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What makes a good surgeon?

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  • Avatar Panscan 
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    I would think that anesthesia would have quite a bit of insight actually.

    You’d have a hard time getting me to believe that demeanor in the OR isn’t pretty well correlated w/ technical ability. Usually in the hospital when someone is being unreasonable or angry one of 2 things is going on.

    1) They are being asked to do something they can do at an uncomfortable time of day (e.g. being woken up at 2am on call)

    2) They are advertising their lack of confidence in their skill set.

    So a surgeon who is a total dick in the OR and loses their mind easily, sorry I’m not going to follow anyone down the path of justification that it’s b/c they are some kind of tortured genius.

    I tend to look for what special forces soldiers call “quiet professionalism.” Confidence w/o being cocky. When I think of the most highly respected surgeons at my current shop (some of whom are world famous) they tend to be middle aged and extremely professional in their interactions. Actually most of them are frankly just really nice people, warm, friendly, etc.

    There is IMHO an entirely unhelpful and unnecessary mystique about surgeons and many obviously have the attitude that non-surgeons are not able to meaningfully assess surgeons. I reject this paradigm completely.

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    I don’t think there is any correlation. some people lose their sh*t, other people don’t.

    it’s not just a surgeon thing. I have no way of telling if a nephrologist or pathologist is good or not. I have no way of assessing any other doctor in another field.

    #197055 Reply
    Liked by Zaphod
    Avatar Panscan 
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    how do you tell if someone is a good family medicine doc? its very hard.

    #197057 Reply
    Avatar NephronDon 
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    I lean on my critical care and anesthesia colleagues. Bad surgeons are easy to pick out: ICU complications on elective cases. Long cases and anesthesia times for relatively simple procedures. My surgical colleagues often tell me of complications of their colleagues. The best surgeons are busy, boring and rarely hear of any problems in the hospital.

     

    In my area, I foresee a big shortage of qualified surgeons. The hospitals are hiring surgeons out of training, that are unseasoned and unmentored, expecting perfection from the start. Young surgeons are not a commodity but a resource that needs to be developed. The older, experienced surgeons are retiring without imparting their knowledge on the younger generation.

    #197122 Reply
    FunkDoc83 FunkDoc83 
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    I lean on my critical care and anesthesia colleagues. Bad surgeons are easy to pick out: ICU complications on elective cases. Long cases and anesthesia times for relatively simple procedures. My surgical colleagues often tell me of complications of their colleagues. The best surgeons are busy, boring and rarely hear of any problems in the hospital.

     

    In my area, I foresee a big shortage of qualified surgeons. The hospitals are hiring surgeons out of training, that are unseasoned and unmentored, expecting perfection from the start. Young surgeons are not a commodity but a resource that needs to be developed. The older, experienced surgeons are retiring without imparting their knowledge on the younger generation.

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    Nephron, maybe we need some mentoring programs where older partners take younger ones under the wing so to speak.  Anyone heard of any formal mentorship programs?

    #197133 Reply
    Avatar Panscan 
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    I lean on my critical care and anesthesia colleagues. Bad surgeons are easy to pick out: ICU complications on elective cases. Long cases and anesthesia times for relatively simple procedures. My surgical colleagues often tell me of complications of their colleagues. The best surgeons are busy, boring and rarely hear of any problems in the hospital.

     

    In my area, I foresee a big shortage of qualified surgeons. The hospitals are hiring surgeons out of training, that are unseasoned and unmentored, expecting perfection from the start. Young surgeons are not a commodity but a resource that needs to be developed. The older, experienced surgeons are retiring without imparting their knowledge on the younger generation.

    Click to expand…

    Nephron, maybe we need some mentoring programs where older partners take younger ones under the wing so to speak.  Anyone heard of any formal mentorship programs?

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    isnt that the definition of residency

    #197141 Reply
    Avatar cerev 
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    I am an anesthesiologist and, while obviously biased, think that I have a pretty good sense as to who the good surgeons are, with some caveats. Those of us who sub-specialize, or those working in a small group, often work with the same surgeons day-in and day-out. We interact daily with them as colleagues and can tell those who:

    – are thoughtful in their decision making vs. those who are not

    – have infrequent complications and take-backs vs. those who have this happen frequently

    – have little blood loss vs. those who are blood-letters

    – are efficient with short operative times vs. those who are not

    – know everything about their patients (physicians) vs. those who rely heavily on other physicians, residents and PAs (technicians)

    – focus on one patient at a time vs. those who run several rooms at once

    – deal well under pressure when there is an unexpected intra-operative complication vs. those who do not

    – rarely need to call for help vs. those who do

    – call for help when needed vs. those who do not

    – have good bed-side manner vs. those who do not

    These are not necessarily all of the things that make a good surgeon. Obviously I do not know all of the intricacies of surgical approach and technique, nor every aspect of pre- and intra-operative decision making (though many of the above are good surrogates for those things). In addition, if the anesthesiologist typically supervises 4 rooms with CRNAs, is never in the OR other than for induction and emergence, or works with surgeons only rarely they probably don’t have much insight. Further, it is probably hard to tell many of these things for cases that are very straight-forward with few complications. That being said, in my sub-speciality I certainly know who I would go to, or have a family member go to, for certain procedures. I imagine the same would be true for ER docs, internists and intensivists who frequently work with surgeons. Judgement, a large component in what makes a good surgeon, is pretty easy to gauge.

    #197143 Reply
    MPMD MPMD 
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    Earnest refinancing bonus

    I don’t think there is any correlation. some people lose their sh*t, other people don’t.

    it’s not just a surgeon thing. I have no way of telling if a nephrologist or pathologist is good or not. I have no way of assessing any other doctor in another field.

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    I mean I do quite a bit of very acute and critical care and I can’t really think of an ER doc I know who loses their stuff who is also an awesome clinician. When a doc starts yelling at work what I hear is “I am well outside of my comfort zone here and getting scared and so I’m throwing a tantrum.”

     

     

    “Your style is determined by what you CAN’T do.”

    -Mitch Hurwitz

    #197158 Reply
    Avatar GPGP 
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    Finding good primary care is hard (I say this as a primary doc). I was referred to an idiot when I moved to this area by someone who used to know him- just incredibly poor care, despite being board certified. You often know who is good and bad when you get new patients and see their prior management, or cross-cover.

    I think specialists, particularly cognitive specialists, can tell who sends good referrals and bogus ones, who takes good care of their patients and not. Hospitalists probably can tell to an extent.

    It’s an entirely different game trying to help a family member out of town – still possible but much harder. I start with credentials and then try to match the family member’s story with their decision making process.

    #197162 Reply
    Zaphod Zaphod 
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    Maybe some people can tell through repeated interaction and comparison, but again, like I mentioned pages ago. The only way for me to really assess someones true capability, ie, treats pts right, assesses them properly and isnt offering too much/little, doing more than they can handle, is good technically, is available and responsive after hours, responds appropriately to issues that arise, and follows up with their pts til they’re done, etc…is to spend a good bit of time in all these clinical aspects of the surgeons care. That is really hard for many people to do, and especially hard if you arent in the same exact field and know what you’re comparing against.

    I know many thoughtful surgeons who care and take diligence in the OR and are technically good, etc…but they arent much around post op at all, off to residents, etc…I know lots of plastic surgeons especially dont even meet pts prior to OR day, and almost never see them after either. Some of these guys are bound to be fine technically, but I dont want them taking care of…well, anyone.

    Theres a lot more to surgery than the OR (very unfortunately as that would be awesome).

    There are a lot of people that probably seem good that are doing unnecessary stuff, not really great in other aspects, just ok technically, or due to lack of comparative basis, and itd be hard to tell unless you had a little more insight. Frankly, what one group thinks is a good consult and another doesnt really is a poor barometer except at the edges. Sadly, its only easy to see the really bad and really good as it shines through all phases of care and interactions. The vast middle is where most are at and where its harder to tell.

    I think our familiarity with medicine and general self trust in these kind of matters leads us to an overconfidence in our ability to assess others skill levels (without serious time spent with and a deep dive into the fuller practice of said person). I would bet against anyones opinion vs. some sort of objective assessment (to be developed by @funkdoc83 and myself) all day long.

     

    #197166 Reply
    Zaphod Zaphod 
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    I lean on my critical care and anesthesia colleagues. Bad surgeons are easy to pick out: ICU complications on elective cases. Long cases and anesthesia times for relatively simple procedures. My surgical colleagues often tell me of complications of their colleagues. The best surgeons are busy, boring and rarely hear of any problems in the hospital.

     

    In my area, I foresee a big shortage of qualified surgeons. The hospitals are hiring surgeons out of training, that are unseasoned and unmentored, expecting perfection from the start. Young surgeons are not a commodity but a resource that needs to be developed. The older, experienced surgeons are retiring without imparting their knowledge on the younger generation.

    Click to expand…

    Maybe at some academic places this can be true, or maybe now surgeons are coming out with little operative experience. In my experience criss crossing the country, its a rare older surgeon anywhere close to retirement that I’d want in a room with me or a family member. Someone with 5-10 years experience? All day. Evidence bears this out as well. Some of the worst surgeons I’ve heard about or come across are those in the 70s-80s that refuse to retire. Its just too difficult to keep up the skills that long and they seem to take forever unnecessarily.

    #197167 Reply
    Avatar veritablpenguin 
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    I can tell you, as a pathologist, which surgeons always have good margins, which surgeons only need 4 tries to find all four parathyroids, and which surgeons truly understand how to take tissue for a lymphoma work-up.  Presumably, an anesthesiologist can tell you which surgeons perform well in the OR.  But the only doc who can tell you how these patients fare post-op are their primary care docs. Some of the surgeons the patients love the most are the worst around, but have a great bedside manner.

    I definitely have my favorite surgeons in town, but when I needed an appendectomy I had the on call surgeon, whom I had never met or worked with, do the job.  Patients don’t really get a choice in this situation.

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    Radiologists are also pretty good at telling who’s good post-operatively, especially ortho/spine.

    Hard to find one person who can tell you who’s good start to finish.  And also, you can be good in some domains and not in others.

    As an anesthesiologist I can generally tell you who’s decent in the OR and to some degree judge their pre-op decision-making.  OR nurses/scrubs probably even better judges of efficiency/technical skill.

    Click to expand…

    Anesthesia is probably an easy judge of preop decision making, and who may be gruff in the OR. Much harder to tell who is ‘good’. Probably right about rads with Ortho, at least they can objectively notice over time if someone has poor union/placements.

    RNs/Scrubs will mostly tell you who they like personally and cant tell the difference, which can be but isnt really correlated to performance. There are some really bad docs out there that are quite likable and get away with a lot, and good ones that dont.

    There unfortunately isnt a simple heuristic, it doesnt exist.

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    how does anesthesia know anything about preop decision making? I guess if you’re talking about if they’re likely too sick for the surgery or something like that. but knowing the kind of ostomy that would be appropriate or etc, they have no clue.

    Not sure about the radiology and spine thing either? imaging doesn’t correlate with symptoms at all for spine stuff so I have no idea how I can make a judgement on the surgeon based on what the patient’s MR looks like, unless they’re putting hardware where it shouldn’t be or something like the dr death guy, which is obviously a very rare exception.

    Wife is MSK rads.  They all know who gets the most infections, whose hardware fails the most, who puts screws in places they shouldn’t, etc.

    As far as anesthesia knowing about pre-op decision making, yes I was referring mostly about who to take to surgery and who not.

    #197178 Reply
    Liked by Zaphod
    Avatar Panscan 
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    not sure there is that much loosening or that many people are getting infected prostheses for it to be statistically significant between surgeons with only seeing a limited amount of cases,  or that your wife would even see them all the time. for instance the ortho can take xrays in their office and see that there’s loosening and then replace the joint, all on their own without a read from rads ever.

    who to take to surgery is a complex decision though. for instance we were doing an ostomy takedown on a lady on 4L of home O2, horrible CHF, etc, absolute horrible operative candidate. to an outsider that is a horrible idea and I thought the same thing at the time. except the attending knew that too and told the patient and she said she would rather die than keep the ostomy and that she was unable to leave the house because she hated it so much. she was literally willing to risk dying so she could have the chance at living without an ileostomy.

    but from the 20 foot view you’d never see that. you’d just see ” wow crazy dr y is doing a takedown on mrs. xyz who is super sick” and then when she dies in the ICU  a week later you say ” hm who knew.”

    This is the kind of stuff I’m talking about (and I think zaphod is too) about how complex all these decisions are and how many levels there are, and if you make a conclusion without being directly apart of the process then it’s very hard for it be accurate.

    #197194 Reply
    Avatar Panscan 
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    or for the loosening or infection angles, again there are numerous variables contributing. maybe one surgeon only operates on non-diabetics or really healthy people. maybe another person is a little more liberal. who is going to have more infections? can make similar arguments for loosening.

    the point is its super hard to say “they had x outcome, that means they suck”. well there are 100 variables that affect the percentage of x outcome they are going to have.

     

    #197198 Reply
    Avatar Grizzle 
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    A few thoughts:

     

    One. It’s the decision not the incision. Bulletproof indications make up for mediocre hands. But this is not necessarily the best thing in the world for all patients. I would love to operate only on healthy 45-year-olds without diabetes, smoking history, social issues, personality disorders, and unrealistic expectations. This would however leave my operative schedule somewhat empty. Much more importantly, it would deprive a large number of people who could benefit from surgery from that surgery just because they are not A+ candidates. Diabetics need surgery too.

     

    Two.  maybe it’s because I am an overconfident surgeon, but I feel that I can figure out in a five or 10 minute conversation with another surgeon how good they are. It doesn’t even really have to be about surgery. If someone can show me that they understand nuance, can find humor in things, especially dark things, and can rapidly alternate between microscopic attention to detail and panoramic big picture view – – they’re the real deal.

     

    Three.   I think referring primary care doctors have probably a better sense of how good a surgeon is than the other professionals in the operating theater. They see the shape the patient was in preop and the shape that they are in once the journey is done. The proof is in the pudding. They also get a sense of how happy the patients are with the overall experience which is a combination of  the bedside manner, the decision-making, and the technical acumen. People like working with pleasant people. If the surgeon is nice, and the surgeries tend to go quickly, anesthesia and the operating personnel don’t complain. When cases run late, and the surgeon is a jerk, people don’t like that person. I would tend to agree though that when everything is in order, the days just run better. The cases are more orderly, people are more relaxed, potential issues are identified ahead of time so there are fewer ball drops. People can talk about their weekend plans, because even a complicated surgery feels like going through the motions. When skill and planning are lacking, even the most routine case feels like defusing a bomb on a school bus.

     

    Four.  360° evaluations of skill are coming. I think it is imperative that we as practitioners start to develop these ourselves so that is not one further thing thrust upon us by the administrator class. I recently flew on a pilot’s last flight. He was turning 65 and faced mandatory retirement. I happened to be sitting next to his wife who is also a pilot. She told me he thought it was strange that today he could take 700 people across an ocean, but tomorrow he was not deemed fit to set foot in the cockpit. I told her that we are having similar discussions in medicine, but there is no hard and fast rule. She found that a little odd, but I reminded her that I can only kill one person at a time. The airline industry has decided it better to force out some competent pilots rather than apologize for letting some incompetent pilots stick around too long. No matter what the process, there are going to be some people unfairly shut out in the cold. I can only urge all of you to be at the forefront of determining the  “objective” criteria that will all be used on us someday. You may not like what’s coming.

     

    Five.  Academic institutions are no guarantee of competence.  I take case volume over publication # any day.  Fortunately, many have both going for them.

     

    -Grizzle-

    #197213 Reply
    Liked by Tim

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