How many of these cases have you done?

Doing a fellowship at a world renowned centre has made me aware of the desire of some patients to know institutional and individual results. Some have 'shopped' around and have done extensive research (usually on the internet) on the experience of an individual surgeon, or that of an institution, for a particular procedure. This is not new. Volume-based outcomes have interested insurers (public and private), politicians, licensing bodies, researchers, etc. It is only recently that patients have become savvy. All this is accentuated by the in-vogue concept of patient safety. (Not a new idea either. Hippocrates mentioned something about this some time ago: 'at least do no harm' in his book Epidemics.) Volume-based results are being published and advertised all over. The idea behind 'centres of excellence' most often is volume driven.

So you are a young surgeon starting out (or perhaps even an old surgeon using a new technique). And say you do not have the benefit of working at the world famous Mayo Clinic. This does have significant clout. Simply being a part of such an institution gives prima facie credibility. You seldom have to explain yourself. The issue of experience and numbers does not usually come up, except for the odd circumstance.

So what do you say when you are asked about your experience...You can hide behind your credentials. The licensing authorities did not cut you loose on the public without having checked you out. Furthermore, your residency and then fellowship at the world famous Ivory Tower should be sufficient. But as we all know this is no guarantee of anything.

Another option is to bend the truth a little (or a lot). Yes, it is true that you did 'some' mitral valve repairs in your training. For those in the know this usually means that you saw a whole bunch; and you sewed P1 and P3 together and put in the band/ring a few times. But does this really mean that you did it? The crucial part of this operation is knowing what to cut out and where to put the first stitch to join the free edges of the leaflets. So now how many did you truly do? This is not to say you cannot do the operation. For the most part you can. But you should have enough insight to start out with the easy cases and get some experience before you tackle some more crazy stuff. All you can hope for is that patients will trust the social contract they have with the licensing and credentialing bodies. If they do ask: have you done this operation before? You can confidently answer 'yes' and hopefully that will be the end of that.

Parenthetically, it has always amazed me the chest-thumping that goes on with some surgical trainees about how much they do. This is part intimidation, part one-upmanship, and part playing the game for jobs. What is more amazing is that some people actually buy it. What is truly frightening is that some believe they are actually 'doing' the operation. Humility and self-assurance works more for me and my conscience.

Moving on...

What if the patient wants to know how MANY procedures you have done. You can go back to your credentials and say that where you trained this procedure was common; or that you trained at the centre of the universe for this procedure; or that you worked with the inventor of the procedure; or that you were hired specifically for your training in this area, etc...The other option is to say, confidently: 'several' or 'many'. Another approach is to say to the patient that they were referred to you because of you skills in this area. The issue of numbers may no longer come up.

But what if the issue of numbers does comes up. When you are starting out in practise, you must be honest. I acknowledge that it is hard to be precise. Be as precise as you can. Also understand that you will likely overestimate your own experience, not because we are dishonest, but because we tend to do that as surgeons. If you cannot be more precise than 'several' or 'many', say so. State that you have performed all the components of the procedure (and perhaps the procedure itself) successfully during your training. State that you are confident in you capabilities as a surgeon to do the procedure successfully. State that you would refer the patient elsewhere if you felt you were not capable of doing it.

I believe that patients will appreciate your honesty. Very importantly, if you have been professional and authoritative (without being authoritarian) and have taken the time to listen and council the patient, the issue of experience will rarely come up. It comes down to trust and caring. If the patient trusts you and they feel that you care about their well-being, they will put their life in your hands, regardless of the number of grey hairs on your head.

Patients erroneously believe in the numbers game. Although there is some truth to volume-based improved outcomes, teasing out the reasons why outcomes are different at different institutions is difficult. It may not always be an issue of volume or your own experience. As a surgeon, you may be very capable of doing certain procedures, yet those around you cannot handle what is involved in diagnosis and post-op care. You need to understand this when offering surgery to patients.

Nevertheless, the issue of numbers WILL come up. The best thing to be is prepared with the truth. I believe that as an individual surgeon you should keep track of what you do and how your patients do. This is more easily said that done. It involves setting up an individual database for your cases. This is time consuming and costly. Your own results should reflect pre-op morbidity, mortality and complications. Long term outcomes of some procedures such as valve repairs would be ideal. I am unaware of commercially available database software for the purpose of individual use. There are larger databases where surgeons may participate, such as the STS Database. Usually this is institutional and expensive. The database in New York is mandatory. Local institutional databases are usually available.

Data should not just sit there, however. It must be used to derive information about your own practise. This information must be used to improve the care of your patients. The collection of data should be independent of 'research'. The primary goal is patient care. As a secondary goal, the information may be analyzed in a larger context and published as knowledge. And remember, with time and experience, knowledge becomes wisdom.