New research continues to reinforce the best means to select the right caregiver for your medical needs.(1) Patients frequently wonder how to choose a surgeon or any provider who performs procedures, whether it be a biopsy, endoscopy or major surgical intervention. The pathway to making the right choice continues to point all patients to one simple method, use common sense! More research validates the intuitive idea that there is enhanced safety of having medical interventions performed by those with subspecialty training and doing larger volumes of the procedures.
The research on enhanced outcomes for patients having procedures by surgeons and at institutions with larger volumes is clear. (1-6) Now adding technical skill, experience and training make the case more compelling then ever to get the information. The British Medical Journal (1) published data confirming enhanced safety based on surgical specialization in a procedure. The recommendation, of course, is to seek care from those with both the highest volume and the greatest specialty training.
How are patients to obtain this information? The simple answer is to ask for individual operator data and institutional data. Both are crucial, especially with higher risk more complex procedures. There are clear reasons institutions and individuals seek specialty certification and designations of centers of excellence in strokes, cancer and myriad other conditions. These are viewed as both quality and marketing tools.
When choosing a physician for an intervention, always ask about the specific procedure, training, volume and outcomes data available. Any reluctance to provide any of this information should send a strong signal...the silence should be deafening.
The more troubling issue is the lack of transparency by both individual providers and institutions regarding the information. The legal mandate to provide the data to patients about the training and volume is embedded in the principles of obtaining informed consent. All risks, benefits and alternatives which a reasonable person would wish to know which could impact their decision must be presented.
Having had two major spinal fusions, I share my own story and path to finding the best provider for me. I needed an intervention for multilevel cervical spinal stenosis which requires extraordinary skill using drills and surgical instruments millimeters away from critical anatomic structures including nerves and the spinal cord. The worst possible outcome from this type of surgery for me was not death but quadriplegia. I researched who did the most cervical spine fusions with the best outcomes in the Boston area. I wanted a dedicated spinal surgeon who did most of his work in the cervical region. Many of my colleagues were shocked that I did not choose a neurosurgeon but I consciously wanted a surgeon who did more cervical spine operations than any one else and neurosurgeons frequently are operating on the brain and do a lower volume of spine work. I found a brilliant orthopedic spine surgeon with unmatched skills to help me. The greatest added benefit was to find that his compassion, kindness and commitment to his patients was just as extraordinary as his technical prowess.
The 'volume pledge' taken by Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan and endorsed by the Leapfrog Group while viewed by some as self serving for academic medical centers, represents a huge step in the right direction. The debate is outlined by the Advisory Group. (7) One should now add training and skill based assessment of outcomes to volume in choosing a proceduralist.
Ultimately institutional data and individual data must be combined with the unique nature of the intervention, and individual circumstances of the patient and medical provider. Practicing evidence based medicine and learning as much as possible about your medical condition with the highest level of patient engagement, enhance your ability to make the best choice. Always seeking a second opinion even for the routine care can only enhance your experience. A conflicting or alternative management recommendation is a crucial piece of information. By collecting data about your medical condition, provider, institution, and seeking second opinions, patients can maximize their chances of a good outcome and minimize risks.
Nicolas Argy, MD, JD
Copyright © 2016 Nicolas Argy
- http://www.bmj.com/content/354/bmj.i3571 http://bit.ly/2a2qQnL
- Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med2003;349:2117-27.doi:10.1056/NEJMsa035205pmid:14645640.
- Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med2002;346:1128-37. doi:10.1056/NEJMsa012337pmid:11948273.
- Reames BN, Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and operative mortality in the modern era. Ann Surg2014;260:244-51. doi:10.1097/SLA.0000000000000375pmid:24368634.
- Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med2011;364:2128-37. doi:10.1056/NEJMsa1010705pmid:21631325
- Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med2002;346:1128-37. doi:10.1056/NEJMsa012337pmid:119482