It’s all about the surgeon … more evidence
Data published in April by Klein et al. have further confirmed the importance of surgical experience as it relates to outcomes of radical prostatectomy. This group has previously reported that there is a learning curve for open radical prostatectomy. In the present study they sought to discover whether the effects of the learning curve are modified by patient risk, as defined by preoperative tumor characteristics.
The study included 7,683 eligible patients with prostate cancer treated with open radical prostatectomy by a total of 72 surgeons. Surgeon experience was coded as the total prior number of radical prostatectomies done by the surgeon before a patient surgery.
There was a statistically significant association between biochemical recurrence and surgeon experience on all analyses. The absolute risk differences for patients receiving treatment from a surgeon who had carried out 10 vs 250 prior radical prostatectomies were 6.6, 12.0, and 9.7 percent in patients at low, medium, and high preoperative risk, respectively. Recurrence-free probability in patients with low risk disease approached 100 percent for the most experienced surgeons. The authors saw no evidence that patient risk affected the surgical learning curve.
They conclude as follows: “Cancer control after radical prostatectomy improves with increasing surgeon experience irrespective of patient risk. Excellent rates of cancer control in patients with low risk disease treated by the most experienced surgeons suggest that the primary reason that recurrence develops in such patients is inadequate surgical technique. The results have significant implications for clinical care.” The “New” Prostate Cancer InfoLink would note that these results also have highly significant implications for patients seeking the highest quality outcomes from radical prostatectomy!
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I certainly agree that expertise begets favorable outcome. What has always concerned me, however, is how does the “learning” physician gain this expertise if patients are all directed to the “experts.”
Let’s say you seek a consult with a surgeon because of their surgical experience, but they are affiliated at a teaching hospital. How do you know who performed your surgery the surgeon you consulted with or the fellow that is learning. And why isn’t it clearly written on the consent forms who will be doing what to your body? On another site my husband read about a patient that consulted with a surgeon at a major university hospital and he was told by the dr I only do 1/2 of the procedure.Post op this guy discovers that the fellow performed the entire ralp and this guy had major complications!!!!
These two insightful comments raise interesting issues that many patients never think about at all (although they should).
With respect to the first comment, learning how to do any surgery requires doing the surgery, as often as possible. The teaching “mantra” applied to surgery is “see one, do one.” Although to be fair the reality is much more like, “see several; assist with several; then do your first with oversight.” However, every surgeon has a “first patient.” The issue in my mind is one of full disclosure by the hospital and the physicians. While I do not think it is necessarily a requirement for the hospital to say, “This will be the first radical prostatectomy this resident/fellow has ever done on his own,” I would argue that they should make it clear that the surgeon is still in training and that he/she will be carefully supervised by his/her mentor throughout the entire course of the procedure.
In regards to the second comment, my entirely personal belief is that this was at best unethical. A lawyer might have a different view depending upon the precise circumstances. However, one should always read one’s consent form with great care. Only last Friday, because I needed a small medical procedure, I modified my consent form before I would sign it to make it absolutely clear that “my” doctor had to be present throughout the entire procedure, even though I understood that others would have certain responsibilities during the procedure. If any physician tried to pull this performance on me, I would simply look at them and say, “Then let’s not start until we are completely clear who is doing what!” The last thing any hospital wants on their hands is a situation where surgery is stopped when everyone is ready to go. It may cost them a LOT of money!
One of the key issues here is that although medicine is, in fact, a “professional service,” some in the medical profession have a tendency to behave as though patients have no relevant opinions because they don’t know enough. I think we can safely say that that is not going to be a viable mindset within the medical profession in most Western countries 20 years from now, but for the time being at least, the onus is on the patient to be very clear about his/her expectations. If the doctor isn’t willing to listen, then the patient might be wise to take his/her body somewhere else.
Easy to say in an elective situation, as radical prostatectomy is. Almost impossible in an emergency, eh? You can’t say “if you don’t fix my rupturing aorta yourself, I am walking out of here.”
It is not always easy to resist in an elective situation either. The realities are such that many surgeons in teaching situations are desperately stretched thin (the same can also happen in private settings, obviously). So while the intent may be to supervise the trainee from A to Z, it’s not only boring to watch every aspect (especially when the trainee is good; it gets more exciting and interesting with a poor trainee), but it’s virtually impossible. We can cite concurrent responsibilities to other trainees in the OR or clinic, secretaries who call about deadlines for abstracts going to the AUA meeting, and limited financial support for training. For the teacher watching repeat performances of surgery, especially with good trainees, the distractions and conflicts abound and interfere with strict adherence to supervision
You want to make sure no trainee works on you? Go to a surgeon who has no trainees. That’s the only way to be sure.
A related point: the comment cites complications. It’s important to understand that complications happen in the best of hands. Why do we seek experience? To reduce (but not eliminate) the possibility that complications will happen.
So given Dr. Krongrad’s (very justified) remarks, and given that radical prostatectomy is always an elective procedure, every patient would be well advised to get it very clear between himself and “his” surgeon exactly who will be doing the procedure — up front and in writing if necessary!