The Most Important Question to Ask When Picking a Surgeon

In a previous note, I addressed the topic of how to pick a "good" physician and hospital (see: Some Tips for Selecting a "Good" Doctor and a "Good" Hospital). Experience of the surgeon for a particular procedure should be added to this list. Below is an excerpt from a recent article that addresses this topic with regard to reconstruction of the anterior cruciate ligament (ACL) by an orthopedic surgeon (see: ACL surgeries may fail to take when doc has done fewer than 60 before yours):

Patients who have their anterior cruciate ligament (ACL) reconstructed by surgeons who have performed less than 60 surgeries are roughly four to five times more likely to undergo a subsequent ACL reconstruction, according to a study by researchers at Hospital for Special Surgery. The study also showed that participating in a subspecialty orthopedic fellowship-training program did not improve the learning curve of young surgeons performing ACL reconstructions....The ACL is one of the most commonly injured ligaments of the knee, with approximately 100,000 ACL reconstructions performed each year in the United States. For years, doctors have known that outcomes in surgery are related to volume. For example, the more ACL reconstructions a surgeon performs, the more proficient they become with fewer patients having to undergo a re-operation. But until this study, doctors hadn’t investigated what the learning curve actually looked like....The researchers found that if a patient was one of the first 10 cases of a surgeon’s career, they were roughly five times as likely to have to undergo a subsequent ACL reconstruction than if they fell in the career cases over 150. If a patient was case 11 to 60, they were 3.7 times more likely to have a subsequent ACL reconstruction. The risk continued to fall with 3.0 for patients in the 61 to 120 group and 1.4 for patients in the 121-150 group. Overall, the frequency of a subsequent ACL reconstruction within one year was 1.7%. The researchers were surprised to find there was no significant association with sports fellowship training and subsequent ACL reconstruction.

It's a well known fact that surgical experience leads to better outcomes. This seems to be very logical to me but I am no sure of the extent to which this is common knowledge among healthcare consumers. The article quoted above addresses the "learning curve" for ACL reconstruction, which is about 60 cases. It turns out to be about 250 procedures for prostatectomies (see: Surgeon's Experience Key To Prostate Surgery Success). This is not be surprising given that this latter procedure is more complex.

Here is the key set of points from my earlier post that can be used in the physician/hospital selection process (see: Some Tips for Selecting a "Good" Doctor and a "Good" Hospital):

• Browse the web to gain knowledge about various diseases and current methods of treatment in order to become "part of the medical team" and therefore engage with your healthcare providers in a meaningful way.
• Choose a high quality primary care physician (PCP) to provide advice and "help you navigate through our challenging but complex healthcare system."
• One way to help assess the quality of individual physicians is to establish whether he or she is board certified. However, board certification is only one indication of quality and it’s certainly no guarantee.
• Ask your local hospital for a list of board-certified internists or other types of specialists who have admitting admitting privileges to that hospital.
• The last and most critical part of selecting a physician is the first appointment, at which time you can evaluate his or her style and knowledge.

You can add to this list, regarding the selection of a surgeon, the number of previous cases that he or she has performed. An appropriate time to raise this question is during the first appointment. I am thinking that the range of cases performed for a surgeon should be something like 50-250 based on the complexity of the procedure. Alternatively, you may want to think in terms of years of practice, which should be a about three if the surgeon has a busy and high quality practice. When you inquire about the number of previous cases, you may also want to discuss how he or she defines success for a particular procedure.