Studies on patient outcomes and surgical quality have focused largely on pre-operative and post-operative measures that are often easy to study and analyze. For example, the Surgical Care Improvement Project (SCIP) utilized by the Centers for Medicare and Medicaid Services (CMS) focuses on a number of quantifiable measures such as timely administration of pre-operative antibiotics to prevent wound infections, administration of blood thinners to prevent blood clots, and post-operative blood sugar control. All of these measures have been shown to reduce morbidity and mortality in surgical patients, but even the strictest adherence to these protocols has failed to reduce the disparities in patient outcomes following surgery.
But it is clear, especially to those of us in training, that not all surgeons are created equally. Just as in any other field, there are those who perform at the top of the pack and others who are less than stellar. Pauline Chen comments on this in her New York Times blog, focusing the light on a perhaps the most important and often ignored factor – the surgeon’s skill. New research out of Michigan seems to suggest that a patient’s outcome is directly related to the dexterity of the surgeon. In the study, surgeons with higher mortality rates took 40% more time to complete an operation than top-ranked surgeons. Their patients also had higher chances of developing significant complications – wound infections, pneumonia, bleeding, etc – and were much more likely to require re-operation or readmission.
The obvious problem? How are patients to know? Currently, patients often rely on word of mouth from friends and relatives to select a surgeon, the recommendation of another health care provider, or are simply assigned to the “surgeon on call”.
Since I follow Chen’s posts, I couldn’t help but notice another one of her other posts about surgeons in training. The combination of these two posts almost certainly leads one to believe that an alarming trend in surgical quality may be brewing. The second post begins with an anecdote about a stellar new surgeon that arrived while Chen was in residency, one who is quicker than most of his colleagues and whose patients fared better. His secret? The hundreds of operations he had participated in during residency.
Which is why recent research about residency training is so concerning. With the adoption of work-hour restrictions such as the 80 hour work week, research suggests that residents are losing out on almost a year’s worth of experience. The surgical landscape has changed over time to less invasive operations – meaning less experience at performing surgery “the traditional way” with larger open incisions in case of complications. Additionally, better medical management of certain illnesses has rendered surgery almost obsolete, reducing the number of procedures the typical resident sees during training.
If indeed a patient’s post-surgical outcome is highly dependent on the skill of the surgeon, and the skill of the surgeon is highly dependent on their operative experience, then it only stands to reason that a patient’s outcome is correlated with a surgeon’s operative volume. And with the reduction in work hours and the changing landscape of surgery, there may very well be a looming quality gap in patient outcomes.