Wednesday, June 10, 2009

Should Doctors Say How Many?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Monday the WSJ Health Blog posted “Should Doctors Say How Often They’ve Performed a Procedure?” written by Jacob Goldstein.   It references another guest post by Adam Wolfberg, M.D -- “Test Poses Challenge for OB-GYNs”
Dr. Wolfberg writes:
None of the published studies of CVS pitted seasoned physicians against novices; what patient would agree to be randomly assigned to an inexperienced doctor holding a long needle? But several reports from individual hospitals demonstrate that the miscarriage rate declined over time as the hospital's staff became more experienced.
These reports point to a dilemma: CVS mavens got that way by practicing, so their present-day patients benefit at the expense of previous patients.
When I first began my solo practice 19 years ago, patients often asked how long I had been in practice.  They ask less often these days.  I have never failed to answer. 
Patients sometimes asks how many times I have done a procedure, but not often.  Early in my practice, and sometimes even now, if it is a procedure I feel a bit uneasy with or haven’t done in a while I will bring the subject up without being asked.  After all, some procedures you just don’t do every day or even every month.  Some diseases you don’t see every month or even every year.
In my mind, many of the procedures I do are built on basic surgical principles.  I withdrew my privileges for microvascular procedures more than 10 years ago.  I didn’t get enough patients referred to me to feel that my skills were kept sharp.  In private practice, unlike at a university, there are no labs to go do practice work in to maintain those rarely used skills.  I have no doubt that I could regain them given the chance, but at what cost (financially or complications). 
Because I gave up my privileges for microvascular procedures, it means I have limited my repertoire of reconstructive procedures important in hand, breast, and other work.  I tell my patients about them.  If a breast reconstruction patient wants a free TRAM flap, then she is referred to someone who does it.  If she  wants to keep me as her surgeon, is there the possibility she is short changing herself on the outcome?  I suppose, but I try (TRY) to be upfront and fair to each patient.

The question asked “should doctors say how often they’ve performed a procedure?” may seem an easy one to answer.   If asked, yes.  If not asked, should it be part of the consent form?  I’m not sure it should for most procedures, but for extremely complex ones, maybe.
What if I did 100 of one type of procedure, but my last one was over a year ago?  What if I have done 50 of a second procedure that is closely related in skill-set?  What if that number is only 15? What if I have never done one and don’t wish to now, but the patient needs the procedure and is not willing to travel to another hospital?  Is it okay that I have “informed” them, but they want to take the risk?  How do I define that risk for them? 
How many of which procedure is enough to become proficient?  How often does it need to be done to remain proficient?  Who gets to define proficient?  Who gets to define the “magic” number of how many is enough to be proficient?  Who get to define how often the procedure needs to be done to remain “proficient”?

As Dr Wolfberg noted
what patient would agree to be randomly assigned to an inexperienced doctor holding a long needle?
So how will these questions be answered?


T. said...

Great post, Ramona!

I often have mixed feelings about asking a patient to a allow a "rookie" to attempt an intubation. But as you pointed out, without practice on real patients in the absence of good simulators, how is any practitioner to develop proficiency? What I try to do is reassure the patient (and warn the student) that I will step in and take over immediately if I feel I need to. But part of learning how to do something well is struggling a little when it's not as easy as expected, and figuring out how to problem-solve on the spot...

I am still awed and humbled by the trust placed in us by our patients.

Karen Little said...

It's really a tough one - I've never actually thought about it before. Fortunately in my setting, patients don't have a choice - it's me or nobody :) Still,I would never do an unsupervised procedure I wasn't comfortable with. I guess that's where real responsibility lies: knowing and being able to acknowledge your limitations.

Jeffrey said...

my professor of surgery brought this up at our research meeting once. he said it seems the thinking out there is that you got to do a certain number of procedures eevery year to maintain your proficiency in it. however, he reckons that it is the training period that matters much more, because say for example a gen surg resident was the primary operator of 500 laparoscopic cholecystectomies under supervision, then that might probably suffice and its highly unlikely his/her skills will be affected even if he/she does only a handful a year. compared to someone who continues to do 100 a year.

not sure if people out there agree, but it seemed to make sense.

Jeffrey Parks MD FACS said...

nice post. always tough to define your limitations, especially as a younger attending. Self appraisal isn't easy; but you have to be honest first with yourself, then the patient...