An article recently published in New England Journal of Medicine studied video submissions of 20 experienced Michigan bariatric surgeons performing laparoscopic gastric bypass surgeries. The videos were rated in a blinded fashion according to surgical skill. The authors then assessed relationships between these skill ratings and risk-adjusted complication rates, using data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients.
The authors concluded that skill – as measured on videotape – varied widely. “Greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department.” In other words, the better the technical prowess, the better the outcome.
Video of high-ranking surgeon.
Video of less skilled surgeon.
The article’s conclusion isn’t shocking or particularly surprising.
Comments from the discussion of this article on the NY Times were blistering. Many of the readers suggested that would-be surgeons should be tested for manual dexterity and hand-eye coordination before even being admitted to surgical training programs.
I don’t doubt that having some measurable requisite skill set would help to identify those candidates more likely to excel in surgery. But, I am not sure how it should be weighted. And I’m certain that limited measurement would not be enough.
Larry Byrd was arguably one of the best basketball players of all time. Basketball clearly involves manual dexterity and hand-eye coordination. Larry Byrd never believed he was born with any kind of a gift. He excelled with tenacity, determination, and practice. He would shoot free throws after school until he was blue on the face. He improved over time. With Larry Byrd, it wasn’t nature – it was nurture. And Larry Byrd turned into a great ball player.
Technical proficiency in surgery is very important. But, surgical outcomes depend upon more than technical prowess.
Judgment matters – a lot. Good judgment comes from experience. Experience comes from bad judgment. Judgment implies a commitment to honest evaluation and persistent self-correction.
Surgical selection matters – a lot. Knowing who to operate on is just as important as knowing how to operate.
Knowing what not to do matters – a lot. One wise surgeon told me he spent his entire residency learning how to operate. He spent the rest of his career learning how NOT to operate.
Communication skills and leadership matter – a lot. Think you’re a superstar? You can be a superstar ONLY if you have a great team. You nurture and keep a great team with stellar communication and exemplary leadership.
Tenacity and persistence matter – a lot. Who likes getting out of bed at 2 AM to take care of a sick patient? No one. The doctor who more consistently lays eyes on that sick patient is more likely to have a positive outcome. Another wise surgeon once told me he’d rather have a resident at bedside taking care of a patient than Harvey Cushing managing that same patient from home. (OK, that statement was made before webcams, iPads, and broadband.)
There are other qualities that make a great surgeon. A commitment to lifelong learning; empathy; an understanding of ethics; supreme-confidence; humility; and more.
My point is that many qualities coalesce to make a great surgeon. And it’s a personal joy to spend time working with and learning from such committed people.
We will agree to disagree about a few of these items. While all the things that you say are necessary for a surgeon to be great, they are mostly innate, not acquired. Consider judgment, for example. It’s true that good judgment comes from making–or watching–bad decisions and their consequences, but how many surgeons have you met who, despite making lots of bad decisions, go on to make them again and again? In my experience, it’s most of them. By the time someone is about 35 years old, either they’ve gotten it, or they haven’t. There are plenty of people making bad decisions to go around.
Skill is developable–if you have the substrate in the first place. You cannot make someone smarter than they are, just like you can’t make them taller than they are. Height is also innate. If you don’t feed a kid, he won’t grow, but beyond providing the minimum amount of food necessary for adequate growth, he’s gonna be as tall as he’s gonna be. Same with skill. I’ve seen people who simply cannot learn certain surgical skills, at least to be able to perform certain tricky tasks with finesse. I’ve watched them work as long as I could stand it, but eventually I had to leave. They might be very senior guys, but they can’t operate worth a flip.
Tangentially, but related: look at how people vote. Either they refuse to learn, or they really have adobe neurons. Many people refuse to use logic–it’s as if they simply do not trust it. They treat it as if it’s a bomb, and they’re afraid that if they push the wrong buttons, it will go off in their face. Infuriating to talk with them? You betcha. No amount of teaching can overcome that. Either you have common sense–and that’s what this is all about–or you do not. If you’ve got it, you can be trained to use it well (or not), but if you don’t have it, no amount of teaching will make you smart and logical.
Consider this quote from one of my favorite books, Up the Infinite Corridor by Fred Hapgood:
“Engineers in those days [fin de siecle] moved almost always through atmospheres of doubt and controversy. And it did not help very much that the thing that was said to be impossible while they were building was taken, when they had finished, to be a wonder. It is not surprising, therefore, that, having to trust their own private calculations of natural forces amid the incalculable noise of the crowd, they developed in time into independent, austere, and utterly self-confident men.
“In their letters, anecdotes, and memoirs, there is not much humor, less wit, and very little hail-fellow-well-met. What does come through is respect for certain oft-mentioned abstract virtues…honesty, accuracy, fidelity. One of the type had carved on his tombstone only the word “Veritas,” and truth in structure is what they all learned to live by. Here and there in their memoirs the members of the elite revealed the name of the power that allowed them to empty themselves into the moment, to pick out the flow of changes that counted, to read the meaning of a shift in temperature or intuit a pool of stress building in a shaft or rope; the power that set them apart and touched their small number with success. They called it a sense for ‘the fitness of things.’
“A sense for the fitness of things was a gift, like any other extraordinary sense. It could not be taught; the old engineers were quite explicit on this point. Those who had it were engineers in their soul, even if they chose to throw away their legacy by going into law, whereas 30 years in the profession could not make those lacking the gift into engineers.”
I have always thought that if you substitute the words “neurointerventional surgeon” or “surgeon” for “engineer,” it still reads correctly. You can’t teach clinical judgment, you can’t teach people how to steer a catheter, you can’t teach someone how something should feel to feel right. You can put it in front of them and either they get it or they don’t. Either it is obvious what you do in a clinical situation or it isn’t. Thought might be required, but if you understand, you will take the high road more often than not. If you don’t, there’s a problem.
JH
Exactly. After 28 years of neurosurgery I can honestly attest to the fact it is more difficult to know when not to operate than what operation could be done.
During ENT residency, one of the attendings said to us at grand rounds, “YOU should pay the first 100 patients that let you perform Rhinoplasty Surgery.” There is a learning curve involved in all surgeries we perform, and we all have to start somewhere. If you end up getting through your first hundred rhinoplasties without doing irreparable damage, you’ll only improve.
The video clips are interesting. The experienced surgeon would be my choice if I ever balloon up to the point where bariatric surgery becomes necessary. I’m not sure why the less experienced doc agreed to be filmed. Looks like his first case. Painful to watch. Eric. 🙂
Very well put. I cannot agree more. How can we get this type of ethos into residency programs? During residency we become acquainted with certain skills, some clearly technical and others are more subtle. We are trained to pay attention only to the technicalities of a given procedure but seldom is emphasis given to the patient as a whole. Medicine is a social science. Surgery is more than a cut, a burn and a stitch. It is a skilled social craft based on science and technology among other things.
Of course the public wants the best for their own surgical care, and are outraged to find out that there is variability in the skill sets of surgeons. Is this a surprise? Heck no.
Demanding a dexterity test before admission to a surgical residency is an irrational response here, based on fear, though understandable.
The Larry Byrd example is on the money. The videos are static. What we can never predict is what will happen over time, and what degree of “grit” each young surgeon has. I have seen very very few surgeons who are virtuosos in the operating room. I have also seen many “ugly ducklings” so to speak. Each of us matures at our own rate, and start off at our own starting line.
I don’t have an answer to that irrational fear.