A Vital Measure: Your Surgeon’s Skill

To those of us in training, the hospital was cursed. At least when it came to a certain operation.

We dreaded being asked to scrub in at these operations because we knew we would be forced to hold patient parts until our fingers went numb and arms quivered. The surgeons hunted, stabbed and slashed their way through the procedure; and whenever their knife would go a little too far, or their knot would slip, or their stitch pull, we braced ourselves for their fury…and for the inevitable extra time it would take for them to correct their errors.

The patients, many of whom had come in to the hospital walking and talking, ended up lingering for weeks afterward with infections, open wounds and other complications.

But everything changed when a new surgeon came on board. Built like a rugby player, he shocked us first with his speed, and then his results. The once unbearable day-long slog became a morning’s work; and instead of spending weeks in the hospital, his patients went home after eight days.

In the operating room, his bear paw hands turned delicate, teasing out tissues, caressing vessels and nimbly knotting thread as fine as human hair. There was not a single wasted movement; and each step blended seamlessly with the next, giving those of us who had the fortune to observe the sense that we were watching not surgery, but a well-choreographed ballet.

“It’s like you’re just standing there holding the needle or knife,” said one friend who was lucky enough to assist the new surgeon, “and he’s moving the body underneath you.”

I remembered this surgeon — and the dramatic differences between his colleagues and him — when I read a study published recently in The New England Journal of Medicine on the relationship between a surgeon’s operative technique and patient outcomes.

It has been clear for nearly 30 years that not all surgeons produce the same results. The reasons, however, have remained elusive. Most studies on surgical quality have focused on what surgeons do before and after surgery, practices that are easy to measure and analyze, like giving antibiotics to prevent surgical wound infections and administering blood thinners to guard against the development of blood clots.

But even with the most compulsive adherence to these pre- and post-operative protocols, and much to the chagrin of many a well-intentioned health care expert, payer and policy maker, significant disparities in patient outcomes after surgery have persisted.

The reason, observers have postulated, may be the one, obvious thing that most of these initiatives have scrupulously avoided: what goes on in the operating room.

Now an innovative collaboration between researchers, payers and weight-loss surgeons, the Michigan Bariatric Surgery Collaborative, has addressed that-which-could-not-be-named. And their findings have confirmed what patients have long suspected and trainees have long known – the dexterity of a surgeon’s hands can account for much of the differences in how well patients do.

Researchers from the group asked a panel of surgeon-experts to review videotapes of operations performed by 20 unnamed surgeons who were part of the collaborative. They then asked the surgeon-experts to come up with a ranking based on the deftness with which operating instruments were used, the gentleness with which tissues were handled, the degree to which the surgeons were able to expose key areas, the time and amount of movement required to perform each step and the general flow of the operation. The researchers then confirmed that the rankings remained consistent by asking a different group of surgeon-experts to evaluate the videotapes.

To the researchers’ surprise, there were huge variations in operative skill between the practicing surgeons, with the lowest ranked surgeons working at what the reviewers considered a level only slightly better than a trainee at the end of residency, and the highest-ranking surgeons working like “masters” in their field.

“You didn’t have to be an expert to see the difference,” said Dr. John D. Birkmeyer, a surgeon who is lead author of the study and director of the Center for Health Care Outcomes and Policy at the University of Michigan. (You can view video clips of a high- and low-ranked surgeon, below. Warning: graphic content.)

Dr. Birkmeyer and his co-authors then reviewed the records of the 20 surgeons’ post-operative complications and compared them with their rankings. Not surprisingly, surgeons in the bottom quartile took 40 percent more time to complete the same operation and had higher mortality rates than top-ranked surgeons. But their patients also ran a significantly higher chance of developing a whole host of complications, including wound infections, pneumonia, bleeding and thrombophlebitis, and required re-operation and readmission to the hospital after discharge more often than patients of surgeons whose rankings were in the top quartile.

The study is the first to reliably measure operative skills in practicing surgeons and correlate those measurements with patient outcomes. “We now have a scientific way to evaluate a practicing surgeon’s skill that is as reliable as about anything we measure in health care in terms of quality,” Dr. Birkmeyer observed.

Being able to measure operative skill could change how patients and doctors approach surgery. Currently, patients have few direct ways to evaluate a potential surgeon and end up trying to divine the quality of operative technique by researching where the surgeon trained, tracking down board certification and hospital statistics or relying on word-of-mouth. Regulatory organizations, too, must base their licensing decisions on indirect information like a surgeon’s training and performance on multiple choice tests and oral exams. These methods of appraisal, even with the best available approximations of operating room scenarios, can only offer indications of how a surgeon might actually perform in the operating room.

Even practicing surgeons, who have few opportunities after residency training to strengthen their operative techniques, may benefit from the research. Dr. Birkmeyer and his colleagues are currently studying how coaching from “master surgeons” might help other surgeons improve their rankings. “There may be some strategies for not just measuring a problem but ultimately fixing it.”

But it’s those practicing surgeons who may also be most resistant to such evaluations. “For surgeons, performance in the operating room is hugely personal,” Dr. Birkmeyer noted. “Having it evaluated can be seen as highly threatening,”

Still, organizations like The Leapfrog Group, whose members include large employers trying to improve health care, are considering using similar methods to help patients identify safer hospitals for surgery. And Dr. Birkmeyer and his colleagues are extending their efforts to include studies looking at how operative technique might correlate with patient outcomes in prostate, colon and spine surgery. “It makes sense that some individuals might be naturally more talented at surgery, like some people are better at music or athletics,” Dr. Birkmeyer said.

“But this isn’t just about who is the better tennis player,” he added. “People’s lives are at stake.”

October 31, 2013 12:57 pm