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Evaluating Surgical Skill to Improve Outcomes: Lets Go To The Replay Booth

Just as elite athletes are born with amazing skill, elite surgeons and doctors in other procedure-based specialties are also equipped with innate abilities that others do not possess.  Surgical skill is often difficult to quantify.  Certainly, outcomes data can be obtained and reputations are formed over time.  Years of training allow the truly gifted surgeons to develop their skills and perfect their craft.  However, all surgeons are not created equal.  During training, residents and fellows learn by watching the senior staff.  As they progress in training they begin to perform procedures with guidance and as they near the end of their training they are working independently with minimal oversight.  Once training is over, most surgeons have little or no opportunity to continue to improve their skills.  So, how can we best evaluate surgeons and allow patients to make more informed decisions?

For patients, it can be difficult to choose a competent surgeon.  Last week in the New York Times, the issue of how a patient may best evaluate a particular surgeon’s skill was discussed.  Surgery can be life-saving in certain situations but every procedure has finite risks associated with it.  Complications associated with a particular procedure are issues that patients must consider when choosing a doctor.  The best physicians have learned to minimize complications and are also adept at dealing with them quickly and effectively when they do occur.   Certainly, metrics such as board certifications and memberships in professional organizations (such as the American College of Cardiology) can provide some guidance.  However, most measures of surgical ability are purely indirect–board exams containing multiple choice questions and oral exams just aren’t enough.  In residency and fellowship, a trainee can complete all of the requirements of the the ACGME and be declared graduated–even with substandard surgical skills.

Now, a new study published in New England Journal of Medicine explores a new more direct and objective way to evaluate surgical skill.  Previous studies have focused more on what surgeons may do before or after surgery in the care of their patients and very little focus was placed on what exactly was done in the Operating Room.  In the new study, researchers brought together a panel of expert surgeons to evaluate 20 other surgeons ability thru the use of videotapes of the same surgical procedure obtained from the Operating Room.  The researchers found that there was a large variance in skills–the evaluators commented that the surgeons rated the lowest had skills similar to those of trainees and that those at the highest end of the ratings were considered “masters”.  For the first time a study now shows what has been intuitive for years–the dexterity of a surgeon makes all the difference in outcome.  The surgeons rated in the lowest quartile took 40% longer to complete their procedures and had much higher complication and mortality rates.  Moreover, those in the highest rated quartile had much lower rates of readmission and re-operation rates.

In addition to evaluation of skill through video review another very reliable source of information is the opinion of the nurses and support staff that work with the surgeons on a daily basis.  Experienced OR nurses are very good at rating the talent of the operating physician.  They quickly recognize gifted hands and can easily point out those that are not.  However, there is no mechanism in place for other staff to provide feedback to a particular surgeon.

As we continue to work towards healthcare reform, assessing the skill and effectiveness of physicians will be an important part of cost containment.  Significant complications and negative outcomes are costly to both the patient as well as the healthcare system as a whole.  Objectively evaluating surgical ability may transform the way in which patients and insurers are able to choose physicians to care for themselves and their families.  As physicians we have a responsibility to provide the very best care for our patients.  We must use every tool possible to ensure that we can continue to improve our skills as we progress in our careers.  Evaluations such as video observation should be incorporated into training programs and may also play a role in continuing education for physicians throughout their careers.  Ultimately we must protect patients and improve outcomes–Primum non nocere.