Make an informed judgment on the abilities of your surgeon

How many of the 40 million plus patients undergoing an operation this year are truly informed of their surgeon’s track record?  I suspect the vast majority of patients entering the operating room today are unaware of existing, vital information that would enable them to make an informed judgment on the professional abilities of their surgeon.

Most patients who end up in a surgeon’s office are there because their primary care physician sent them to the “best” surgeon in town.  They arrive, blindly trusting the judgment of their primary care physician.  What I find even more intriguing is that most primary care physicians are also unaware of the same existing, vital information necessary for them to make an informed decision on the “best” surgeon in town.

When you sign (and probably do not read) that consent form for your upcoming hysterectomy, knee replacement, heart bypass, or laparoscopic cholecystectomy, you consent to knowing the what, why, and potential what if’s of the operation.  However, are you informed enough to consent to knowing the “who” of the operation?

Patients undergoing surgery today do not have access to compiled performance data and because of this, I believe, are prevented from making informed decisions on the competency of their surgeon.  Today’s medical (and legal) system intentionally blocks patient access to pertinent performance information, information readily available to hospitals, insurance companies, and federal government agencies.

Why is this?  Why do hospitals have access to specific data on every surgeon’s performance in your community when patients about to enter the operating room do not?  Why is the patient, the one most directly affected by it, prevented from accessing this data?  For that matter, how does a patient begin to research the “real”experience of their surgeon, uncover the “real” performance data.  The diplomas, residency, fellowship training, board certification, and societal memberships only touch the surface.  Many of these questions asked have no good answer yet.

I believe in total transparency in the surgical profession and it is time to open up the hospital/insurance company books and take a look at information the public is craving for … information necessary to give a real informed consent.

Paul Ruggieri is a general surgeon and author of Confessions of a Surgeon.

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  • http://twitter.com/DarrellWhite Darrell White

    What data would you like to see, Dr. Ruggieri? Which of this data is available from hospitals and insurance sources? How would you propose to referee local differences in reporting this data? 

    We have our data compiled in house and share with anyone who asks. A major study from Sweden just looked at cataract outcome data and found the greatest challenge to be local interpretation of “standard” measurements (eg. visual acuity) causing difficulty in comparing surgeons.

    I heartily agree that verifiable risk-adjusted outcomes should be public. 

  • Anonymous

    Unfortunately most of the “performance” data that hospitals collect has nothing to do with the ability of the surgeon. Data on start times, length of cases, whether abx were stopped within 24 hrs, and even infection rates and post op DVT are practically useless when trying to decide whether the surgeon knows how to do a high quality ACL reconstruction. The typical data available would only confuse most patients. Transparency is good, but the most important data on a surgeon, long term outcome data, does not exist except in the rare high quality published study.

  • Michael Kirsch

    Agree in principle that patients entitled to know their surgeon or primary care physician or car mechanic or teacher or financial planner or coach are high quality, but how would you do it?  Patients will soon have access to quality profiles of physicians that will appear legitimate but will not be.  They will based on the false promises embedded in the pay for performance charade.  Patients will read and believe ‘quality data’ that will not include those true quality determinants that can’t be measured.  Just cause you can count it, doesn’t mean it counts.

  • Ann Brown

    As a lay person all you have is a general feeling of bedside manners and a wall of degrees to look at.  There is NO information available to compare the number of procedures a doc had performed and the outcomes and patient satisfaction results.  By the time the swelling has gone down and you realize it isn’t going to be any better, and you realize the doctor has lied that everything is “fine” — you have outrun the statute of limitations to sue.  The doctor I went to for a second opinion told me the doctor who botched my foot surgery doesn’t like patient dissent and will throw you out of his office if you disagree with him.  Yes, this is what our litigious society has earned for itself.  We should be like the United Kingdom – the loser pays all legal fees.  That would stop frivolous lawsuits and engender real fairness.

  • Ann Brown

    I worked for 10 years as a nuclear medicine technologist.  Critical to my job was the ability to be precise in injecting radioactive materials for diagnosis.  Some on our staff were simply not as gifted or competent at finding and accessing veins – but they all would say they were very good at injections to allay patient fears. Similarly, some technologists simply did mediocre work, being less precise in getting good camera angles and processing poorer quality images.  It kind of came down to whether one had a perfectionist sort of aptitude, however, those same average employees were employed and deemed satisfactory.  

    In the same sense, there are gifted surgeons who care deeply about outstanding results.  Unfortunately most patients don’t know enough to be able to communicate the important facts that count in determining who is a gifted surgeon because it requires a level of knowledge they do not have.  I have had 3 operations on my right foot and the great toe joint remains elevated off the floor, killing my ability to run or walk for long distances (orthotics are impossible to get right).  From the patient perspective, it’s a Russian roulette, a gamble because you have no choice but to rely on what the doctor says he/she is competent at, and who is going to say they cannot perform well at their livelihood specialty?

  • http://pulse.yahoo.com/_QSINMKGBLNT7HW3SF37JPWABQM Alexander

    Making such performance data available to the public will have the undesired effect of preventing the sickest patients from being considered surgical candidates.  Surgeons will need to have a very high percentage of quality outcomes in order to remain in practice, so patients with significant comorbidities will be denied surgical options for treatment, yet these are the patients that likely need it the most.

  • Anonymous

    What about substance abuse?  In the spirit of making an informed judgment, shouldn’t a patient have the right to know if their surgeon or anesthesiologist is currently in mandated rehab?  And their record of recidivism?  Especially any history of stealing drugs meant for their patients.  Patient advocacy groups say that impaired doctors are coddled by hospitals as part of a culture of clemency and second chances and, unless convicted of a felony, are allowed to continue practicing during rehab. If any of you doctors here ever need an operation, wouldn’t you also like a heads up on this type of information before making a decision?

  • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

    Dr. Ruggieri, I couldn’t agree with you more.  There was a time, in the not too distant past,
    that primary care physicians were able to keep up with the educations, qualifications,
    and—as you so cogently pointed out—the all-important statistical clinical data on performance outcomes of the subspecialists, to whom they referred their patients. Today, time constraints and the burgeoning numbers of newly trained procedural specialists make this a daunting task for keeping up, for many primary care physicians—although I suspect that many primary care MDs still keep a short list of recommended surgeons, within their own community or hospital catchment area, which, is based on relative sound clinical observations from working with the surgeons and/or from observing their surgical outcomes among patients shared in common.  For this reason, I would hope that patients would still be better off seeking the recommendation of a procedural specialist, from their primary care MD—as opposed to seeking a recommendation from a friend, office co-worker, barber, neighbor, yellow pages,
    etc.  I too believe the public has a definite need for a transparent source of all physicians’ clinical performances and their outcomes data—with the caveat that the architects of such “transparent sources” are legitimate, objective clinical-peer-review MDs—not a popular news periodical, or the PR personnel from a hospital’s or clinic’s corporative management.

    As I wrote in The Medical Profession Is Dead and the Doctor Is “Critically ill!”:  —‘In past years, it was considered a routine but crucial part of good  primary care, to educate one’s patients regarding such pitfalls in the medical system. It used to be considered a professional and ethical responsibility to send
    one’s specialty referrals to the best possible physician available for meeting their patients’ needs. In other words, the best primary care doctors in past times applied the golden rule in referring patients. If they wouldn’t want their own family members seeing a particular doctor, then they didn’t refer their patients to that physician, either. In those days, the best primary care doctors knew who were the best sub-specialists and vice versa. Each recommended the other when the need arose. Medicine then was still an honorable profession, percolating with pride, and to be held in high esteem, by colleagues, highly
    esteemed, was one of the most rewarding aspects of it. To be thought of as one of the best thinkers was a kind of carry over from the competitive one-up-man-ship of the clinical medical school years and, believe it or not, was more important than financial success to most physicians then. In those
    days medicine was a proud profession.’—Alan D. Cato MD, F.A.A.F.P. and author of The Medical Profession Is Dead and the Doctor Is “Critically ill!”
    (Oct., 2010)

  • Anonymous

    In order to enhance the validity of a patient’s informed judgement that would lead to a valued informed consent, there are questions should be asked to the physician who makes the referral to the surgeon.  First, would you be at ease in his O.R.?  Second, can I contact previous patients who were subject to the same surgical procedure?  Third, would you recommend another opinion?  Do not forget to be accompanied always by a loved one.  Do not forget that medical personnel that don’t have any problem in introducing themselves is a sign of people who stand by the information they are giving you.  So do not hesitate to write down their names and the information they gave.  A surgeon who practices patient centered care would reenforce the questions above and promote the idea of a patient who is in charge of his own health.

  • Anonymous

    I trusted my then-PCP to send me to the “best” surgeon. Her primary interest was in making as much money off me as possible. We discussed the procedure and scheduled the outpatient time for it. When I woke up, she told me that what I wanted was “impossible” to do and was furious that my spouse refused to consent to a much more extensive procedure. So essentially what I got out of that experience was a very expensive period of unconsciousness with some lovely color photographs to “prove” that there was no way she could have done what I wanted. I later found out through patient websites and then the local news that she had a terrible reputation and ended up having to close her practice due to not being able to keep patients or accurate financial records. So much for my PCP’s judgment (one of the many reasons she is no longer my PCP).

    I ended up finding a specialist out of state who coordinated my care for a year through non-surgical means, but he finally said that I did indeed need surgery. However, he recommended a completely different type of surgery from what Surgeon #1 wanted. So I did my own research online, contacted actual patients, and got the very best person in my area to complete the procedure.  When I showed him the photos, he said that what I had originally asked for was indeed possible and should have been easy but also had a likelihood of failure within 5 years, and he agreed with the out-of-state specialist’s assessment based on my condition after a year had passed. He also provided me with specific statistics on his own complication rates, the number of surgeries he had performed, and names and contact information of patients as well as journal articles he had written about the procedure.

    I am completely satisfied with the outcome six months later. I just wish I had done my own research to begin with. It’s too bad the kind of information I was able to find isn’t readily available for all types of surgery.

  • Anonymous

    Absolutely,

    It is unbelieveable that there is secrecy.  Patients will fight back, and look for options. There is an elitism to medicine and a ‘private’ members club mentality. I was dating someone who completed a fellowship as a neurosurgeon, at University of Toronto and he is abusive, aggressive and if he passes his board examinations, there is nothing anyone can do. He should be charged with sexual harassment.

  • Anonymous

    I went to Jihad Kaouk at the Cleveland Clinic for prostate cancer surgery.  Jihad Kaouk represented that he was board certified, volume experience of 2000 prostatectomies, including 1000 open, with outcomes of greater than 95% preservation of potency and 99% for continence. I suffer devastating permanent injuries.  Many other patients have reported horrible outcomes, many life threatening.  Court documents reveal that he had done only 400 total procedures and 0 open at the time of my surgery.  My informed consent document was disappeared authorizing only him to do my surgery and the Cleveland Clinic admits residents did much of my surgery. There is no evidence Kaouk was ever present during my surgery. He reported by telephone to my wife after my surgery of “getting stuck and having trouble” but I have a picture perfect op report written in third person. No resident or surgeon met with me or my wife after surgery or during my stay in the hospital.  A CMS investigation led to a letter of admonishment to the Cleveland Clinic CEO, Mr Cosgrove, “”WE HAVE DETERMINED THAT THE DEFICIENCIES CITED
    ARE SIGNIFICANT AND LIMIT YOUR HOSPITAL’S CAPACITY TO RENDER ADEQUATE CARE AND
    ENSURE THE HEALTH AND SAFETY OF YOUR PATIENTS.”  I have been unable to verify the credentials claimed by Jihad Kaouk.  FOIA responses say this would be a violation of his privacy.  Although a website showed Jihad Kaouk to possess an Iowa medical license,  the Iowa state medical board stated  Jihad Kaouk  “did not meet our
    eligibility requirements and that was the reason he withdrew his
    application.  I have learned that I am one of many victims in a system which protects doctors with no concern for patient injury.  Sexual predators are exposed and not given special protections.  Why should rogue doctors be treated any differently.  How many more unsuspecting victims must suffer injury because of this broken system.

  • Anonymous

    My son had a kidney transplant at the Cleveland Clinic with his aunt as the donor. The surgeons David Goldfarb and Jihad Kaouk were the head of their respective departments and claimed to be the best for these surgeries. They told us as a team they had done over 300 kidney transplants together. The donor was injured with numerous tears in her abdomen that required additional surgery and the kidney was also injured and put in my son which became black and septic within a month. Had we been able to look into the medical background of Kaouk we would not have let him perform this surgery. It is our right as patients. kidneytransplantkiller.