Fair point, but then the article is demonstrating that people trained to do specific types of care actually might have better outcomes than generalist education.
This still seems significant to me.
Most of the comments so far seem focused on the fact this was done in a resource-limited setting, and comparing specialists to generalists. I think that's important to keep in mind, and maybe the title was misleading (I didn't post the article).
However, a study like this would be difficult to do in less resource-limited settings due to all sorts of issues, some of which are due to prudence, and some of which probably less so. It's typical of medical research in developed countries to not lower the standard of care, so this sort of study might never get done otherwise.
So, if you take it for what it is, it's suggesting that a type of procedure classically pointed to as a reason for strict medical licensing forms in fact does not necessarily work the way you think in terms of training background and outcomes. It doesn't point to getting rid of licensing, it just suggests that a particular type of educational and training background does not necessarily result in better outcomes.
This type of finding isn't uncommon in different areas of medicine, and the research is often fighting against double standards, in the sense that you're not just comparing training models, you're comparing time with training program experience as well: the alternative training tracks are often newer and involve less opportunities to have worked out problems, improve certain issues etc.
The irony is that this sort of thing is playing out in the US anyway, under the radar. For example, medical schools are often reducing coursework to a 1.5 years or even 1 year, meaning that a PA with an additional 2-3 years of training post degree often has as much experience in the clinic as a new MD. If you took them and gave them 3-4 years of additional training, they'd probably look similar in outcomes to someone coming out of a residency. I might be wrong about that, but healthcare administrators are increasingly voting with their dollars and apparently don't really see a significant difference in outcome.
The comparison makes sense in the context of Sierra Leone, where the study was done. The full article mentions that there are very few surgeons there, and that basic surgeries are usually done by general MDs or ACs, the types of training compared.
Certainly relevant to Sierra Leone and other poor countries, probably not relevant to rich countries that generally have surgeons do this type of surgery.
A minor clarification, it compares MDs to ACs. It says ACs are associate clinicians who have an amount training somewhere between a nurse and a doctor.
At least the way it's used in the US (I know hacker news is not only the US) a medical assistant is someone who has less training than a nurse and is often doing administrative work.
As many commentors note, this is a comparison based on Sierra Leone MDs and assistants. Sierra Leone (as the article notes) is nearly at the bottom of the international "human development index", so very poor - there are not enough surgeons or even MDs to treat everyone.
The surgery studied is an elective hernia surgery. In a wealthy country this could be done in a "hernia repair factory" and I recall, but won't find, a study showing that is the best case: the more practice the surgeon has, the better the outcomes. I would expect the same results here: if the MDs do not specialize in hernia repair, they will be beat by the specialist (even if not an MD).
Very importantly, this was a RANDOMIZED clinical trial. That means that counfounding variables should be equally distributed by the randomization. You generally do not have randomization when you are comparing outcomes, e.g., between the Cleveland Clinic and the Mayo Clinic in the US. That is a great feature of the study. It gives me much more confidence that what they detect is a true difference, not caused by a factor like selective recruitment.
Hernia surgery is not only routine, but quite straight forward. Mesh implants are easy to handle and offer a good long-term outcome. It's one of the first interventions a beginner in the field would learn to master. Also, I am not sure about Sierra Leone, but in Europe and the US it is commonly done as a keyhole surgery, so it requires some dexterity with the tools. The study chose to examine open surgery, which is easier to perform but leads to more post-operative complications. Also, they only looked at elective surgery, so only at cases when the hernia didn't cause further problems demanding a more timely treatment, such as bowel constriction or even inflammation or incarceration. These can be much more challenging to treat properly.
All that being said, the authors purposefully sought to compare performance for a type of surgery that doesn't offer many obstacles for somebody new to the job. I guess it helps to identify tasks that highly-skilled MDs are freed up from doing when they are already scarce in a given location. But it's hardly an indicator that much what they do could be done by others, as some would probably like to believe.
There were only 5 MDs and 6 ACs. How confident can we be that they are measuring the effects of the groups, and not just the individuals? For example, you might get the same result of you compare one group of 5 MDs against another group of 5 MDs.
I suppose someone who does the same thing every day will get good at it.
The balance is probably something about not pushing the boundaries of understanding, or developing new techniques due to the lack of theoretical knowledge.
I would imagine it gets elevated to an MD on call, similar to how I would expect a dental assistant to be more proficient at routine teeth cleaning than the dentist, but I would expect a dentist to be more proficient at something like a filling.
I have seen quite a few people sewn up after surgery and with few exceptions the work that is visible has always looked sloppy to me. Crooked incisions, odd spacing of stitches, knots that look like 4+ half hitches stacked on top of each other, loose ends dangling, etc. I realize the point is not to make your surgery look pretty, but damn, I have seen packs of steaks tied up nicer than my wife’s c-section sutures.
There's a number of good reasons and also bad reasons for the appearance of incisions.
Crooked incision: flank incisions rarely end up perfectly straight and I understand the cesarian in the conscious patient is not optimal from a surgical positioning standpoint, though good for the patient and baby.
Odd spacing: in live tissue, even when you measure 6mm or whatever the tissue seems to move. In addition, there is often a bit of subcutaneous tissue that is hidden better with one placement over another.
Half hitches: these are bad knots, and one of the failure modes of the square knot. If surgeons are leaving lots of these they might be careless. However, monofilament suture has more likelihood to form them and it's preferred on the skin.
Loose ends: monofilament suture is a little unforgiving and the last throw often does not stay in place. This is why 4 throws of the square knot is preferred.
Speed: how long do you want your patient to wait for you to finish the cosmetic portion of the incision? A model might have a plastic surgeon on hand to finish the job.
The layers you cannot see are the important ones from the standpoint of no hernia or infection. Hopefully they are all done flawlessly, but there cosmesis is not the goal.
Often times the reward given to a medical student, after observing a surgery, is being allowed "close" the incision. Not saying it's the case here, but possible.
The truth is that much of medicine is about access to baseline care that a highly trained technician can do. You don't need an MD for it. And people in the world will suffer for lack of access.
In the First World, people get either perfect care or none. The discourse is dominated by "tell that to the guy who is paralyzed by a bush doctor" and "tell that to parents who lost their kid to a charlatan".
Outcomes are everything and a comprehensive public health process allows for making tradeoffs in access and quality to ensure outcomes.
This reminds me of this Russian patient back in school..."you know, back in Russia, you'd be lucky to get a doctor, the nurse would usually take out your appendix". Never was sure she wasn't pulling my leg...
I understand the HN mods changing titles of sensationalist clickbait, but can we agree that maybe titles of articles in scholarly journals should not be changed?
This piece compares non-surgeon MDs with non-MDs (medical assistants) performing minor surgeries in resource-limited settings.
Its a bit of an odd comparison, as the non-MDs have specifically trained in a 3-year program to perform minor surgeries (CapaCare).