seattle, and, well, he's been around a long time and, well, you know..." It took a few years before it stopped happening -- probably at least as coincident with my premature graying as with anything meaningful. But in time, for whatever reasons, the outflow stopped; in fact, there was the not entirely rare inflow from those parts...
In describing my mentors and their influence on me, I've said I thought I didn't fully get what they were trying to impart until I'd been out from under them for a couple of years. It's true. But in the context of the article in question, I'm trying to consider in what ways it's the case. Smoother; faster; more confident. An evolving sense of how I saw myself and what I wanted to be. But safer? Getting better outcomes for my patients? I'm inclined, of course, to say no; but maybe data would show otherwise. It's not the first time an article has appeared tying outcome to experience. It certainly makes intuitive sense. And yet it's not the whole story. If I could figure it out ahead of time, I'd rather be operated on by a less-experienced surgeon who does things right than one with hundreds of cases under the belt, done less well.
When I've given readings of my book, a question I'm regularly asked is how to find a good surgeon. It's a toughie, for the non medically-connected person. I begin with the idea of trusting your primary doc; if you have one you like and believe in, you ought to be able to assume she or he wouldn't steer you wrong. Other than the occasional political issue, and the fact that most primary docs don't really understand what goes on in an operating room, I think it's a good bet. Whatever else is true, they do see the patients again after they've sent them off; flesh-and-blood feedback. And, of course, credentials mean something. Training at an excellent program increases the likelihood that a surgeon knows his or her way around a body. Doesn't guarantee. Nor is the opposite true: one of the best surgeons I know trained at a pretty unremarkable place.
Not every operation I learned ended up in my armamentarium in practice. And here's the tricky part: I didn't reject certain cases just because I didn't do them often. Some operations, while complex and challenging, involve nothing but a combination of techniques I used all the time: Whipple procedure; esophagogastrectomy. Uncommon as they might be in terms of numbers, my ability to do them and do them well was not in question. Not in my mind, at least; nor in the outcomes. Other operations involved either techniques I didn't employ regularly, or had the potential for post-op complications with which I didn't deal often enough to feel like I had the breadth of judgment to bring to bear. So I didn't do them: major liver resections; colectomy with ileo-anal pouch creation. (In regards to the latter, I helped a recently minted surgeon do one and showed her a few tricks that shaved a couple of hours off her operative time and smoothed the patient's recovery.) I could do any of those; but I didn't.
What are we to do with this experience/outcome data? If we only go to experienced surgeons, at some point there won't be any, right? How do you get patients if you need to have had patients to get them? Anyone want to sign up to be fodder?
New procedures have, without question, a learning curve. It takes time to get the hang of laparoscopy, for example. One would like to think that, after several years of long days and nights and rigorous supervision, any trainee would come out the other end knowing how to operate. If you know principles of dissection, of exposure, how to handle various tissues, you ought to be able to translate that to most any operation in a way that keeps the patient safe and provides the expected outcome. Somewhere in my mind, in ways I can't entirely sort out -- yet -- it seems to be that there's more going on here than experience with a particular operation.
If there's a solution to the patients' dilemma -- knowing where to go for what procedure -- it ought to involve some sort of mentoring program for surgeons. I may not need to have done two hundred repetitions of an operation if I've received the benefit of training by someone who has. That is, of course, what residency training is all about. But there's more to it than that. My surgical life is entirely involved with a single laparoscopic procedure nowadays. Three surgeons, three anesthesiologists doing one procedure, over and over. From the point of view of smooth operation, in all senses of the word, it's a soaring pleasure. Likewise outcomes. And when other surgeons are planning to start doing that operation, they must be mentored for several cases before getting privileges to do it on their own. These guys are among those that do the mentoring. It might be ideal if for each operation there were such super-specialty centers. But is that practical? Wouldn't people prefer not to have to scatter their body parts across the country?
With the advent of the eighty-hour work week (which, according to many of my pals in academic surgery, is diluting the experience of trainees), such a thing becomes even more critical. If the American College of Surgeons had the resources, it would be arranged that every new surgeon, on completion of training, would be taken under the wing of one who'd been around the block a few times. Such a program would identify those that need a little more polish before being loosed on the world, would impart the knowledge that only comes (apropos that comment about the need to go to training hospitals for certain precedures -- the best surgeons I know, by far, are those in private practice) from being in private practice; and most importantly -- assuming such a thing were possible (probably not) and done in a meaningful way (conceivable) -- would give patients the confidence that they'd be getting a good product when they expose themselves to the surgeon's knife.