Do some surgeons suck at surgery?

Q-Optics, surgical ergonomics - redefined
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
YankeeBean said:
Interesting. I'm inclined to say that you cannot say all surgeons do all that is necessary -
Click to expand...

Does your kind reject truth?
Members don't see this ad.
 
Members don't see this ad :)
YankeeBean said:
Interesting. I'm inclined to say that you cannot say all surgeons do all that is necessary - foley catheter does not have a port for medication, and this patient (quadriplegic with cerebral palsy, btw) was without their prescribed seizure medication for 6 days - 19 seizures in 6 days, in a patient who is otherwise managed so well that they have 1 or 2 seizures a week at most. I'm fairly certain this surgeon didn't do everything that was necessary, do you?
Click to expand...

A foley cath can be substituted for a gtube. It is done all the time when they fall out. You can put the meds and tube feeds through where the pee would come out. If the guy wasn't getting his meds that is due to something else or someone screwed up.
 
dpmd said:
A foley cath can be substituted for a gtube. It is done all the time when they fall out. You can put the meds and tube feeds through where the pee would come out. If the guy wasn't getting his meds that is due to something else or someone screwed up.
Click to expand...

For the record, this was an entirely new gastrostomy. It had fallen out, but the tissue healed, so a new gastrostomy was performed in an area with less scar tissue. I understand that foleys can be used temporarily, but this patient was sent home with the foley in place, with no follow up identified nor instruction to the caretakers that the foley was to be replaced. This surgeon, I assure you, thought the foley was the permanent solution.
 
YankeeBean said:
For the record, this was an entirely new gastrostomy. It had fallen out, but the tissue healed, so a new gastrostomy was performed in an area with less scar tissue. I understand that foleys can be used temporarily, but this patient was sent home with the foley in place, with no follow up identified nor instruction to the caretakers that the foley was to be replaced. This surgeon, I assure you, thought the foley was the permanent solution.
Click to expand...
He thought that because tubes can be used for all sorts of things, especially in general surgery. They are not limited to be used for only one function. Wounds, fistulas, etc. may also require creative solutions. It doesn't mean it's wrong, indicative of malpractice or a sign of incompetence.

I have also used foleys as primary (i.e. new) G-tubes. It's perfectly acceptable and reasonably common. They don't need to be "replaced" with a "real" G-tube. They can be used indefinitely and replaced as needed.
 
Shoving tubes inside a person is wrong. Who was the genious that came up with that idea? Helmets and cups with no penetration. Please get smarter cause I am only here for so long.
 
Smurfette said:
He thought that because tubes can be used for all sorts of things, especially in general surgery. They are not limited to be used for only one function. Wounds, fistulas, etc. may also require creative solutions. It doesn't mean it's wrong, indicative of malpractice or a sign of incompetence.

I have also used foleys as primary (i.e. new) G-tubes. It's perfectly acceptable and reasonably common. They don't need to be "replaced" with a "real" G-tube. They can be used indefinitely and replaced as needed.
Click to expand...

Yes.
 
southernIM said:
You do realize you're being trolled by medstud104, right?
Click to expand...

Seriously though, who came up with the idea to shove a cath into a person? I know there is a better way. Perhaps I sound strange now, but wait until it makes sense. Just trying to help.
 
pmapunk66 said:
http://www.nejm.org/doi/full/10.1056/NEJMsa1300625

Scary.
Click to expand...

Not that scary. Differences of less than a percent in some categories may not be clinically relevant, and all of those complication rates are still quite acceptable. I wonder if we simply submitted recordings of laparoscopic surgeons in practice for 1 year vs. 10 years, then compared complication rates, how things would shake out...
 
pmapunk66 said:
http://www.nejm.org/doi/full/10.1056/NEJMsa1300625

Scary.
Click to expand...

The title of the article is more concerning than what the actual data suggests. The two "big things" would be mortality and leak. Leak was non-significant between the groups. Mortality was significant, but the number needed to harm would be fairly large. I mean, even the less skilled surgeons had a mortality rat of less than 1%. When you're doing a complex laparoscopic case in a subset of patients who all have multiple comorbidities, that's pretty good.

What's taken out of the equation here are the factors besides surgeon skill that may affect a patient's outcome. Anesthesia care, nursing care on the floor, etc. have quite a bit to do with it as well. And when you look at the major difference between groups, it's "pulmonary complications", which I suspect is what also drove the difference in mortality. That's certainly something that can be affected by postoperative care. And I'd futher wager that the postoperative care associated with the highly skilled surgeons was better, even if simply by nature of their higher volume. When nursing staffs are used to dealing with a certain type of patient, they get better care.
 
I thought the NY Times article was pretty misleading. The NEJM article showed a small (0.26% vs 0.09% vs 0.05% across quartiles 4, 2/3, 1) absolute risk increase in death, and modest increases in infection, obstruction, and pulmonary complications. It's difficult to entirely attribute these outcomes to the peer-graded skill of the primary surgeon. These results aren't the "shocking expose" that the NY Times make them out to be.

Furthermore, the only characteristics of surgeons that the NEJM article correlated to graded surgical skill was # of procedures performed. So the NY Times readers calling for an investigation into the matter should just wait a couple years; the quartile 4 surgeons will be quartile 1 surgeons after getting a few dozen more operations under their belts.

Btw, favorite reader comment: "Why doesn't CMS or some other respected group get a handle on this?"
 
Another of my criticisms: This only takes into account technical ability with respect to patient complications. When you look at Table 2, you'll note that the patients had significantly more comorbidities in the lower skill groups. And it's not just one thing--it's a number of things, including lung disease. So were the increase in postop pulmonary complications due to some operative factor, or just because they were higher risk to begin with? And if the latter is the case, then it's not surgeon skill that's implicated, it's clinical judgement/patient selection. That, to me, is more interesting, but not what has come out of the study.

Don't get me wrong, it's a well done study. And that's to be expected coming from someone like Birkmeyer. I just think it risks over-emphasizing technical skill. Yes, there is some minimum level required to be proficient. But once you reach that point, there are other factors that are likely as important. Some of those may be surgeon-related, and some may be related to the systems and/or patient. I just think we have to be careful about how much of the responsibility we shoulder with respect to known complications of surgical procedure. I'm all for patient ownership, but that doesn't mean CMS/private insurers should be finding ways to penalize us for known complications of surgical procedures.
 
Last edited:
Ok, fair point. Missed the risk adjustment.

And yes, it's at least reasonable to believe that technical skill is associated with clinical judgement. But that does not mean interventions to improve operative skill will necessarily improve clinical judgement. I'd argue that operative skill and clinical skill develop in tandem, but through different mechanisms. The question would be if you took the bottom quartile, and developed interventions that improved their technical skill only, would they necessarily see improved patient outcomes? I think that's far from established.
 
southernIM said:
Definitely agree with that. It's a little hard to imagine that if you can make the surgeon in video 2 look like the one in video 1 with some short term directed coaching, that their outcomes will magically get that much better.
Click to expand...
But that's why I found this study so non-representative of most surgery. I think we would all agree that lap surgery is a "difference magnifier", where the spectrum between "below average" and "above average" is a lot bigger than in open surgery. There's nobody who struggles to tie a knot or close fascia in an open case, but there are plenty of people who are just not that smooth with lap stitching. Then you go beyond that even more, lap RYGB is at the far end even for lap procedures in terms of difficulty. You're talking about a procedure that has already been recognized as being so hard that there are lots of papers on how many cases one needs to be decent at it.

I haven't seen this in any discussion of the paper, either. I buy the internal validity but I don't at all buy the external validity. There probably are huge differences in outcomes among lap RYGB surgeons of varying skill but that's <0.1% of all cases. I bet there's minimal difference among these same surgeons in appy or chole outcomes.
 
You must log in or register to reply here.
Next unread thread

Similar threads

SoleScholar
General surgery vs podiatric surgery
Replies
3
Views
1K
RM38
R
M
Royal college of physicians and surgeons of Canada. General surgery board exam preparation
Replies
0
Views
460
MPitchaimuthu
M
P
Nausea/Motion sickness with laparoscopic surgery
Replies
7
Views
656
DoctwoB
DoctwoB
H
MS4 applying CT surgery
Replies
11
Views
3K
droliver
droliver
Surgeon D.O.
Surgery videos?
Replies
3
Views
886
Miles Gloriosus
Miles Gloriosus
Top