Do some surgeons suck at surgery?

[FutureDoctor317]

Going through my surgery clerkship, I seemed to notice that a lot of surgeons like putting down other surgeons. I heard people say things like he's too slow, scared to perform big surgeries by himself, or this guy did whatever in the OR once. It always seemed unprofessional to me but got me curious. Do you guys think that surgical skills vary dramatically between attending surgeons? Do you think there are doctors out there that end up finishing a surgical residency and are not competent to perform surgery?

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[cpants]

Going through my surgery clerkship, I seemed to notice that a lot of surgeons like putting down other surgeons. I heard people say things like he's too slow, scared to perform big surgeries by himself, or this guy did whatever in the OR once. It always seemed unprofessional to me but got me curious. Do you guys think that surgical skills vary dramatically between attending surgeons? Do you think there are doctors out there that end up finishing a surgical residency and are not competent to perform surgery?

In short, yes. Some surgeons aren't good at surgery. If you spend any time operating with other surgeons, you will quickly start to realize this. Ask any surgery resident and they will rapidly be able to identify a couple of docs they would never allow to lay a knife onto themselves or a loved one. Completing a residency just means you showed up every day, not that you are competent.

 

[KLPM]

There is a local private general surgeon where I am from. She easily takes 2 - 3 times longer than everyone else to complete routine lap chole/appy. She orders tests illogically and her complication rates are extremely high. Most of her patients will end up at the hospital for some issues related to her operation.

Is she bad?

 

[Trauma Surgeon]

In short, yes. Some surgeons aren't good at surgery. If you spend any time operating with other surgeons, you will quickly start to realize this. Ask any surgery resident and they will rapidly be able to identify a couple of docs they would never allow to lay a knife onto themselves or a loved one. Completing a residency just means you showed up every day, not that you are competent.

I thought this was only true for European surgeons? With the rigorous training that you receive, case-logs, in ward exams, ABSITEs, and so on... I was under the impression that once becoming attending you would have some kind of "minimum" surgical skills that was equal between the attendings!?

 

[SLUser11]

Going through my surgery clerkship, I seemed to notice that a lot of surgeons like putting down other surgeons. I heard people say things like he's too slow, scared to perform big surgeries by himself, or this guy did whatever in the OR once. It always seemed unprofessional to me but got me curious. Do you guys think that surgical skills vary dramatically between attending surgeons? Do you think there are doctors out there that end up finishing a surgical residency and are not competent to perform surgery?

I would opine that the trash-talking among surgeons far outweighs the actual incidence of surgeon incompetence.

Certainly, there are some surgeons that are more gifted than others. Some surgeons are simply better trained than others. In general, however, most surgeons are competent and capable to perform surgeries within the scope of their practice, regardless of what the residents, OR staff, and other attendings think.

Personality has a lot to do with the perception of ability. I may be dubbed by FPs as the "best surgeon in town" when they speak to their patients, despite them never actually seeing me work. This is potentially based on my good outcomes, but more likely, it's because I'm nice to them, and we sit together at the lunch table. The same goes for inability......if a surgeon is a jerk to residents and OR staff, their bad outcomes will be advertised and amplified.

I certainly don't mind when patients tell me "I've heard you're the best in town, and if my doctor had cancer, he would come to you." However, I've only been in practice for a year, so I'm not sure that I've earned that praise yet....I think my pleasant disposition gets me farther than my bad@$$ skillz (with a Z).

Sometimes, I feel the same way when I hear residents or OR staff badmouth another attending...are they really that bad, or is there some bias altering their perception?


Anyway, sorry about the rant...to answer your question directly: yes, there are some surgeons that are not good technicians, but inadequate surgeons who put the well-being of patients in danger are not too common...certainly seem to be more common in training environments, though....

 

[Kahreek]

I thought this was only true for European surgeons? With the rigorous training that you receive, case-logs, in ward exams, ABSITEs, and so on... I was under the impression that once becoming attending you would have some kind of "minimum" surgical skills that was equal between the attendings!?

what

 

[maxheadroom]

Personality has a lot to do with the perception of ability. I may be dubbed by FPs as the "best surgeon in town" when they speak to their patients, despite them never actually seeing me work. This is potentially based on my good outcomes, but more likely, it's because I'm nice to them, and we sit together at the lunch table. The same goes for inability......if a surgeon is a jerk to residents and OR staff, their bad outcomes will be advertised and amplified.

I certainly don't mind when patients tell me "I've heard you're the best in town, and if my doctor had cancer, he would come to you." However, I've only been in practice for a year, so I'm not sure that I've earned that praise yet....I think my pleasant disposition gets me farther than my bad@$$ skillz (with a Z).

1. I think the "My PCP said you're the best" thing is a PCP trying to reassure the patient that the surgeon is good. Frequently it's more like, "Dr SLUser hasn't caused any major catastrophes that I know of yet and we can actually get you in to see him quickly."

2. Agree, quite a bit of it is that you're nice to the PCPs. Almost as much is that you've been nice to previous patients of that PCP and s/he had good feedback from the patient. PCPs view the consultants that they use as a representation of themselves. If the consultant is nice, helpful, makes the patient happy, then the PCP sees that as a good reflection upon themselves. Bad consultants cause a headache for PCPs who have to spend time apologizing to the unhappy patient.

3. The three A's of surgical practice . . . available, affable, able . . . notice that "able" comes last.

 

[Yoyomama88]

honestly performing the surgery well is one thing, but actually using your brain to decide if surgery is indicated for a patient is another. You need to be excellent at both to be a great surgeon, doubt many surgeons are excellent at both 95% of the time.

 

[rph3664]

The same goes for inability......if a surgeon is a jerk to residents and OR staff, their bad outcomes will be advertised and amplified.

Ditto pharmacy and nursing. Trust me, even those of us who never set foot in the OR know who does, and doesn't, belong in the OR.

 

[SLUser11]

You need to be excellent at both to be a great surgeon, doubt many surgeons are excellent at both 95% of the time.

I disagree. Great surgeons are common. Appropriate surgical decision making is also common.

As much as we pride ourselves on our ability to make the right decision to operate (or not operate), I think practicing surgeons become button men to some degree. It's not like the community general surgeon is hemming and hawing for hours trying to decide if an appendix or gallbladder should come out...those cases are often pretty straightforward.

 

[VA Hopeful Dr]

1. I think the "My PCP said you're the best" thing is a PCP trying to reassure the patient that the surgeon is good. Frequently it's more like, "Dr SLUser hasn't caused any major catastrophes that I know of yet and we can actually get you in to see him quickly."

2. Agree, quite a bit of it is that you're nice to the PCPs. Almost as much is that you've been nice to previous patients of that PCP and s/he had good feedback from the patient. PCPs view the consultants that they use as a representation of themselves. If the consultant is nice, helpful, makes the patient happy, then the PCP sees that as a good reflection upon themselves. Bad consultants cause a headache for PCPs who have to spend time apologizing to the unhappy patient.

3. The three A's of surgical practice . . . available, affable, able . . . notice that "able" comes last.

As a PCP.... yes, yes, and yes.

 

[Yoyomama88]

The reason why unnecessary appendectomies and cholecystectomies happen daily is because Button men surgeons THINK the diagnosis is straightforward when in fact it is not. This of course and the whole fee-for-service gig in private practice doesn't help either.

 

[SLUser11]

The reason why unnecessary appendectomies and cholecystectomies happen daily is because Button men surgeons THINK the diagnosis is straightforward when in fact it is not. This of course and the whole fee-for-service gig in private practice doesn't help either.

That's extremely insulting, intentional or not.

What is your level of real-world experience with this?

 

[VisionaryTics]

That's extremely insulting, intentional or not.

What is your level of real-world experience with this?

Pre-clinical medical student.

 

[VisionaryTics]

The reason why unnecessary appendectomies and cholecystectomies happen daily is because Button men surgeons THINK the diagnosis is straightforward when in fact it is not. This of course and the whole fee-for-service gig in private practice doesn't help either.

honestly performing the surgery well is one thing, but actually using your brain to decide if surgery is indicated for a patient is another. You need to be excellent at both to be a great surgeon, doubt many surgeons are excellent at both 95% of the time.

The stuff you post on the allopathic board does a pretty good job of highlighting your ignorance regarding the practice of medicine. I don't think you'll win arguments against attending surgeons.

 

[Yoyomama88]

Clinical Medical Student now. I've seen enough so far to see how low of a threshold many of these general surgeons have for operating.

Colectomy to "cure" a patient of constipation who happened to also be on 80 mg of oxycodone daily pre-op.



Cholecystectomy done on a patient complaining of lower left quadrant abdominal pain after eating. Surgery did nothing.

 

[Yoyomama88]

LOL do you guys live under a rock?


http://www.usatoday.com/story/news/...sary-surgery-usa-today-investigation/2435009/

 

[mimelim]

LOL do you guys live under a rock?


http://www.usatoday.com/story/news/...sary-surgery-usa-today-investigation/2435009/

Did you actually read the article or just the title? Serious question.

 

[mimelim]

The reason why unnecessary appendectomies and cholecystectomies happen daily is because Button men surgeons THINK the diagnosis is straightforward when in fact it is not. This of course and the whole fee-for-service gig in private practice doesn't help either.

To be honest, you must know very very little about appendectomies or choles. You should probably have some sort of foundation before you start going after people.

 

[Yoyomama88]

Wow I must be striking a chord with all you surgeons. The only way to fix the problem is to admit there is one. Unnecessary surgery is rampant in the U.S. healthcare system. Fact.

 

[Yoyomama88]

Wow impressive, how exactly were you able to determine my knowledge of indications for appendectomy and cholecystectomy from my prior posts? You must be psychic.

 

[Yoyomama88]

Have any of you ever actually offered a patient with appendicitis IV antibiotics instead of appendectomy? While you can make the argument that if an appendix is at risk for bursting, you should go straight to appendectomy, but what is the actual risk of this happening? It depends on the size of the appendix and if a fecalith has been identified, correct?

What is the downside to prescribing antibiotics to a patient, observing the patient, and then deciding on surgery given the fact that 50 PERCENT OF PATIENTS will be cured with antibiotics alone?

You can bet the majority of surgeons will not even offer this non-surgical approach to a patient. Why? What is the reason for this?

 

[Yoyomama88]

As far as I'm concerned, if the patient is not at risk for rupturing their appendix, and you perform surgery without offering this option, then you are performing a borderline unnecessary surgery.Was the surgery ABSOLUTELY necessary? No...it was not.


I bet if you told the patients about the risks of general anesthesia, incisional hernias, and adhesions, you might convince them to try an antibiotic before an invasive procedure.

 

[core0]

As far as I'm concerned, if the patient is not at risk for rupturing their appendix, and you perform surgery without offering this option, then you are performing a borderline unnecessary surgery.Was the surgery ABSOLUTELY necessary? No...it was not.


I bet if you told the patients about the risks of general anesthesia, incisional hernias, and adhesions, you might convince them to try an antibiotic before an invasive procedure.

And what are those risks if you are all knowing?

 

[Yoyomama88]

Who cares what the actual numbers are? Any rational person wouldn't subject themselves to the major risks of surgery if that condition has a high likelihood of being cured by an antibiotic. I'm speculating here, : the risk of dying from uncomplicated appendicitis is probably similar to the risk of dying from the operation itself.

 

[SLUser11]

Who cares what the actual numbers are? Any rational person wouldn't subject themselves to the major risks of surgery if that condition has a high likelihood of being cured by an antibiotic. I'm speculating here, : the risk of dying from uncomplicated appendicitis is probably similar to the risk of dying from the operation itself.

Donny, you're out of your element...

 

[Yoyomama88]

Yea pull up the data and we'll see how crazy i am. What is crazy is the overzealous demeanor of surgeons.

 

[ThoracicGuy]

The reason why unnecessary appendectomies and cholecystectomies happen daily is because Button men surgeons THINK the diagnosis is straightforward when in fact it is not. This of course and the whole fee-for-service gig in private practice doesn't help either.

An accepted number of negative appendectomies is around 18% nationwide. Appendicitis is usually a clinically diagnosed disease that you won't know for sure until you get in there. As for unnecessary cholecystectomies, I can think of few instances when that happens. Can surgeons make the wrong diagnosis? Absolutely. Do they make the wrong diagnosis on purpose just to be able to bill a little bit more? That's ridiculous. I'm not sure if you had a bad experience on a surgery rotation or what... in the past I remember you saying that surgery should be the last option for anyone...

 

[Yoyomama88]

From the article ""I think there's a higher percentage who are not well trained or not competent" to determine when surgery is necessary, Santa says. "Then you have a big group who are more businessmen than medical professionals — doctors who look at those gray cases and say, 'Well, I have enough here to justify surgery, so I'm going to do it.'"

The pressures are real. Doctors' income can hinge largely on the number of surgeries they do — and the revenue those procedures generate. Those numbers also can determine whether doctors get privileges at certain hospitals or membership in top practices.

There's no way to know what portion of unnecessary surgeries are related to these more subtle pressures, as opposed to poor training or fraud. Researchers simply know they're happening."

 

[Yoyomama88]

And surgery should always be a LAST option. The only reason it ever becomes the First option is because there are no other options that could possibly work. So surgery only becomes the first option by default in specific circumstances.

Any time there are any other Less invasive/Less Risky options on the table that can work for a patient, those should be tried before surgery.

 

[thedrjojo]

And surgery should always be a LAST option. The only reason it ever becomes the First option is because there are no other options that could possibly work. So surgery only becomes the first option by default in specific circumstances.

Any time there are any other Less invasive/Less Risky options on the table that can work for a patient, those should be tried before surgery.

Um, what? You really are a tool it seems and definitely out of your element.

And for apps has really only been extensively studied in highly selected populations which are very hard to generalize too... Some studies excluded any signs of peritonitis, another enrolled about 1/hospital/month which clearly shows selection bias... A well powered and more generalizable one showed 26.6% failure at 2 weeks, and most show about 30-40% failure by 1 year. Cochrane in 2011 decided the evidence was insufficient to recommend either way... So I'm sure you know more than them...

Medical decisions are not often black and white. Asymptomatic 60% carotid stenosis... Do you take the surgery with high perioperative stroke/death risk (3%) but a much greater reduced 3year stroke risk (11% vs 5%) compared with medicine alone (ACAS)... So your bs blanket statement is, bs. Comparative effectiveness research is needed, and in many cases, highly favors surgery, and in others it favors medical management, and we'll, people are getting fistula earlier than less invasive catheters, and ulcer surgery is almost unheard of...

 

[loveoforganic2]

Clinical Medical Student now. I've seen enough so far to see how low of a threshold many of these general surgeons have for operating.

Colectomy to "cure" a patient of constipation who happened to also be on 80 mg of oxycodone daily pre-op.

Cholecystectomy done on a patient complaining of lower left quadrant abdominal pain after eating. Surgery did nothing.

And surgery should always be a LAST option. The only reason it ever becomes the First option is because there are no other options that could possibly work. So surgery only becomes the first option by default in specific circumstances.

Any time there are any other Less invasive/Less Risky options on the table that can work for a patient, those should be tried before surgery.

You're conflating invasion and risk, which don't necessarily go hand in hand. You really think less than a semester into clinicals you have the knowledge base to cogently argue against individuals with 6+ years of practical experience on you? Good grief

 

[ThoracicGuy]

And surgery should always be a LAST option. The only reason it ever becomes the First option is because there are no other options that could possibly work. So surgery only becomes the first option by default in specific circumstances.

Any time there are any other Less invasive/Less Risky options on the table that can work for a patient, those should be tried before surgery.

Most conditions that lead to surgery have other options that can be tried on the table. The reason why surgery is the best option for many of those conditions is that it has the best chance for success. You can try medical management of your coronary disease and it can work for some people, but studies show that long term survival is improved in three vessel disease with operative bypass. You can try medical management of your breast cancer. Some chemo/radiation treatments out there can shrink the tumor to nothing or almost nothing. Your best chance for long term survival, though, is surgery with possible chemo/radiation. So your blanket statement that surgery is only an option if nothing else works shows your supreme ignorance when it comes to medicine. You seem to act like you know it all and you aren't even out of medical school yet. You are not as smart as you think you are...

 

[mehc012]

As far as I'm concerned, if the patient is not at risk for rupturing their appendix, and you perform surgery without offering this option, then you are performing a borderline unnecessary surgery.Was the surgery ABSOLUTELY necessary? No...it was not.


I bet if you told the patients about the risks of general anesthesia, incisional hernias, and adhesions, you might convince them to try an antibiotic before an invasive procedure.

Wow, you don't read before you respond, do you? The poster you are responding to specifically said that they discuss both options with the patients...and that most choose the surgery. Hell, if you came up to me and said "I can get this appendix out today and it will definitely solve the problem...or we could do abx, skip the surgery with xyz risks, and sit around here for a few days taking drugs that make you have terrible diarrhea, with a 20% chance that you'll need surgery anyway" I might just go with the surgery myself. People generally tend to assume that the risks of anesthesia don't apply to them anyway, just as they assume they will have no adverse reactions to any OTC meds even though there's a disclaimer a mile long inside the label.

 

[SLUser11]

And surgery should always be a LAST option. The only reason it ever becomes the First option is because there are no other options that could possibly work. So surgery only becomes the first option by default in specific circumstances.

Any time there are any other Less invasive/Less Risky options on the table that can work for a patient, those should be tried before surgery.

I applaud you on your ability to anger so many people with a few ignorant-yet-brilliant posts. That is talent. And, you are unintentionally acting out the surgeon stereotype of "sometimes wrong, never in doubt," which I am enjoying.

I think it's fine to mouth off in an anonymous internet forum, but I urge you to overcome some of your bias when you encounter real-life surgeons in your clinical years. Most of them are very experienced, and know the risks, benefits, and alternatives to surgery much better than you do. They've spent their entire professional careers making difficult choices and dealing with the positive and negative consequences. My comment about "button men" was based on my opinion that many surgical decisions are actually quite simple, and not much thought is required....e.g. appendicitis and cholecystitis.

I have a question for you: If you developed appendicitis tomorrow, would you demand that the doctors treat you non-operatively?

 

[Dr.LeoSpaceman]

I applaud you on your ability to anger so many people with a few ignorant-yet-brilliant posts. That is talent. And, you are unintentionally acting out the surgeon stereotype of "sometimes wrong, never in doubt," which I am enjoying.
?

This whole exchange kind of reminds me of dealing with some of the patients who are physicians (but not surgeons) or other allied medical fields with inguinal hernias and absolutely refuse a mesh repair because of the "risks of the mesh". They've never done a hernia repair, but they're absolutely sure they know what the right way to do it is.

 

[MOHS_01]

The reason why unnecessary appendectomies and cholecystectomies happen daily is because Button men surgeons THINK the diagnosis is straightforward when in fact it is not. This of course and the whole fee-for-service gig in private practice doesn't help either.

 

[MOHS_01]

And surgery should always be a LAST option. The only reason it ever becomes the First option is because there are no other options that could possibly work. So surgery only becomes the first option by default in specific circumstances.

Any time there are any other Less invasive/Less Risky options on the table that can work for a patient, those should be tried before surgery.

really, kid, you gotta stop -- you're killing me here.

 

[MOHS_01]

I applaud you on your ability to anger so many people with a few ignorant-yet-brilliant posts. That is talent. And, you are unintentionally acting out the surgeon stereotype of "sometimes wrong, never in doubt," which I am enjoying.

I think it's fine to mouth off in an anonymous internet forum, but I urge you to overcome some of your bias when you encounter real-life surgeons in your clinical years. Most of them are very experienced, and know the risks, benefits, and alternatives to surgery much better than you do. They've spent their entire professional careers making difficult choices and dealing with the positive and negative consequences. My comment about "button men" was based on my opinion that many surgical decisions are actually quite simple, and not much thought is required....e.g. appendicitis and cholecystitis.

I have a question for you: If you developed appendicitis tomorrow, would you demand that the doctors treat you non-operatively?

dude -- give him a z-pack and send him the **** home.

"Sorry about your luck, kid. 'dem's the breaks when you want to be a "conservative", non-invasive statistic."

 

[Yoyomama88]

An example of saying that surgery should be done before chemotherapy for cancer is only valid because it is more efficacious and increases survival. But notice how your example was based on a severe illness. It's plausible that surgery can be a first choice here and provide a patient with a good benefit/risk ratio.

However, when you start operating on conditions that are mild or pose no risk for long term complications/significant morbidity, the chances of your operation becoming unnecessary are more significant. For example, a patient recently died at one of our hospitals due to an infection after an abdominal hernia repair. The stakes are higher in surgery and i believe surgeons must always keep this in mind. It's rational to conflate invasiveness with risk. Surgery tends to be a risky proposition.


If there are more efficacious treatments that are non-surgical, they should be tried before surgery.
I also agree that decisions are not always black/white and surgery can be a first option in certain circumstances, but these circumstances should be when non-surgical options are not efficacious, and pose significant risks to the patient. You all think I am biased against surgery due to my lack of experience and I think you are all biased for surgery because of your desensitization to operating. When you operate everyday, it's easy to forget about the seriousness of what you are doing.

 

[Yoyomama88]

For the record, I would take the anitbiotics.

 

[DrNick Riviera]

However, when you start operating on conditions that are mild or pose no risk for long term complications/significant morbidity, the chances of your operation becoming unnecessary are more significant. For example, a patient recently died at one of our hospitals due to an infection after an abdominal hernia repair. The stakes are higher in surgery and i believe surgeons must always keep this in mind. It's rational to conflate invasiveness with risk. Surgery tends to be a risky proposition.

At our hospital, someone recently died of c diff while the medical service was treating him for cellulitis with broad spectrum antibiotics. They should really stop using those things i guess...

 

[SLUser11]

For the record, I would take the anitbiotics.

So you say. I think when hypothetical becomes reality, and you're sitting on the hospital ward for 10 days, NPO, fevers, abscesses, persistent RLQ pain with no progress, generating significantly higher hospital bills and cost to society, you would be singing a different tune. Appendicitis may not kill you, but it can seriously mess up your social calendar.

No one has a better appreciation of the seriousness of surgery than surgeons. Surgeons live, eat, sleep, breathe their complications and the bad ones stick with them for a very long time.

Quoted for truth, and very similar to what I said in my last post. It is extremely ignorant to assume surgeons are desensitized to the act of surgery due to experience....we know the complications better than anyone.

GoPens, you're entering a world of pain.....

Am I the only one around here who gives a s#@t about the rules?!?

 

[Southplains]

From another thread,

Which clerkships/shelf exams have the most amount of information that is "new" and fairly unrelated to information tested on Step 1???

After perusing review books, it seems that Internal Medicine, Family Medicine, Pediatrics, Psychiatry have information that were already well established in the pre-clinical years.


I feel as if OB/GYN and Surgery are the ones that will have the toughest learning curve and have the most "new " information.


Can anyone comment if this perspective seems accurate.

You've already recognized your ignorance, you must be trolling in this thread.

 

[TallScrubs]

For example, a patient recently died at one of our hospitals due to an infection after an abdominal hernia repair. .

Until it strangulates and they have a SBO.

 

[Yoyomama88]

I'm not saying non-operative approaches never have risks. But generally speaking, most medications won't kill you/severely harm you. Obviously some can. Warfarin, long term antibiotic usage, corticosteroids, serotonin syndrome, TPA, Lithium etc. can cause severe issues in certain circumstances. But in general, an internist is less likely to provide medications that can cause severe morbidity/mortality on a daily basis.

In contrast, surgeons do surgeries that always harm people (which is fine as long as the justification/benefits are there to make the harm worth it) and radiologists also perform diagnostic tests which provide high doses of radiation on a daily basis. When your primary mode of treatment always harms a patient, I'm just saying you better be damn sure you're doing it for the right reason.

 

[Yoyomama88]

P.S. There's a reason why the top 5 specialties in malpractice for physicians are surgical specialties. Yea you gen surgeons are #3.

 

[Vermicious Knid]

P.S. There's a reason why the top 5 specialties in malpractice for physicians are surgical specialties. Yea you gen surgeons are #3.

lol what an awful argument. Surgery by its very nature is more dangerous than medicine, generally speaking.

 

[Yoyomama88]

Thank you for confirming my argument. So antibiotic over appendectomy for you? And if excellent surgeons are so common, why do such a high percentage get sued every year?

 

[armybound]

surgeons deal with a practice that is high risk. the nephrologist's work isn't as readily seen, felt, or experienced like a surgeon's is. we put patients through a lot, so they're probably more likely to be unhappy with us.

also remember that people tend to sue based on interpersonal interactions moreso than outcomes.