A superb study by the Michigan Bariatric Surgery Collaborative showed that the more skilled surgeons were, the better were their outcomes.
Surgeons submitted a video of their choice depicting their performance of a laparoscopic gastric bypass. Since it was self-selected, it was presumably their best work. At least 10 of their peers, blinded as to the name of the surgeon, rated skills on the video, which had been edited to include only the key portions of the case.
Surgeons in the lowest quartile of ratings for surgical skill had significantly more postoperative complications, readmissions, reoperations, and deaths.
A New York Times article about the paper featured a couple of short video clips—one from a not-so-skilled surgeon and one from a very skilled surgeon. The differences are obvious and dramatic.
According to the discussion section of the paper, the Michigan bariatric surgeons are now watching each other operate and will soon be receiving anonymous feedback about their technique from their peers.
It is not clear whether this will improve the skills of the lower-rated surgeons or have any effect on outcomes.
Many people rightfully praised the research. Some suggested that all surgeons should be scrutinized in this same fashion. I agree that the study was well done and shows that better surgeons have better outcomes. But there are some problems with generalizing this to all surgeons.
The American Board of Surgery recently noted that there are about 30,000 board-certified general surgeons in the United States. This raises a number of logistical issues.
Let’s say we focus on the most common major surgical procedure: laparoscopic cholecystectomy. Ten surgeon raters would have to view at least 15 to 20 minutes of video for each of the 30,000 board-certified general surgeons. How long would that take? Who would collect and edit all the videos? Who would make sure that the ratings were consistent? Who would collate and distribute the results? How would follow-up be done? Who would pay for all of this?
And that is just for the board-certified general surgeons. What about the general surgeons who are not board-certified and all the other surgical specialists? Maybe gastroenterologists should have their endoscopy procedures scrutinized. Maybe primary care docs should have selected office visits recorded too.
This is similar to the enthusiasm that surrounded the concept of using retired surgeons to coach other surgeons. The idea was based on an “n” of one surgeon, who had access to an expert coach and wrote about it. I blogged about the logistical difficulties that would preclude coaching from becoming widespread. To my knowledge, in the 2 years since I wrote that post, coaching has not caught on as a performance-improvement measure.
It’s too bad, because in an ideal world, video evaluation of operative procedures and coaching would be great. Unfortunately, we don’t live in an ideal world.
Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 8800 followers on Twitter.