Thursday, April 28, 2016

Joint replacement - how many does a surgeon need to do to be 'experienced'? Jimi Hendrix

Three Hospitals Hope To Spark A Reduction In Surgeries By Inexperienced Doctors

We quote directly from this recent article:
"The largely unfettered ability of surgeons with minimal expertise to perform high-risk procedures — particularly at hospitals that lack experience caring for significant numbers of patients — has been the subject of a contentious, long-running battle known as the volume-outcome debate.

A groundbreaking 1979 Stanford study found that patients who underwent operations at hospitals that did more of those surgeries had significantly lower death rates than those treated at hospitals where they were done infrequently. That finding has since been replicated repeatedly across many specialties and found to apply to surgeons as well as hospitals. Last month, a large study found that the risk of complications was far higher among surgeons who performed only one thyroid removal annually than among those who did 25 or more of the tricky procedures per year.

Recently the volume battle was reignited when a trio of prominent health systems — Johns Hopkins, Dartmouth-Hitchcock and the University of Michigan — pledged that they will require their surgeons and 20 affiliated hospitals to meet minimum annual thresholds for 10 high-risk procedures. The three systems have asked other hospital networks around the country to join them.

Under the terms of the volume pledge, believed to be the first of its kind, surgeons must perform at least five pancreatic cancer surgeries annually in hospitals where 20 such operations are done each year. For knee or hip replacements, the requirement is 25 per surgeon and 50 per hospital. There are provisions for emergency surgery and for surgeons who sometimes do not meet the threshold because they were on leave; such surgeons might be required to perform a certain number of procedures under supervision."

Comment: The surgeon is the method.
For any person, it takes time to acquire a new skill - whether it is painting, golf, woodcarving or a surgical procedure new to that surgeon. The manner in which the skill level moves from beginner to advanced is referred to as the 'learning curve'. This learning curve is different for every person and every skill. 

The learning curve has been well documented with respect to the acquisition of surgical skill. We like to say, 'the surgeon is the method'. It matters who holds the surgical tools, just like it matters who holds the paint brush.

Jimi Hendrix asked the question "Are you experienced" as shown in this link.

It also takes a certain volume of cases to maintain skill at a mastery level, as shown in these posts

At present, only a few hospitals have taken the 'volume pledge', so it falls to the patient to inquire about the experience of the surgeon

In a prior post we suggested that patients considering surgery ask the following questions of their surgeon:

1 What is my diagnosis?
2 What is the name of the surgery you propose?
3 Do you have any financial relationships with the companies making the products that will be used?
4 Is their any rush in doing this surgery, or is it elective?
5 What are the alternatives to this surgery?
6 How many of these surgeries have you personally performed?
7 Are you fellowship trained to perform this operation?
8 What complications have you and others experienced with this procedure?
9 What are the usual results of this operation in your hands?
10 What is the likelihood that I will have lingering pain, limitations or disability?
11 What special care, rehabilitation will I require for the period after surgery?
12 How long is it likely to be before I can return home, return to work, return to my recreational activities?
13 Do you consider me a good candidate for this surgery in your hands?
14 If I wanted to get a second opinion, will you provide me with all my records to take to another surgeon?

We suggest patients take this 'check list' to their surgeon for the preoperative discussion.


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