Journal of Vascular Surgery
Volume 45, Issue 1 , Pages 214-216, January 2007

Caseload outcome credentialing: Taking from the have-nots

  • James W. Jones, MD, PhD, MHA

      Affiliations

    • Corresponding Author InformationCorrespondence: James W. Jones, MD, PhD, MHA, Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
    • ,
  • Laurence B. McCullough, PhD

Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Tex.

Article Outline

 

“Not even a dog-killer can learn his trade from books, but only from experience. And how much more is this true of the physician!” Paracelsus

The Surgeon-in-Chief at a large metropolitan hospital long has championed a new database that compares operative outcomes by surgeon and procedure. The methodology of data collection and analysis is exemplary. The director of information technology has just completed the initial analysis, and the data clearly show that several of the older surgical attendings have higher than average mortality rates for specific procedures. The vascular surgeon’s patients, in particular, have a statistically significantly higher stroke rate after carotid artery procedures with low caseload, but his other vascular work is satisfactory. He is not scheduled to be recredentialed for 10 months. What should be done?

A.The vascular surgeon has past outstanding credentials with election multiple times as a “Best Doctor.” Collect more data.

B.Don’t worry. Referring physicians will stop sending cases that he performs poorly.

C.Recredential those with worse records by procedure.

D.The data may not be properly adjusted. Wait until you have more data.

E.Have any surgeon who has poor results for a specific procedure monitored.

Wherever there are some who are the best at something, there must, by definition, be someone who is worst. As betterment is the goal of all applied science, clinical medicine seeks to improve by finding better ways to re-establish health of patients. A mainstay of clinical studies during the last century has been to divide treatment experiences of a specific disease entity into those who did well and those who died or had complications. Standard variables have included preoperative (mainly demographic-related or disease-related) and intraoperative (mainly operative technique used, operative efficiency and blood loss). Although a hierarchy of surgical talent by institution and individual surgeon has been widely acknowledged within the profession, surgical technique was considered uniformly good throughout the literature. After all, quality of surgical technique influencing both sides of the equation should cancel out in comparative studies.

Each practicing surgeon who performs highly technical procedures, from the first day of residency, harbors no doubt that the outcomes are linked to the exposure, intraoperative judgment, exactitude, efficiency, and hemostasis of their performance. Surely, surgery is a team effort, but the surgeon remains the virtuoso. It is frustrating for an accomplished surgeon to operate with a suboptimal surgical team, but an outstanding team cannot make up for a surgeon’s suboptimal performance.

The vascular system is most unforgiving of technical errors. By providence, perhaps, the busiest and most experienced surgeons at any institution are usually the most respected. They may simply have developed better rapport with referring physicians, but although no sane surgeon fails to court referrers, the elite are often more rushed and less humble.

More than two decades ago surgeons began to acknowledge that, unlike the manufacture of luxury automobiles and other high-end merchandise, surgical procedural results might be related to the volume of some operations in hospitals.1 The key insight was that low-risk patients had poorer outcomes in low-volume hospitals. After hundreds of articles subsequently examining almost every surgical specialty, especially orthopedic and vascular cases, the overwhelming consensus has emerged that there is a caseload threshold in hospitals below which outcomes worsen significantly.1, 2, 3, 4, 5, 6

Surgeons, however, not hospitals, perform surgery. Results of a high-volume cardiovascular surgical group were no different whether their cases were done at a high-volume or low-volume hospital.6 Birkmeyer and associates7 examined data from more than 474,000 patients undergoing eight different surgical procedures and found that the proportion of beneficial effects of individual surgeon’s caseload volume in relation to the hospital volume varied from 100% down to 24%, depending on the procedure. Major vascular procedures were more dependent on a surgeon’s caseload volume than nonvascular procedures. Lung resection and cystectomy operations benefited least from busier surgeons, which is a reasonable statement to surgeons performing both major vascular and lung procedures: the precision and efficiency required differ. Patients undergoing carotid endarterectomy (CEA) by surgeons doing less than one procedure per month (18% of 35,821, or 6,448 patients) had approximately twice the stroke rates, and mortality rates doubled, compared with busier surgeons.8 Poor outcomes tripled when performed by dabblers doing a case a year.9 Dr Oscar Creech, a vascular surgical pioneer with superb technical talent, summed up the importance of operating room performance as: “Most postoperative care takes place in the operating room.”

These data relate directly to the ethical concept of the physician as fiduciary of the patient, which is the core concept of surgical ethics. Invented at the end of the 18th century by the Scottish physician-ethicist Dr John Gregory (1724-1773) and the English physician-ethicist Dr Thomas Percival (1740-1804), this concept has three components:

First, the physician commits to becoming scientifically and clinically competent, which includes continuous improvement of knowledge and skills.

Second, the physician commits to protecting and promoting the patient’s health-related interests as the physician’s primary concern and motivation, keeping self-interest systematically secondary.

Third, the physician maintains, strengthens, and passes on medicine, as a public trust, for the benefit of future physicians and patients.

The ethics of scientific and clinical competence, the first component of fiduciary responsibility, require surgeons not to undertake procedures for which they are not competent or are not any longer competent; for example, from atrophy of fine motor skills. In the era of evidence-based surgery, competence is becoming defined in terms of the volume of procedures needed for acceptable outcomes. Given the well-established connection between threshold workloads and acceptable outcomes, a surgeon whose outcomes are no longer acceptable, as in this case, has a strict ethical obligation to immediately stop performing the procedure in question. His surgical processes should be carefully analyzed in a disciplined, professional peer-review. If this review results in a judgment that the surgeon’s deficiencies are irremediable, then he should not be permitted to perform the procedure in order to fulfill his fiduciary responsibility to protect the health and lives of patients. Percival captures what is at stake here when he addresses the ethical obligations of the aging surgeon:

“As age advances, therefore, a physician should, from time to time, scrutinize impartially, the state of his faculties; that he may determine, bona fide, the precise degree in which he is qualified to execute the active and multifarious offices of his profession.”10

Percival’s point can be generalized to cover reasons other than age resulting in subpar surgical performance. Percival entrusted this task of self-assessment to the court of individual conscience, a slender reed upon which to hang a weighty responsibility. We should not, opting instead for peer-review through existing quality improvement processes.

Answer A proposes that a prestigious education and professional accolades are reliable markers for good outcomes. Cardiovascular surgical outcomes are not related to prestige indicators such as medical education at a top-rated school or training at an institution renown for surgical care.11 Foreign medical graduates’ outcomes were no different than those with diplomas originating in the United States. Likewise, the professional honor of being elected or selected to a “Best Doctors” publication does not guarantee better results.12

Relying on the referral process to send patients away from those with poor results and to the higher quality surgeons is not supported by available data. The accessibility of surgeon-specific risk-adjusted mortality data in the “Consumer Guide to Coronary Artery Bypass Graft (CABG) Surgery of Pennsylvania” is known to 82% of referring cardiologists, but 87% of cardiologists reported that it had “minimal influence on their referrals.”13 In New York, where risk-adjusted surgeon-specific CABG mortality rates are published in the news media, we find similar disinterest among referring physicians: two thirds of referring cardiologists think that the data are accurate and two thirds state that the data do not influence their referral decisions.14 More surprising, a survey of patients undergoing cardiovascular operations where a surgeon’s outcomes are readily available found <1% knew the published record of their surgeon.15 Option B is not viable.

Option D is a common depreciatory courtroom tactic: attack the validity of the source. If one does not like what the data say, complain that the data are flawed, and therefore, unworthy of belief. Death is a solid end point and statistics are as objective a method as science has available. It is, however, hoped that the surgeons were kept informed and had input while the data program was being developed.

Monitoring surgeons whose results for a procedure are statistically below other surgeons’ standards, option E, is an often-used practical alternative but it is not the best ethical answer. Scientific methodology has resulted in data to confirm that the surgeon in question is performing substandard carotid surgery. Monitoring is a qualitative surveillance measure designed to confirm what is already known. In this case, rehabilitation from formation of new synapses and practice development resulting in increased caseload is highly unlikely. A decision to monitor would allow added patients to bear the outcome shortfall from unwarranted compassion toward a fellow surgeon.

Our choice is C because procedural credentialing is a privilege, not a right, which rightly serves a single purpose, to protect patients from practitioners whose skills are less than is otherwise available.

There is a particular red flag in regard to this specific case of a surgeon at career end who may need to slow down a busy practice because of decreasing stamina and motor skills. The decreasing volume combined with the ravages of time can irreversibly reduce the effectiveness of previously highly qualified surgeons.9, 16 This phenomenon, as in the present case, is seen in procedures requiring proficient hand-eye coordination as in CEA. In the same study, the problem was not found in aortic aneurysm procedures.16 The authors noted that “For most procedures… surgeon age is not an important predictor of operative risk,” so recredentialing should be procedure-specific. Frequency of procedural experience is more than a surrogate marker for quality, it is the mostly unappreciated mainspring of a surgeon’s technical skills. Procedural specialties are separated epistemologically by the difference in knowing something and knowing how to do something. Surgeons must know how to do something. Memorizing and mastering the textbook concepts of vascular surgery do not make a vascular surgeon. A surgeon’s essence results from the focusing of acquired motor skills to provide operative therapy. Idle motor skills wane just like other memories, perhaps even faster.

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References 

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 James W. Jones, MD, PhD, MHA, Surgical Ethics Challenges Section Editor

 Competition of interest: none.

PII: S0741-5214(06)01755-1

doi:10.1016/j.jvs.2006.09.027

Journal of Vascular Surgery
Volume 45, Issue 1 , Pages 214-216, January 2007

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