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.