Experience Counts: What you need to know before choosing a surgeon

Dear Readers,

Here’s the second in our occasional series of newsletters on getting better medical care for yourself and your family.

Our first newsletter focused on the problem of conflicts of interest in medicine — what you need to know in general, and how to find out if your doctor has a conflict that might affect the quality of your care. Click here to see that newsletter again.

This issue expands the discussion into the related topic of why experience counts — especially when choosing a surgeon.  We’ll focus on the story of minimally invasive prostate surgery with the device called the da Vinci robot. But the lessons apply to any kind of surgery or medical procedure.

As before:  Feel free to “unsubscribe” on the button at the bottom of this email. But if you find it helpful, pass it along to people you care about.

Practice Makes Perfect: Essential Knowledge for Anyone Facing Surgery or Any Medical Procedure

As every new technology comes on the medical scene, both patients and their doctors can too easily be dazzled by the promise of something new and better. This is especially true with minimally invasive surgery of any kind. The promise is: Smaller cuts in your body, quicker recovery time, fewer complications.  So what’s not to like?

If you knew the surgeon about to cut you open had trained for your case with only a single weekend course with the manufacturer, and that he or she had done maybe a handful of the same procedure since that weekend, would you hesitate before signing the consent form? You should.  Read on for more.

Prostate surgery with a robot called “da Vinci” is often sold to patients as the latest and greatest technology and a way to get a better outcome. But on the key long-term complications — urinary incontinence and erectile dysfunction — the “minimally invasive” robotic surgery may be no better than traditional surgery, and may be worse if the operator is inexperienced.

A recent study in the Journal of the American Medical Association (JAMA) criticizes the benefits of the “minimally invasive” surgery as oversold. The operation does cut the average time in the hospital from three days to two, but brings with it both more short-term complications plus more long-term injuries like impotence.

Click here to read the official abstract of the study on the JAMA website.

The lead author is Dr. Jim Hu of Brigham and Women’s Hospital in Boston. “There has been rapid adoption of minimally invasive radical prostatectomy, however, outcomes have not been superior,” Hu said.

Surgeons are trained to use the robot in a weekend course with the manufacturer. Dr. Hu said that a big part of the problem could be surgeons not getting enough experience with the device. He said he has now done more than 700 robotic prostate surgeries, but “it took several hundred cases before I thought I was doing really well in preserving erectile function and continence.”

The new study brings home an issue that is discussed at length in my book, The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst. Choosing the right surgeon is key to success, and patients need to ask about the surgeon’s volume of cases exactly like theirs. For robotic prostate surgery, it’s easy to find a surgeon with hundreds of cases. If that’s an option, why would anyone settle for a surgeon who has only done a few dozen?

Finding the Answers on Your Surgeon’s Experience

It’s simple. You MUST ask the question: “What is your experience with this procedure?”  But there’s a lot more to ask as well. Here’s a discussion excerpted from my book, “The Life You Save”:

1. “Do I really need any surgery?”  (A busy surgeon – and busy means a lot of doctors have confidence in this surgeon — will be more candid than a surgeon with time on his hands to tell you that waiting might be the most prudent thing to do.)

2.    “What is the exact procedure that you would recommend for a family member if they had the same thing I have?” (You need to make sure the surgeon and you are both talking about the exact kind of procedure proposed for you, not some close cousin.)

3.    “Who would you ask to do the operation on a close family member of yours if you couldn’t?”

4.    “How often do you do this kind of procedure?” You want to hear: “Every week” (and if you hear “a few times a year” or less, you want to drop this surgeon).

5.    “Is there anyone at your institution (in your partnership, in my town, etc.) who does these procedures more than you do? If so, would you mind if I speak to him or her?” (A defensive response to this question is a red flag.)

6.    “How long have you been doing this procedure?” (Be careful with this one, because some surgeons can honestly say “years” but have less experience in volume of cases than a fresh-faced young surgeon who has just finished rigorous sub-specialty training at a major teaching hospital with several cases every week. The more important focus is volume of recent cases.)

If you want to find out about the hospital’s volume with cases like yours, I recommend you Click herefor an article in my patient safety blog that talks about how you can easily find out which hospital in your area has the highest volume of surgeries for a variety of specific common procedures.

Some tips from my first newsletter also apply here. As I wrote:

Asking questions of authority figures can be awkward. But when it’s your life at stake, we need to appreciate that silence can be fatal.  It also helps to know that good practitioners welcome questions and are never too busy to give you the complete scoop.  Here are a few tips to get started on becoming a more questioning, pro-active medical consumer. And remember, it gets easier with practice.

  • Do some Internet research at authoritative, reliable websites. I have culled out a few of the best in my book, “The Life You Save,” and you can read the list here on my book’s web site.
  • Write down your questions and take the list with you to the doctor’s office. (You should also always have with you a list of all medications you are currently taking, and if you have a new health problem you’re trying to get diagnosed, it’s very helpful to write a short history of when it started, what makes it worse or better, and other details.
  • Take someone with you and have them ask questions for you.  This person also can be the reality check to help bring out symptoms that you may be too embarrassed or fearful to mention yourself.

Your Legal Right to Know Your Surgeon’s Experience

Medicine is still debating whether doctors have an ethical obligation to tell patients that they might be better off going to another surgeon or another institution for care they need.  But at least in some states, patients have a legal right to know that information, as part of the “informed consent” process. Read here for a true story about how this legal precedent was established in Maryland by one of our firm’s clients, Billy Boone.



Here’s to a healthy 2010!

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Patrick Malone
Patrick Malone & Associates