Finding a Surgeon
Finding a surgeon refers to the process of choosing a doctor with specialized training in one or more branches of surgery to perform a specific procedure. It is almost always done in the context of elective surgery rather than emergency operations.
Recent changes in the healthcare professions
Choosing a surgeon is a relatively new development in health care. Until fairly recently, many people, particularly in rural areas in the United States and Canada, relied on one doctor who generally treated all members of the family for most illnesses and some surgical procedures, including tooth extraction and childbirth. These general practitioners often treated the same patients over a period of many years and consequently knew their medical histories quite well. Most hospitals were socalled general hospitals, and admitted patients for a wide variety of surgical procedures. Since World War II, however, advances in medical knowledge and technology have led to increasing specialization of both health care professionals and the facilities they work in. As of 2003, three members of a family, each scheduled for a different surgical procedure, might well be sent to three different hospitals or clinics in three different cities as well as having three different surgeons performing the operations. Under these circumstances, choosing a surgeon can seem both complicated and confusing.
Referral to a surgeon
In the United States, most people with health insurance belong to a health maintenance organization (HMO) or similar health care plan that either assigns them to a doctor or asks them to choose from a list of primary care physicians, or PCPs. PCPs are usually family practitioners, pediatricians, or internists, although some health care plans allow women to choose a gynecologist/obstetrician as their PCP. The PCP is sometimes referred to as a gatekeeper, because he or she makes decisions about referring patients to surgeons and other specialists. In some managed care plans, the PCP simply assigns patients to specific surgeons; in others, the patient may be given a list of surgeons to choose from. Many people use the PCP's list as a starting point for choosing their surgeon, and may ask the PCP for his or her opinion of the surgeons on the list. Such procedures as cosmetic surgery are not usually covered by HMOs, but many people will consult their primary care physician about this type of surgery anyway on the grounds that the PCP knows their medical history and may be able to give them a "short list" of local surgeons to consider.
In Canada, Australia, and other countries with publicly financed health care systems, patients usually have two options when surgery is considered. They may have the operation performed in a public hospital, in which
Basic considerations in choosing a surgeon
TYPE OF PROCEDURE. Surgical procedures vary considerably in complexity and the length of specialized training needed to perform them. Some can be carried out by a general surgeon, who is a physician who has completed residency training and passed an examination given by the American Board of Surgery, or ABS. The ABS, which is one of 24 certifying boards that comprise the American Board of Medical Specialties (ABMS), provides a lengthy definition of the training and experience required of general surgeons. According to the ABS, a general surgeon should be competent to perform basic procedures in all of the following areas, though not necessarily the "full range and complexity of procedures" in each field.
The ABS defines the following fields as "essential in the comprehensive education of a broadly based surgeon":
- alimentary (digestive) tract
- abdomen and its contents
- breast, skin, and soft tissue
- the endocrine system
- head and neck surgery
- pediatric surgery
- critical care surgery
- surgical oncology (cancer treatment)
- organ transplantation
- trauma and burns
- vascular surgery
After certification by the ABS, a surgeon may undergo additional training in one of 10 surgical specialties as defined by the American Board of Medical Specialties (ABMS):
- colon and rectal surgery
- neurological (brain and nervous system) surgery
- obstetrics and gynecology
- ophthalmology (eye surgery)
- orthopedic (bone and joint) surgery
- otolaryngology (ear, nose, and throat surgery)
- pediatric surgery
- plastic surgery
- thoracic (chest) surgery
To complicate the picture even further, some surgical specialties are further divided into subspecialties. For example, plastic surgeons may specialize in plastic surgery of the hand, or plastic surgery of the face and neck. Similarly, some ear, nose and throat specialists specialize further in pediatric otolaryngology. For this reason, one of the first questions patients should ask their primary care provider in choosing a surgeon is the degree of specialization required to perform a specific procedure as well as the reasons for having the operation. Among other considerations, specialization will affect the range of choices available to the patient regarding the hospital or clinic where the operation is performed as well as choosing the operating surgeon. Some highly specialized procedures may require patients to travel long distances to a hospital or surgical center in another city.
ALTERNATIVES TO SURGERY. The Agency for Health-care Quality and Research (formerly the Agency for Health Care Policy and Research) publishes a booklet called Questions to Ask Your Doctor Before You Have Surgery, which can be downloaded from the Agency's web site. The third question discussed in the booklet concerns such nonsurgical treatments as medications or changes in diet and lifestyle. Elective surgical procedures have potential risks as well as benefits, and patients should ask about both before committing themselves to having an operation. Some health care professionals advise exploring medical options first before agreeing to surgery when both types of treatments are available for a given condition and there is time to try nonsurgical approaches.
CREDENTIALS AND SKILL LEVEL. It is important for patients to check a surgeon's credentials and length of experience. After a doctor has received his or her MD or DO from an accredited school of medicine or osteopathy, he or she must pass a national licensure examination and a set of licensing procedures set by each state in order to practice general medicine or surgery in that state. Most surgeons have their medical school diploma and state licensing certificate framed and displayed on an office wall where patients can see them.
The American College of Surgeons recommends that patients look for the following credentials when they consult or are referred to a surgeon:
- Board certification. Board certification means that the surgeon has passed a rigorous examination administered by one of the specialty boards belonging to the ABMS. The ABMS publishes an annual directory of board certified medical specialists that can be found in many hospital libraries as well as university or medical school libraries. Patients can also call their local county medical society to verify a surgeon's specialty credentials.
- Fellowship in the American College of Surgeons. A surgeon with the letters FACS after his or her name is a Fellow of the ACS and is a board-certified surgeon.
- Approval for practice in accredited hospitals or other health care facilities. Patients can verify the accreditation status of the facility where the operation is to be performed by contacting the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for hospitals, or the Accreditation Association for Ambulatory Health Care (AAAHC) for outpatient surgery centers. These organizations are listed below under Resources.
An additional consideration is the number of procedures of a specific type that the surgeon performs on a regular basis. The more specialized the procedure, the more important it is for the surgeon to practice his or her skills. For example, the Johns Hopkins urology website states that a surgeon consulted for prostate surgery should have performed at least 150 prostate operations, and that it is preferable if he or she performs the same operation every day or several days a week. For some types of surgery, including joint replacement and cancer surgery, patients should look for a surgeon in high-volume medical centers where specialists have acquired a great deal of experience performing the specific procedure that the patient needs.
PERSONALITY ISSUES. In addition to a surgeon's level of skill and experience, his or her personality should be taken into consideration. Because many operations require dietary changes, certain types of exercise, or other detailed preparations, the patient should feel comfortable about talking to the surgeon—particularly when it comes to asking important questions about the operation itself or the surgeon's length of experience. Some patients are afraid to talk to surgeons because they have heard that surgeons have a reputation among other health professionals for being impatient, bossy, and generally lacking in "people skills." One popular article on doctors' personality styles describes the typical surgeon as fitting the "dictator" pattern, and several studies have reported that over 50% of doctors advised to seek anger management counseling are surgeons. As of 2003, however, a growing number of surgeons are recognizing that patients who take an active role in their treatment have better outcomes, and that a well-informed patient is their best ally. Patients should not hesitate to talk to several different surgeons in order to find one whose personality is a good fit with their own. One writer tells of an Australian patient who did some research at a nearby library on the operation he was going to have and then consulted two different surgeons. The first surgeon was pleased that the patient had taken the time to read about the operation, and was quite happy to answer a number of questions. The second surgeon brushed the patient aside. The patient told the writer, "[His attitude toward patients was to] keep them ignorant. Don't tell the patient a thing. I kept at him, and when I'd finished, I told him I didn't think much of his answers and that I wouldn't be back."
DISCIPLINARY HISTORY. Although only a small percentage of doctors in the United States have ever been disciplined by a professional peer review, sued for malpractice, or had their licenses suspended—about 0.5% per year—patients who are considering surgery should find out if any of the surgeons they have consulted have a history of disciplinary actions taken against them. The Federation of State Medical Boards has compiled a database called DocInfo that can be searched on the Federation's web site for information about a specific practitioner's record.
Patients considering elective surgery should collect some information about the procedure in question and the qualifications required to perform it before they talk to a specific surgeon. People with Internet access can obtain information about surgical operations as well as credentialing processes on the web sites of the various surgical specialty associations. Links to these associations can be found on the ABMS web site. Many surgical specialty groups have patient education brochures and other informational material available for downloading free of charge. Most of these materials can also be obtained by writing, telephoning, or e-mailing the associations.
Other useful sources of information include hospital and outpatient surgery center web sites. These sites often have reader-friendly descriptions of specific procedures as well as information about the hospital or clinic's accreditation, location, and other important features.
Another good source of information about choosing a surgeon is first-person accounts of surgical procedures. There are a growing number of patient guides to plastic surgery, joint replacement surgery, oral and facial surgery, cancer surgery, and other procedures written by
The next step in choosing a surgeon is asking other health professionals to recommend specific practitioners. As was mentioned earlier, most patients begin with their primary care doctor. Patients who have been treated recently by a medical specialist should also ask him or her for recommendations about surgeons. For example, someone who has been seeing a specialist in pulmonary (lung) medicine for asthma treatment will want to ask him or her for the names of good thoracic surgeons if an operation is recommended. One author of a popular patient guide suggests asking the PCP or medical specialist who they would ask to do the surgical operation if they themselves needed it.
Other sources of recommendations include home health care nurses or physical therapists, who are often familiar with the work of local surgeons. One expert in sports medicine has been quoted as saying, "If you want a good surgeon, ask a physical therapist. We see patients from all the surgeons. I see the same good surgeries come from the same good surgeons and the same lousy surgeries come from the same lousy surgeons. You see it all the time."
A third source of recommendations is other people who had the same procedure that the patient is considering and were pleased with the results.
As recently as the 1960s, it was considered unprofessional for doctors or dentists to advertise themselves except for brief listings of their specialties in professional association and local telephone directories. The spread of high-pressure advertising techniques that originated in the business world into medicine, however, has resulted in the production of web sites, radio announcements, and printed advertisements for doctors that can be confusing to patients who are looking for a surgeon. In particular, plastic surgeons who specialize in cosmetic procedures (face lifts, "tummy tucks," etc.) have been accused of exploiting people's vulnerabilities and fear of aging in their advertisements. The American Medical Association (AMA) has a set of guidelines issued in 1996 and updated in 2002 that warn doctors against using publicity containing deceptive or misleading claims. Patients looking for a surgeon should be wary of doctors who claim that they have unique skills, "secret" techniques, or an improbably large number of satisfied patients. In addition, an attractive web site or impressive advertisement should not be a substitute for a personal interview with the surgeon.
Patients who are considering surgery should not be shy about getting a second opinion if they feel unsure about having an operation after they talk to a surgeon. In fact, many health plans require patients to seek a second opinion for certain types of elective surgery before they will approve the procedure. Some insurance plans will reimburse patients for the cost of seeking a second opinion. The Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA), publishes a brochure (Publication No. 02173) for Medicare patients on seeking second surgical opinions.
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Accreditation Association for Ambulatory Health Care (AAAHC). 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091-2992. (847) 853-6060. <www.aahc.org>.
Agency for Healthcare Research and Quality (AHRQ). 2101 East Jefferson Street, Suite 501, Rockville, MD 20852. (301) 594-1364. <www.ahcpr.gov>.
American Board of Medical Specialties (ABMS). 1007 Church Street, Suite 404, Evanston, IL 60201. (866) ASK-ABMS. <www.abms.org>.
American Board of Surgery (ABS). 1617 John F. Kennedy Blvd., Suite 860, Philadelphia, PA 19103. (215) 568-4000. <www.absurgery.org>.
American College of Surgeons (ACS). 633 North Saint Clair Street, Chicago, IL 60611-3211. (312) 202-5001. <www.facs.org>.
Centers for Medicare and Medicaid Services (CMS). 7500 Security Boulevard, Baltimore, MD 21244-1850. (410) 786-3000. <cms.hhs.gov>.
Federation of State Medical Boards of the United States, Inc., P. O. Box 619850, Dallas, TX 75261-9850. (817) 868-4000. <www.fsmb.org>.
Health Canada/Santé Canada. A.L. 0900C2, Ottawa, Canada, K1A 0K9. (613) 957-2991. <www.hc-sc.gc.ca>.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). One Renaissance Boulevard, Oakbrook Terrace, IL 60181. (630) 792-5000. <www.jcaho.org>.
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Rebecca Frey, Ph.D.