“Critical Mass” Is The Name of the Game In Surgery
27 Sep 1998
Suppose you need a radical cancer operation. Or angioplasty to remove a blockage in coronary arteries. Or a coronary bypass operation. Who should perform these procedures? Where should they be done? These are questions that patients and families of an aging population are asking more often. The answers may mean the difference between life and death.
One component of the answer is “Critical Mass”. Or, put another way, the old dictum is still true, “Practice makes perfect.” Whether you’re a plumber or a surgeon the more work you do the better the results.
Dr. James Hollis, Assistant Professor of Medicine at Duke University in Durham, North Carolina, stressed this point at a meeting of the American Heart Association.
Patients, he said, were more likely to die or require emergency bypass surgery at the time of angioplasty when treated by low volume surgeons working in low volume hospitals.
During angioplasty doctors try to open a coronary artery that is partially blocked by an atherosclerotic lesion. One method is to insert a balloon into the coronary artery which pushes the lesion against the wall. Or to insert a “stent”, a device which holds the arterial walls open.
But there’s a problem. Dr. Hollis reported that over half the doctors performing angioplasty in the U.S failed to do sufficient cases to acquire expertise. You don’t have to be a rocket scientist to conclude this causes needless complications and deaths.
In 1988 in an effort to avoid these catastrophes U.S. doctors were issued guidelines. They were instructed not perform angioplasty unless they were doing 50 cases a year. And hospitals were advised they should do a minimum of 200 procedures or none at all.
So what happened? A large number of physicians and hospitals ignored the guidelines. The result was predictable.
A survey showed that for doctors performing fewer than 25 angioplasties a year, 6.1 % of patients required either follow-up bypass surgery or died in hospital. For doctors doing over 50 cases a year 4.7 % of patients required bypass or died.
This proved what has been known for years about coronary bypass surgery. High volume surgeons working in high volume hospitals have fewer post-operative complications and deaths.
Canadians are better protected from super-surgery than Americans. It’s impossible to have cardiac surgery in a small community hospital in Canada. The government refuses to purchase equipment for a hospital that does not have proper staff and back-up facilities.
In the U.S. hospitals can carry out these procedures if they can afford the expensive setup and have doctors on their staff willing to undertake the surgery.
But in Canada there’s not total protection. For instance, a recent report reveals that radical surgery for cancer of the pancreas is at least twice as risky if done by a low volume surgeon in a low volume hospital.
In fact, in a hospital that does fewer than three cases a year the risk can be four times higher!
What is shocking is that surgeons who are performing fewer than three cases a year subject patients to this complicated operation. That requires a surgeon with either the technical wizardry of a Michael Jordan, or someone who believes he or she is related to the Almighty.
No one should do a gallbladder operation who is only doing less than three a year. And no one, absolutely no one, should do major cancer surgery unless that person is a high volume surgeon.
Surgical skill is not the only factor to determine the number of complications and deaths following surgery. Good anesthesia is critical in these operations. So is the availability of nurses specially trained in these techniques and infection control.
Patients should not need a course in “medicine 101” to reach this conclusion. But studies in the U.S. reveal that patients often make the wrong decision. If given the choice of a large hospital far away from home or a small community hospital nearby they choose the one close to home.
For any operation the best insurance policy includes a first class surgeon with skilled hands. And for angioplasties, bypass surgery and major cancer operations it is especially risky to think otherwise. So where should they be performed?
Not all things are done better in university hospitals. I know surgeons in small community hospitals that I would trust with my own life. Others in university hospitals that I wouldn’t trust with my dog. But pound-for-pound one of the wisest decisions in major procedures is the choice of a university hospital.
These teaching institutions must obviously have a high volume of all kinds of surgery, and they control stringently whose hands do the cutting.
