Who Will Do My Surgery?

Photo Credit: Gary Minnaert

On the WebMD message board on Joint Replacement there are a number of posts concerning serious problems that have occurred in each individual's surgery. One thread that ties these together is that is appears that the original surgeon that operated on the patient who posted the issue did not, would not, or could not solve the problem. What is this all about?

There are many serious problems in health care. One of the more hidden and dangerous ones is doctors performing surgeries for which they are not properly trained.

In reference to joint replacement, there is a lot of literature concerning the minimal volume of operations that separate surgeons with lower versus higher complications. I know of no US Hospital that requires surgeons to have this volume tie to their privilege to perform this surgery at that hospital.

In a report from Brigham and Women's Hospital (Harvard), for first time (primary) hip replacement, the surgeons who performed more than fifty a year had lower complications.

The same group at Harvard reported on knee replacement volume. Knee replacements done by surgeons who performed more than fifty procedures a year had lower complications an adverse outcomes. Hospitals that performed more than 200 procedures a years had lower complications as compared to hospital that did less than twenty-five procedures.

In another report, patients had higher satisfaction in hip replacement if the surgeon performed more than thirty procedures a year and the hospital performed more than one-hundred.In another report, patients has higher satisfaction in hip replacement if the surgeon performed more than thirty procedures a year and the hospital performed more than one-hundred.

In a report from the VA in Boston, surgeons who performed more than four shoulder replacements a year had lower complications than those who did less than four.

So what can we conclude here?

At the very least, the surgeon you choose should perform a minimum of thirty primary joint replacement procedures a year for you to have an optimal satisfactory result with lower complications. This means:

• Thirty total knee replacements
  
• Thirty partial knee replacements (unicompartmental)
  
• Thirty primary total hip replacements
  

I know I could have gone for the fifty number but we can at least start at the minimum of thirty.

What are you to do? Ask your surgeon. He or she should be able to tell you whether or not they do at least thirty cases. It is not important as to the actual volume. There is no proof that there is a difference in quality between a surgeon who does one hundred or three hundred. In fact, more volume per surgeon after a certain number may beg the question - who is actually performing the surgery (the surgeon, an assistant, a surgeon-in-training)?

You can follow-up the answer with a letter to your surgeon:

Dear Surgeon:

I am pleased to be having surgery with you. As per our discussion you assured me that you perform at least thirty procedures a year of the procedure I am having with you. My decision to have this procedure with you was dependent on this fact. Thank you and I look forward to this procedure.

Signed,

The Patient

What would be the purpose of this letter? It may represent an implied warranty of the accuracy of the information you were given. It will certainly scare the bejesus out of any blatant liars and scoundrels.

Should hospitals should require a minimum of a certain procedure by a surgeon on staff? Absolutely. A reasonable approach is to set the volume standards and give a surgeon a reasonable amount of time to achieve these. This allows new or growing surgeons to reach these volumes. One can say, you need to reach these volumes within three years of you performing the first procedure at this hospital.

Size may not always matter, but it appears that volume does.

Dr. K.

Related Topics:

• WebMD Video: Joint Camp - Preparing for Hip and Knee Replacement Surgery
• WebMD Video: Computer-Guided Knee Replacement

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