Video review of surgeons: Can the logistical issues be overcome?

Last month, a superb study by the Michigan Bariatric Surgery Collaborative showed that the more skilled surgeons were, the better were their outcomes.

Surgeons submitted a video of their choice depicting their performance of a laparoscopic gastric bypass. Since it was self-selected, it was presumably their best work. At least 10 of their peers, blinded as to the name of the surgeon, rated skills on the video which had been edited to include only the key portions of the case.

Surgeons in the lowest quartile of ratings for surgical skill had significantly more postoperative complications, readmissions, reoperations, and deaths.

A New York Times article about the paper features a couple of short video clips — one from a not-so-skilled and one from a very skilled surgeon. The differences are obvious and dramatic.

According to the discussion section of the paper, the Michigan bariatric surgeons are now watching each other operate and will soon be receiving anonymous feedback about their technique from their peers.

It is not clear whether this will improve the skills of the lower-rated surgeons or have any effect on outcomes.

Many people rightfully praised the research. Some suggested that all surgeons should be scrutinized in this same fashion.

I agree that the study was well-done and shows that technically better surgeons have better outcomes.

But there are some problems with generalizing this to all surgeons.

The American Board of Surgery recently noted that there are almost 30,000 board-certified general surgeons in the US. This raises a number of logistical issues.

Let’s say we focus on the most common major surgical procedure — laparoscopic cholecystectomy. 10 surgeon-raters would have to view at least 15 to 20 minutes of video for each of the 30,000 board-certified general surgeons. How long would that take? Who would collect and edit all the videos? Who would make sure that the ratings were consistent? Who would collate and distribute the results? How would follow-up be done? Who would pay for all of this?

And that is just for the board-certified general surgeons. What about the general surgeons who are not board-certified and all the other surgical specialists? Maybe gastroenterologists should have their endoscopy procedures scrutinized. Maybe primary care docs should have selected office visits recorded too.

This is similar to the enthusiasm which surrounded the concept of using retired surgeons to coach other surgeons. The idea was based on the experience of one surgeon, who had access to an expert coach and wrote about it. I blogged about the logistical difficulties that would preclude coaching from becoming widespread. To my knowledge in the two years since I wrote that post, coaching has not caught on as a performance improvement measure.

It’s too bad, because in an ideal world, video evaluation of operative procedures and coaching would be great. Unfortunately, we don’t live in an ideal world.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • Deceased MD

    Learning by video might have some value. i am not a surgeon but I can see it might. My concern though is that it does not become a grade system like one is back in school or in this case residency. It could be interpreted as devaluing. But if it was viewed as CME that might be different. And heaven forbid, with any kind of video that it does not end up on youtube.

    • Skeptical Scalpel

      Good point. If this ever becomes widely used, tight control of the videos is essential. But as we have seen, bad stuff usually comes to light.

      • rbthe4th2

        Sometimes it is better if it is. I see nothing wrong with a doctor getting help from his peers to do better. Better they get help than a patient go south, you know? I don’t think any one wants that.

        • Skeptical Scalpel

          I’m not against video review of cases. I just don’t think it is practical to do for every surgeon in the US.

          • rbthe4th2

            Hmmm. What about a voluntary program like the above, but then allow the ones who find out they’re tops rated, to put that somewhere? Like on a website?
            Would retired surgeons be able to help you think? Maybe those recently retired would be up for it.
            Not trying to be nosy, but do you think this would work for those surgeons rumored to be a problem to be critqued in this way by a group from a competiting hospital? I don’t know if that’s what is done in hospitals now, but my concern is that I’ve seen the ‘I know this guy, he’s ok’ and rather than have problems with friendship or cronyism get in the way, maybe someone from another vantage point would be helpful.
            I’m just throwing things out that I don’t know if they’ll work but at least its something that I think may help docs who need skills help and lessen a burden of lawsuits. Anything keeping lawyers out of the mix helps, at least that is my take.

          • Skeptical Scalpel

            Interesting ideas. Much as I hate to say it, I can’t see surgeons doing this to then allow their competitors to brag about it online. The problem with rating surgeons from other hospitals is who outside of the special research setting in Michigan has the time or motivation to spend hours doing this without some kind of pay? And how would the raters be validated?

          • rbthe4th2

            I have NO problem with your honesty and I TRULY appreciate it.
            Well, what about those recently retired out of surgery, or could this be considered part of the CME requirements?
            That is interesting about the raters being validated. Would the ACS be any help? There are groups for the subspecialties, wouldn’t that help?
            You guys are really that competitive? I’ve seen it more they cover for each other rather than a competition.

          • Skeptical Scalpel

            How many recently retired would want to do this? How many are capable of doing it. The Michigan study involved a fairly complex type of surgery. Not everyone does it.

            I don’t know about the ACS or other societies. Again, someone would have to do the work.

            As for the competition, you have no idea.

          • rbthe4th2

            Seems my reply didn’t get here.
            I would think bariatric surgery has 2 items: 1) stick a tube down the throat into the tummy, cut the excess, sew up, there is your sleeve and 2) the bypass, which is probably something that after the first 100, so after your first year or so, when you do your graduate training, you’ve got that down pat.
            I would think maybe some part time work?
            You’re right I don’t have any idea. I’ve seen them stick together. I’ve also seen one surgeon bad mouth another group. Without saying what I heard, I asked about the other surgeon through people I know. They told me about his OR habits – the complete opposite of what the one surgeon said.
            So its hard to know. I also can’t see what the problem is, there is MORE than enough work for everyone from what I’ve heard. If so, why the problem on the “competition”. I would think with all the stress and lawsuits, the more people, less stress, less chance of lawsuits.
            Educate me for what’s different.

  • EmilyAnon

    Videotaping operations must be kind of common what with the hundreds of surgical videos available on Youtube and other online sites. Even though the patient is not identified, the surgeon and hospital usually are. How do other surgeons view these doctors who willingly display their surgeries to the general public?

    • Skeptical Scalpel

      It’s really not that common, but I can see why you might think so. I think it’s mostly harmless self-promotion,
      but it can give lay people the wrong impression. For example, thanks to
      editing, a complex case might appear to take 6 minutes and have no
      bleeding. I hope no one picks a surgeon based upon a single YouTube video.