Cowboy Surgeons

Would you want to undergo an operation done by a surgeon who rarely performs the procedure?

Apparently, it happens more often than you might think and three of the country’s leading healthcare systems are trying to put a stop to it.

Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan are cracking down on hospitals in their systems that offer surgical procedures even when the hospitals and surgeons don’t perform them often.

This move comes on the heels of an analysis done in May by U.S. News & World Report that found that patients are more likely to die or have complications from common procedures when undergoing them at low-volume hospitals, compared to those that do many of them.

Cowboy Surgeons

The 10 common procedures include bariatric staple surgery, hip and knee replacement surgeries, and certain types of heart surgery.

"It's a promising, bold move. I hope other hospitals across the country follow," Leah Binder, director of the Leapfrog Group, a consortium of major employers, told U.S. News.

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Low Volume Tied to High Risk

The three hospital systems are voluntarily imposing these minimum limits on themselves. This affects both the 20 hospitals in the three systems and the surgeons who work there.

Not all doctors will be happy with this move.

"I think there’s a lot of work going on trying to, if you’ll pardon the pun, cut away that cowboy mentality," Dr. Tyler Hughes, a surgeon in rural Kansas, told New Hampshire Public Radio (NHPR). "Because ultimately this isn’t about us, the surgeon. It’s about the patient."

According to the U.S. News report, low-volume hospitals put patients at risk of death and complications simply because the surgeons don’t perform many of the procedures during the year.

Low-volume hobbyists are bad for patients and we have to stop them.
Dr. John Birkmeyer, Dartmouth-Hitchcock Medical Center

Low-volume hospitals often service sparsely populated areas of the country. Although these centers may keep patients from having to drive several hours for a procedure, the risks may outweigh the benefits.

"Low-volume hobbyists are bad for patients and we have to stop them," Dr. John Birkmeyer, a surgeon and chief academic officer at Dartmouth-Hitchcock Medical Center, told U.S. News.

Birkmeyer helped to draft the new guidelines being adopted by the three medical centers.

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Surgery Limits Could Save Lives

According to Birkmeyer, each year 1.3 million people in the United States undergo one of the 10 procedures affected by the guidelines.

More than 250,000 of these are done in hospitals with below-average volume.

Birkmeyer estimates that if these procedures were carried out by more experienced surgeons instead of so-called “cowboy surgeons,” more than 1,300 deaths could be prevented each year.

If you don't do something very often and it's complicated, you're not going to do it as well as someone who makes their living doing it.
Dr. Peter Pronovost, Armstrong Institute for Patient Safety and Quality

In addition to a higher risk of death, patients also face complications from their surgery, such as infections or failure to accomplish the procedure’s goals. Both can require another surgery and additional risks.

"If you don't do something very often and it's complicated, you're not going to do it as well as someone who makes their living doing it," anesthesiologist Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, told U.S. News.

Pronovost helped draft the new standards.

Online Tools Rate Hospitals and Surgeons

The problem of low-volume surgeries, though, isn’t limited to small hospitals that see fewer patients. This can also happen in major medical centers.

“We see this within our own health system, when surgeons whose primary interests are elsewhere do that [operation] just because it showed up on their doorstep,” Birkmeyer told U.S. News.

The link between low surgical volume and poorer outcomes has been known as far back as a 1979 report in the New England Journal of Medicine. The new guidelines, though, are the first coordinated attempt at setting minimum numbers for surgeons and hospitals.

Procedure volume is only one factor that determines surgical outcome. In fact, some small hospitals may provide excellent care even at smaller volumes.

It’s hard for me to imagine a patient that would react poorly to a health system deciding that only experienced, proficient surgeons will be doing operations.
Dr. John Birkmeyer, Dartmouth-Hitchcock Medical Center

The surgical volume analysis in U.S. News was part of a new set of hospital ratings called Best Hospitals for Common Care, which will evaluate hospitals in five procedures.

Another recently released tool, developed by the nonprofit news outlet ProPublica, ranks nearly 17,000 doctors against their peers for common elective procedures such as hip replacements and gallbladder removal.

Even with these new rating systems, some patients may continue to choose local hospitals — which are closer to support from family and friends — but Birkmeyer is confident of the new guidelines.

"It’s hard for me to imagine a patient that would react poorly to a health system deciding that only experienced, proficient surgeons will be doing operations," he told NHPR.

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