
A Vital Measure: Your Surgeon’s Skill - tokenadult
http://well.blogs.nytimes.com/2013/10/31/a-vital-measure-your-surgeons-skill/
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DanBC
The UK has a concept of patient choice. The patient can choose one of four
hospitals to have their surgery. This is supposed to drive up quality.

Obviously it doesn't. Experts have difficulty telling why one surgeon is
better than another (Ann works on more difficult cases than Bob; Ann uses an
older technique than Bob; Ann isn't as good as Bob; etc etc) so patients end
up choosing based on waiting times, or the car parks, or weird things.

There's a lot of room in medicine for better use of numbers. It's weird that
"ethics" prevents us from using these data to save lives.

~~~
carbocation
Ethics used to prevent pharmacists from telling patients what was in
medication bottles. Norms can change.

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haldujai
People often forget that the medical profession's highest priority isn't the
health of you, the patient. If you were to grab a medical ethics book you will
first be told that the well being of the population as a whole surpasses any
individuals rights.

Let's assume a hypothetical where doctors are ranked, let's also assume that
insurance will pay for all doctors. Naturally demand for these physicians or
surgeons will rise dramatically. If we take Ontario (Canada) as a case, we can
see a situation where there is not a free market and physicians can't start
charging more. What happens? Well wait times become significantly longer and
people start waiting longer to see the best physician possible rather than
having a more immediate operation with a lower ranked physician. There is, of
course, increased risk the longer you wait for an operation even as simple as
a hernia. But patients often don't understand that and can't make logical
choices without being 'forced', for lack of a better word, and told they must
do it soon with surgeon X. In this case overall population health decreases,
complications, morbidity and mortality rise from delays. You also run the risk
of complex patients being unable to be operated on by the best because they
are too busy doing an operation on a cut and dry case. This is the case in
Ontario (largely anecdotal evidence, albeit from a very large pool) where
people flock to Toronto on the perceived notion that surgeons affiliated with
the most academically prestigious medical school are better than those in a
community centre.

It is important to ask whether the lower ranked surgeons should or should not
be able, and allowed, to perform the operations, if they are unqualified they
shouldn't be allows to practice. The idea of rankings to improve patient care
really rests on the notion that the lower ranked surgeons have an effectively
higher risk rate (note that I did not say statistically significant). Saying
that complications go down from 2% to 1% with higher surgeons while
significant is not effectively a difference that should affect choice. I don't
know the precise numbers but this is something that must also be considered
before making any judgements. While I have no vested interest, and no opinion
on the matter, it is important to think why the system is the way it is rather
than blindly changing things in the name of progress. This system would allow
physicians to charge more in the US (due to more demand, which has it's own
slew of ethical considerations) and the medical establishment is greedy to say
the least. If the top surgeons could make more money with little to no harm
they would.

~~~
apsec112
Rationing with waiting lists is dumb, always has been and always will be. The
smart ways to ration are by money (better surgeons charge more), or by QALY
(better surgeons do more important operations on sicker people). And even with
single-payer, there's no reason you can't pay better surgeons more.

It's true that not everyone can have a top surgeon. But for serious surgery,
the "complication" is frequently _death_. It's extremely silly to tell people
that 1% chance of death vs. a 2% chance of death "shouldn't affect their
choice". I don't know about you, but I _don 't want to die_, even as I accept
that small chances of death are sometimes unavoidable.

Regarding medical ethics, obviously _in the abstract_ we should prefer saving
ten lives to one life. But _in practice_ , it's often better to have a rule
like "don't kill people" than "kill people when it serves the common good".
"Don't kill people" is very easy to understand, and very easy to enforce. The
"common good" is abstract and fuzzy, and can be used to justify anything from
fighting malaria in Africa to Stalin's Holodomor ("can't make an omelet
without breaking some eggs").

~~~
haldujai
Sorry but you're incorrect. Your assumption of the complication being death is
exaggerated, the surgery in question here is not that serious. Even if it were
death someone would have to model the adverse effects of the increased waiting
list. People waiting might result in an increase in mortality surpassing the
doubled risk from surgeon error.

How do you quantify which surgeons are better? I'm not an expert but surely
this study's methodology is not without it's own assumptions. Things like
complication rate vary wildly with patient population and other factors. This
isn't a telemarketing job where you quantify easily. Similarly how can you
quantify who the best programmer is? What is the economic cost of quantifying
who the best surgeon is? How expensive is it to apply this study to every
surgery? We must ensure that the rankings system is valid before applying it
to prevent perverse incentives such as only taking low risk cases. You don't
want a USNews Week type system like you have for universities which has
obvious flaws and biases.

You say waiting lists are dumb, but why? Are you 'killing people' by letting
an inferior surgeon operate? Why is 'don't kill people' easy to understand and
enforce? By not killing one to save ten are you not killing ten people? You're
seeing this as black and white. This is not the case. Whether it is better to
save one or ten I am not the person to judge, but you are oversimplifying this
drastically.

The ethical question here is NOT sentencing someone to death like killing
someone to harvest organs. It's more similar to doing nothing to save someone
most likely to die in order to save ten, like how they do military triage.

Life is 'abstract and fuzzy'. This isn't an engineering challenge, as you say
there are several things to consider. Stalin ignored the human aspect, is this
right or wrong? How can you blindly answer this without supporting your
conclusion. What seems humane isn't always the right answer to things. By your
same argument are layoffs ever justified despite it being for the common good
for the company and the remaining employees?

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murtza
Data on patient outcomes for individual healthcare providers is not currently
available, but the data at the hospital level is. If a hospital is a Medicare-
certified, then it is required to report quality of care metrics including
deaths, complications and readmissions.

When researching and comparing doctors, as rschmitty mentions, gather all the
relevant publicly-available data such as your state's malpractice claims
database, research publications, and quality of associated institutions.

Check out Medicare's Hospital Compare tool to see the quality of care metrics
for your local hospitals:
[http://www.medicare.gov/hospitalcompare/search.html](http://www.medicare.gov/hospitalcompare/search.html)

Here is the quality of care dataset that includes over 4,800 US hospitals:
[https://data.medicare.gov/Hospital-Compare/Agency-For-
Health...](https://data.medicare.gov/Hospital-Compare/Agency-For-Healthcare-
Research-And-Quality-Measure/vs3q-rxc5)

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danso
The state of New York, every couple of years, publishes a report that rates
all of the heart surgeons, including how many operations they did and how many
of their patients died. This data is shown at both the surgeon and the
aggregated hospital level:

[http://www.health.ny.gov/statistics/diseases/cardiovascular/](http://www.health.ny.gov/statistics/diseases/cardiovascular/)

AFAIK, NY is the only state that does this. Looking at the report gives you a
good idea of how complicated doing any kind of indexing of performance
is...for example, there is an attempt to calculate expected mortality rate, as
a high mortality rate for a surgeon may indicate that that surgeon, being the
top of his or her field, may deal with the most critical and difficult cases.

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tokenadult
Here is a link to the medical journal article discussed in the newspaper
column submitted here:

"Surgical Skill and Complication Rates after Bariatric Surgery"

John D. Birkmeyer, M.D., Jonathan F. Finks, M.D., Amanda O'Reilly, R.N., M.S.,
Mary Oerline, M.S., Arthur M. Carlin, M.D., Andre R. Nunn, M.D., Justin
Dimick, M.D., M.P.H., Mousumi Banerjee, Ph.D., and Nancy J.O. Birkmeyer, Ph.D.
for the Michigan Bariatric Surgery Collaborative

N Engl J Med 2013; 369:1434-1442 October 10, 2013 DOI: 10.1056/NEJMsa1300625

[http://www.nejm.org/doi/full/10.1056/NEJMsa1300625](http://www.nejm.org/doi/full/10.1056/NEJMsa1300625)

"Background

"Clinical outcomes after many complex surgical procedures vary widely across
hospitals and surgeons. Although it has been assumed that the proficiency of
the operating surgeon is an important factor underlying such variation,
empirical data are lacking on the relationships between technical skill and
postoperative outcomes."

My mother was a surgical nurse at my state's best teaching hospital. She once
was able to line up the "all star team" when one of my near relatives needed
surgery. When the best surgeon at the hospital operates with the best surgical
resident at the hospital, assisted by the best anesthesiologist and the best
team of surgical nurses (my mom, of course, did NOT join the surgery team, as
it is just too tense to operate on a near relative) work together, the surgery
outcomes are fine. Informal referrals like this work for patients who know
someone who knows who the good surgeons are. For the long-term development of
better patient outcomes, it will be important to have a data-gathering system
that turns informal impressions of who does good work from anecdotes into
carefully measured data that are shared with hospital administrators and
residency program teachers and insurers and others who have power to nudge
poor-performing surgeons either to improve their skills or change their areas
of practice.

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DanielBMarkham
I had this surgery, a roux-en-y, so as you can imagine I found the videos very
interesting! (Wonder if somebody recorded my surgery?)

Before I had the operation I did a lot of research on the internet, but it was
difficult to pin down particular surgeons. As the article points out, you can
find stats on hospitals, so I went with that. In addition, surgeons can be
certified by various boards, so I also used that. Then you can look at
complication rates by surgical center -- very important. Finally, you can look
at the size of the practice and how many patients they process per year. More
is better. Surgeons who do a lot of the same thing for many years with lower
complications than average are probably working towards the top of their game.

But that was hours and hours of research, and I imagine it all boils down to
exactly what this article brings out: skill in the operating theater. (From my
experience I think a strong secondary trait is the ability to carefully pre-
screen future patients)

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nezumi
So, how do surgeons train? The commentary in the videos reminds me of martial
arts training. It takes years to become fluent in most martial arts and the
requirements are quite similar - a steady hand, economy of motion, spatial
awareness, etc. But a good art has a curriculum where those skills can be
trained independently of situations where you might injure yourself or others.
Another possibility is - perhaps some people just don't have the knack for it
and won't develop it. Is anything done to weed them out at the start of their
training?

~~~
hershel
Some Canadian dental schools require passing a dexterity test. This is not a
requirement in the u.s.

~~~
jessaustin
My brother is in dental school in the USA. A dexterity test was part of the
_admissions_ process.

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onesun
Why hasn't it occurred to anyone before now that surely all surgeons are not
created equal? As an engineer, I can't legally share examples of my work with
potential employers because it's owned by the company I work for. Does anyone
know if this applies to surgeons too? Can potential employers of surgeons
request to see these videos to assess their performance?

~~~
ye
All that matters is the success rate. Watching videos of individual surgeons
is pointless to pretty much everyone except surgeons.

I'd love to have the stats on each doctor.

~~~
PeterisP
Stats are hard because of all the other factors involved. It would be quite
likely for the very best surgeons to have lower survival rates than mediocre
surgeons, simply because the mediocre surgeon would refer the objectively
harder cases to the expert, which would give better chances for that
particular patient while lowering his 'batting average'. And if you give
direct financial motivation for doctors to avoid taking such patients, then
it's a bad thing for the whole system.

Stats can help you weed out obvious outliers - i.e., the ones who should be
kept away from patients; but it's not so simple to make them useful in actual
prioritization.

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conorh
Interesting article. My wife is a surgeon and I'm interested to see what she
has to say about it. One small anecdote - recently she had a colleague
(another surgeon) ask her discreetly whether she would recommend another
surgeon for an operation. Her colleague had known this other surgeon for many
years, worked in the same department as them in fact, and still did not know
if the other surgeon was good or not.

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narrator
The best way to choose a surgeon is to get a personal recommendation from a
doctor who is a personal friend. This will at least prevent you from getting
the absolute bottom of the barrel.

~~~
conorh
See my other post in this thread about this, but I disagree. Even other
surgeons often do not know how good another surgeon is - unless they have
operated with them directly.

~~~
jessaustin
Many members of my family have been on the staffs or in the employ of various
hospitals. From what I've heard, if one has an inside connection it would be
very difficult to _avoid_ learning of a particular surgeon's poor therapeutic
outcomes. It's true that past results are not perfect indicators of future
results, but unless you just transferred to this hospital, every nurse on
every floor has a firm opinion of whether she'd let you operate on her family.

~~~
conorh
I guess it depends on who you ask. My wife (a surgeon) says that this is often
not true for most of the staff. For example if you ask the OR/Floor nurses
they will know if the surgeon is truly terrible, but in her experience
(hearing from the nurses) she says that she is often surprised by who they
think is a good surgeon. She does say however that the anesthesiologists
working with the surgeon usually have a good idea.

~~~
jessaustin
I'm sure she's right, in that many nurses, administrators, and non-surgical
physicians wouldn't have the nuanced understanding of surgical ability that
she does. Just the same, I expect their rough sorting isn't _too_ far off the
mark. They certainly know more than the general public!

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epo
"Skill" as a catch-all term is a meaningless word bandied about by those
trying to sound as though they know what they are talking about.

There are two sets of attributes, the first (commonly called "skill" but
perhaps better called "technique") describes how well you can carry out the
"motor" activities of your job. The other, and more important in critical
circumstances, is "judgement".

To describe it by analogy with driving, in the beginning you concentrate on
developing experience in operating the vehicle, eventually this becomes more
or less automatic. People call this skill and they are wrong, it is a set of
learnt reflexes. More important is judgement, knowing how to maintain road
awareness, knowing when and how to overtake, when to speed up and when to slow
down etc, etc. NB when people talk about the dangers of drinking and driving
it is impaired judgement they are mostly talking about (although there is some
impaired skill such as poor reaction times which stops them getting out of
problems their degraded judgement has got them into).

Judgement comes with experience and follows skill acquisition. With surgeons
you would hope they know how to make a cut (they have technique). What you
really want is someone who knows where and what to cut (they have judgement).

And yes, all of this applies to programming and systems design.

~~~
crusso
_The other, and more important in critical circumstances, is "judgement"._

Whether I die because the surgeon was clumsy and nicked my aorta or because
the surgeon exercised poor judgement by not counting sponges routinely so he
left one that caused a fatal blood clot would be irrelevant to me because I
would be dead.

All that matters are outcomes based upon an apples to apples comparison of
similar patient contexts.

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jbl
I'd be interested in reading the original paper. It wasn't immediately obvious
if the researchers had stratified surgeons by experience (either number of
times procedure had been done or years in the field). I would imagine less
experienced surgeons to still be developing their technique.

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IvyMike
In the film "Manda Bala", there's a scene where a team of surgeons, led by the
world expert in this particular procedure, insert a scrap of reshaped
intercostal cartilage under a patient's scalp to reconstruct an amputated ear.
The motion the team displays in that two second clip is a beautiful as any
choreographed dance move.

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liminal
Reminds me of this old Kids in the Hall skit:

Bad Doctor:
[http://www.youtube.com/watch?v=Pbjypn9JtKE](http://www.youtube.com/watch?v=Pbjypn9JtKE)

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stiff
Anyone knows what operation are they doing in the video?

~~~
Ives
Looks like a gastric bypass.

