Monday, 28 March 2016

How to Pick a Good Surgeon in Three Questions

There’s been a lot of negative press around surgeons lately. Ranjana Srivistava described a very disturbing case of suspect (and what sounds like money-driven) decision making by a surgeon in a system that allowed for it. I don’t think what she describes is representative of all or even most surgeons, but I don’t doubt the veracity of what she describes, it’s a very believable story to me.

And all this is on the background of months of exposure for bullying and sexism in some quarters of the surgical profession.

It’s easy to see why somebody going to see a surgeon at this time might do so with a sense of dread or mistrust.

Choosing a surgeon is pretty daunting at the best of times. Doctor rating sites tend to be based around things other than the quality of a doctor’s practice. Most give as much weight to the visual attractiveness of a doctor’s room, the friendliness of reception staff and their punctuality as they do to a doctor’s knowledge. None that I know even attempt to measure a surgeon’s skill with the knife. Frankly I don’t put much store in them.

So how do you choose a good surgeon then? Well this is how I would do it. I’m not saying it’s the only way, but these are the questions I would ask.

The questions I would ask, more or less in order of importance are as follows.

Question 1. “Which M and M meeting(s) do you participate in?”

M and M (Morbidity and Mortality) meetings are the cornerstone of quality surgical practice. There’s an adage that only two kinds of surgeons don’t make errors, those that don’t recognise their errors and those that don’t operate. In a robust morbidity and mortality meeting the participating surgeons present every patient that has had a bad outcome, whether that be death, a disability, a wound infection or an unplanned return to the operating theatre and the case is discussed by the surgeons in the meeting. The meeting reviews whether the correct decision was made in deciding to operate, the type of operation performed and whether the outcome was avoidable, and suggestions are often made about how to prevent complications. Different surgeons will suggest a range of different suggestions for things they’ve tried that have or haven’t worked and whether they have found themselves in similar situations. Data is kept and surgeons who keep presenting with the same complications can be identified.

These meetings are usually held on a department/hospital level but for very specialised surgery (e.g. paediatric craniofacial surgery in NSW) they might be held at a state level to get sufficient expertise in the room.

Beware a surgeon that doesn’t participate in M and M meetings. M and M is the primary way surgeons get feedback on their performance and the primary way that surgeons keep an eye on each other to ensure everybody is meeting today’s standards for acceptable operating technique and decision making.

A surgeon who doesn’t participate in M and M doesn’t have that degree of feedback and to an extent is professionally isolated. “Self-review” is no substitute. There is nobody to check them if their approach is out of date and not in line with best available evidence, there is nobody to give feedback on how they manage their cases and nobody to challenge their decision making if it’s out of kilter. It also speaks to a surgeon’s priorities and how seriously they take examining their own shortcomings, and their self-perception if they feel they don’t need review.

By virtue of passing RACS exam it’s reasonable to assume every surgeon meets an acceptable standard of practice when they first start. But what is acceptable practice, as well as a surgeons technical skills can change over a 30+ year career, M and M helps ensure that surgeons continue meeting those standards.

This is the single most important question for me. I would be very hesitant about going to a surgeon who doesn’t regularly participate in an M and M meeting.

Question 2: “Is there anybody you would recommend for a second opinion?    

The answer should never be “no”. A good surgeon should support your right to be informed and comfortable in making decisions about your health. Many great surgeons I know will actively suggest a second opinion for all complex and major surgeries.

Beware the surgeon who suggests you don’t get a second opinion. It speaks either to a sense of professional isolation, unwillingness to have their decisions reviewed, an overly mercantile attitude or an unchecked ego. None of these are good things.

A good surgeon should be happy to suggest some names and facilitate a second opinion for you. If they’re not, that’s a red flag.

Question 3: “What will it cost?”

People don’t have limitless money. Surgery is important (often vital and life-saving) and a quality surgeon is important but it shouldn’t be used as a license to extort money. Surgeons charge a range of fees, as most providers do in a free market, but rates significantly above the AMA suggested rates should have to be justified.

Sometimes rates above what the AMA suggests are justified. Some cases are particularly and unusually complex compared to other operations of the same type. Some practices, especially in rural or remote areas with low patient volumes will have higher administrative costs without the economies of scale larger practices may have. All of these are good justifiable reasons to set a higher fee for a case.

Surgeons who charge many multiples of the AMA rate for simple cases just as a matter of routine because they can, either through reputation, celebrity or lack of competition show a degree of mercantilism that my bleeding left wing “healthcare for all” heart isn’t comfortable with.
If a surgeon can’t justify the fee they are charging that’s a red flag for me as well as my finances. I have to know that I am my surgeon’s first priority rather than my wallet, or else I couldn’t be comfortable placing myself in their care.

In summary:                

Like I said at the beginning these are just questions I would ask and this is just my personal opinion. I think if a surgeon answers those three questions well then it helps to establish that you’ve picked a surgeon who is not professionally isolated, who has colleagues checking their practice and knowledge is up to scratch, who is committed to quality and who has your care rather than your potential to earn them money as their first priority. That’s much more important to me than how attractively their waiting room is judged on a doctor rating site.