A new kind of patient is emerging (or has emerged, depending on your practice) – an informed, internet-savvy, choosy patient, born out of the union of advanced technology and overriding consumerism. More than ever before, health-related information is available to this patient. Good and bad information is a few clicks away; published by thousands, accessed by millions, and policed by few.
At some point in his or her health trajectory, this patient will likely require a surgical intervention. Woe to the surgeon hit with the onslaught of Googled patient stories, You-Tubed surgeon repertoires (because who doesn’t put their best stuff online – look at me, Mum!) and some sort of, mostly irrelevant, checklist created by a Facebook patient-advocacy group. After wading through this pool of internet hullabaloo, the surgeon will finally recommend the appropriate intervention, only to be met with ‘and how many of these have you done?’
When I was a trainee, a mentor gave me some interesting advice in regards to this question: ‘Say “Oh, I’ve done a number of these procedures” because, even zero is a number.’ While this answer is funny, albeit purposefully misleading, it hints at a common concern of physicians. ‘Do I have to answer this question? I’m actually offended it was even asked.’ My inner, white-coat-shrouded, hierarchy-abiding, Hippocratic oath-spouting, super surgeon scoffs at the audacity of a patient to even think to ask such a question. (Don’t act surprised, you know you have one hiding inside you, too.) We have entered an era of consumer-driven medicine, as dangerous as that is, where quality drives reimbursement, even privileges. Dare I say, that may be a good thing. So is it so wrong to include surgeon volume in informed consent? How do we go about doing that?
Point: Patients should not have access to surgeon numbers, nor should they ask.
Recently, I went on a cruise to the Bahamas with my family. This trip required two flights on commercial airliners, two bus rides, and a voyage on a very large boat. Not once did I think to ask the pilots, the bus drivers, nor the ship’s captain their crash records or number of flights/bus trips/voyages. Why? Because I have trust in those industries; in the training of those individuals, the systems that oversee them and the equipment they operate. And more importantly, I don’t want to know. I like being ignorantly happy. Additionally, I cannot imagine the amount of research it would take to fully investigate each part of my journey to identify potential risk. It wouldn’t stop at the pilot/bus driver/captain, but would include all the maintenance workers for each of those vehicles, air traffic control, the coast guard, and on and on and on. No amount of information could completely allay my fears. And I’m pretty sure no one is going to give me all the information anyway. So, as far as an individual surgeon is concerned, how helpful is one number? Any surgeon will tell you, the success of a surgery is dependent on many more variables than just the surgeon. The guy in the basement processing your instruments can ruin your whole day.
Let’s just say, for argument’s sake, that an open display of surgeon-volume becomes a natural part of consent. Where does it stop? What’s next? Complication rate? Readmission rate? Number of near-misses? By complying with consumer demand, you increase consumer desire. And, the consumer desire is to always know more and control more. It’s called demand for a reason. Thus results an unintended transfer of power. Kind of a dirty word to use in medicine, but it is power nonetheless. In most settings, power and knowledge are proportional – as they should be. Those with the most knowledge also have the power. A good example is a police force. The person with the power to put me in jail should also have the most knowledge about my rights and the law I have broken. If a police officer had less knowledge than the citizen, but still the power to incarcerate, chaos would ensue. The same would happen in medicine. We would become retail sales people as opposed to the guardians of medical care, complying with the wishes of under-informed patients, regardless of potential health risks to the patient and the population.
Ultimately, the sacrificial lamb in this situation is the trainee. How does a trainee or recent graduate answer the question of case volume? A downstream effect of publicly available surgeon-volume is a shift of surgical cases toward seasoned surgeons and away from trainees and younger surgeons, with disastrous consequences for the future of medicine.
Counterpoint: Patients should have access to surgeon volume and should be encouraged to ask.
Selfishly, this is the reason I have a job. I am a minimally invasive gynecologic surgeon. My training itself is designed to give me a special focus and high numbers in certain types of surgical procedures. And I like that the literature endorses better outcomes, lower cost and higher patient satisfaction with high-volume surgeons. If I were the patient, that is what I would want. Wouldn’t we all? Is it fair for us to expect a wall of protection as surgeons, while we secretly dig a tunnel under that wall when we become patients? Additionally, when patients ask for information, this adds another layer of accountability, and accountability, whether we like it or not, is a good thing. If we don’t police ourselves, someone else will. The tide of patient demand will not stop, and higher authorities, with dollars on the line, will capitulate. If we don’t offer up the information that is requested, someone else will. I would much prefer it come from me than a page on an internet site.
Really, we should not be asking ourselves ‘how do we answer this question’, but ‘why are patients asking in the first place?’ Patients ask this question because they are afraid, and they want the best-possible outcome. Who can blame them? I am frequently in awe of patients, actually. They willingly lay themselves down on my table; naked, cold, surrounded by strangers, with needles in their arms and choose to become unconscious, while I move their bodies and stick them with sharp instruments. They understand that a slip of the knife could have disastrous consequences. Yet, they trust me. That is an amazing and heavy responsibility. I have a duty to put them at ease. If that means giving them an account of my experience, I will. But in addition to your volume, patients should have a grasp of your training, your years spent working with a mentor and the other qualifications you have that allow you to stand in that room, obtaining informed consent. If they still have concerns, offer to scrub this case with a senior partner, someone they feel comfortable with assisting you. When patients question our credentials, this comes more from a fear of loss of control than an attack on our abilities. Stand up for yourself, recite your qualifications, be confident in your skills, and use that knowledge to create confidence in your patients, too.