400 Cases: Quality and Safety

What is the ideal number of cases a cardiac surgeon should do in one year to maintain competency? Estimates range from 100 to 200 cases. It may be argued that doing more cases will translate into better outcomes. However, I will question this assumption and state that there is a threshold above which improved outcomes and safety are compromised. I do not know what this threshold is, but I have chosen an arbitrary number of 400 cases per year as a starting point to put forth my arguments.

My arguments do not apply to the most advanced and specialized centers in the world. These I would consider as quaternary referral institutions. In these centers, the infrastructure exists such that a surgeon may perform 400 cases in one year without the limitations I will outline below. These clinics will have associates, fellows, advanced support staff, and infrastructure that make 400 cases per year for one surgeon safely possible. It also attracts and recruits surgeons and physicians with skill and motivation that are at the upper end of the bell curve. This essay applies to the rest of us.

If a cardiac surgeon performs 400 cases in one year and he/she works 48 weeks in that year (4 weeks off), then they are doing just over 8 cases per week. If an average daily case load is 2 cases per day, then the surgeon is operating 4 days in a week. This leaves one day for an outpatient clinic, continuing medical education, administrative responsibilities, and research (if applicable), assuming a “normal” working day and a 5-day week, excluding on-call duties.

Doing 8 cases per week over time, in my opinion, will lead to chronic physical and mental fatigue. I believe surgeons are trained and encouraged (not overtly) to ignore fatigue and it’s deleterious effects on performance. This “toughness” is rewarded during training by silent approval and the opportunity to do cases. It is later rewarded financially in a fee-for-service environment. This circumstance is further aggravated when on-call duties are taken into account. Some surgeons will operate the next day after having been up the previous night. This acutely fatigued state will aggravate the chronic condition. The negative effects of acute fatigue in the form of sleep deprivation have been clearly documented in medicine. I am unaware of research on the effects of chronic fatigue in medicine, but it is likely to have a similar negative effects. Much like flying an airplane, operating in a cardiac case is a very complex task, where fatigue will compromise the safe conduct of the operation, and potentially lead to an adverse outcome.

Operating is not only a technical act. It is not enough to just know how to operate, but also to know who to operate on, what operation to do, and how to deal with complications as they arise. These are the components of good surgical clinical judgment. Most, if not all, of the decisions about the patient and the operation should be made before one even enters the operating room, including how to deal with potential problems. This can only be done if the surgeon has the time to review thoroughly, completely, and in detail all the available patient data. In addition, the surgeon should have the time to think about the case and develop a plan. The key word here is time. If these intellectual components of surgery are not adhered to with discipline, then quality of care and patient safety are compromised. How can an average surgeon working at an average institution and doing 8 cases per week adequately prepare for a case? I do not believe that they can. To use the flight analogy again, flight planning is as important as the flying.

A surgeon who spends his or her time in the operating room will also not have much time to dedicate to the patients, either pre-operatively or post-operatively. How many patients complain that their surgeon is rushed and does not spend the necessary time to address their concerns? This happens much too often.

Surgeons are not only called upon to operate. They also have other responsibilities related to their profession. These include administrative responsibilities related to their own practice and the institution in which they practice. They also include continuing medical education or maintenance of certification. The latter, in particular, are exceptionally important to the well being of patients. In addition, research and teaching may be components of an academic practice. All of these aspects of a surgical career require time and attention to be done well, or to be done at all. I have directly observed, and experienced as a trainee, the negative effects of a busy surgical practice on research and teaching. I can only surmise the compromises being made to continuing medical education. A professional pilot is expected to have ongoing training and assessments of competency and time is allocated for these endeavours. We owe to our patients and trainees the time to stay current in our discipline. We are also obligated to be academically productive if we are in a University practice.

Most importantly, as human beings, surgeons should also have the time to spend with family and to pursue “hobbies”. This will make us more balanced individuals and in the long run happier people. This can only benefit our patients.

In conclusion, a cardiac surgeon who does 400 cases in one year may be compromising quality of care and patient safety, if they are working in less than a quaternary referral center. What is the ideal number of cases to maintain competency? What is the ideal number of cases to maintain proficiency? These numbers may be an issue for debate. However, it is clear to me that 400 are too many. A surgeon doing this many cases should re-evaluate their practice and perhaps offer younger surgeons more opportunities to attain and maintain competence, while at the same time enhancing the quality of care and safety of patients.